Left Colectomy Research Articles

Robotic left colectomy with double indocyanine green guidance and intracorporeal anastomoses.

Radical surgery is the mainstay of treatment of colon cancer. Lymphatic drainage of splenic flexure colon cancer is variable, and the exact site of lymphatic dissection is uncertain. Hence, a true consensus of what kind of colectomy should be performed for tumours of the splenic flexure is lacking. Segmental left colectomy (splenic flexure colectomy) (extended), left colectomy as well as subtotal colectomy (extended right colectomy) all have their proponents. Robotic colectomy addresses the limitations of straight laparoscopic colon resections. We report our technique of single-docking totally robotic left hemicolectomy for splenic flexure adenocarcinoma using Da Vinci Xi® Surgical System (Intuitive Surgical, USA) with indocyanine green near-infrared fluorescence for the assessment of both the lymph nodes and intestinal blood flow in real time.

Enhanced recovery program versus traditional postoperative care for elective open colorectal cancer surgery

Background Traditional colorectal surgeries usually require a relatively long hospital stay of ∼10 days. Inadequate pain control, intestinal dysfunction, and immobilization are the main factors associated with delay in recovery. Enhanced recovery protocols have been used to optimize the perioperative care. Objectives To study the outcome of the enhanced recovery program for selected patients with colorectal malignancies subjected to elective surgery compared with similar patients subjected to surgery with traditional perioperative care. Patients and methods This prospective study was performed at Fayoum University Hospital from April 2008 to June 2017 and involved 97 patients who had uncomplicated colorectal cancer and were planned for elective open colorectal surgeries. They were divided into two groups: group A (44 patients) was subjected to surgery based on fast-track protocol and group B (53 patients) was subjected to surgery based on traditional perioperative care. Hospital stay, perioperative morbidity, mortality data, postoperative pain, and patient satisfaction data were collected, statistically analyzed, and recorded. Results In groups A and B, respectively, the mean±SD age was 47.3±5.1 and 43.7±6.1 years, the number of males was 31 and 44, whereas the number of females was 13 and nine. According to American Society of Anesthesiologists (ASA) score, 43.2 and 54.7% of patients were ASA I and 56.8 and 45.3% were ASA II in groups A and B, respectively. Overall, 40.9 and 43.4% underwent low anterior resection, 36.4 and 22.6% sigmoidectomy, 22.7 and 28.3% right colectomy, and 0 and 5.7% left colectomy in groups A and B, respectively. The mean±SD length of postoperative hospital stay was 3.58±0.24 and 8.84±1.87 days in groups A and B, respectively. There was no mortality in the two groups, and overall morbidity rate was 22.7 and 22.6% in groups A and B, respectively. Overall, 4.5 and 7.5% had wound infection, 2.3 and 0% had abdominal wall dehiscence, 11.4 and 11.3% had persistent vomiting, 2.3 and 3.8% had postoperative fever in groups A and B, respectively. Moreover, one (2.3%) patient in group A required readmission and resurgery to manage anastomotic leakage and peritonitis. Conclusions Enhanced recovery program for elective colorectal cancer surgery has a very good effect on postoperative recovery, as it shortens the length of hospital stay, with high safety and good patient compliance; therefore, we strongly recommend the application of such protocols, provided the availability of well-trained and adequately experienced personnel in well-equipped centers.

Short- and long-term outcomes of laparoscopic segmental left colectomy for splenic flexure colon cancer: comparison with propensity score matching.

PurposeSplenic flexure colon cancer (SFCC) is a rare disease that accounts for 2%–8% of colorectal cancers, and the extent of surgery and resection is still debatable. There have also been few studies on the safety and feasibility of laparoscopic surgery for SFCC. The purpose of this study is to evaluate outcomes and prognoses of surgery for SFCC.MethodsWe included patients with stage 1 to 3 who had undergone laparoscopic surgery for distal transverse-to-sigmoid colon cancer at 2 hospitals from March 2004 to December 2016 and collected data by retrospective design. We defined SFCC as being cancer between distal transverse and proximal descending colon. The short- and long-term outcomes of the anterior resection (AR) group (those patients who had undergone laparoscopic AR for mid and distal descending to sigmoid colon cancer) and the left colon resection (LR) group (those who had undergone laparoscopic segmental left colectomy for SFCC) were compared using propensity score matching.ResultsThe median follow-up period was 60 months. The numbers of subjects in the AR and the LR groups were 948 and 118. After 2:1 propensity score matching, 236 vs. 118 patients were selected. There was no significant difference in 5-year disease-free survival (80.7% vs. 78.6%, P = 0.607), and both the 5-year overall survival (89.2% vs. 88.2%, P = 0.563) as well as short-term outcomes showed no statistical difference in most of the variables.ConclusionLaparoscopic segmental left colectomy can be one option among the standard procedures for SFCC.

Preoperative assessment of patient comorbidities before left colectomy: Comparison between ASA performance status scale and a new computed tomography physical status score

PurposeTo compare a newly developed preoperative computed tomography physical status (CT-PS) score with the American Society of Anesthesiology performance status (ASA-PS) scale in the assessment of patient preoperative health status and stratification of perioperative risk before left colectomy. Materials and methodsPreoperative chest-abdomen-pelvis CT examinations of patients who were scheduled to undergo elective laparoscopic left colonic resection for cancer in two centers were reviewed by two radiologists blinded to clinical data for the presence of several key imaging features in order to assess general, cardiac, pulmonary, abdominal, renal, vascular and musculoskeletal status. CT examinations of patients from center 1 were used to build a CT-PS score to predict ASA-PS≥III. CT-PS score was further validated using an external cohort of patients from center 2. ResultsDuring a 2-year period, 117 consecutive patients (63 men, 54 women; mean age, 65±13 [SD] years; age range: 53–90 years) who underwent laparoscopic left colectomy for cancer in center 1 (66 patients, building cohort) and center 2 (51 patients, validation cohort) were retrospectively included. Ninety-one percent of patients were ASA-PS 1–2. Overall postoperative morbidity was 23% and severe morbidity 12%. The area under the receiver operating characteristic curve of CT-PS score was 0.968 (95% CI: 0.901–1.000) in the building cohort and 0.828 (95% CI: 0.693–0.963) in the validation cohort. The optimal thresholds yielded 87% (95% CI: 83–91%) sensitivity and 100% (95% CI: 91–100%) specificity in the building cohort and 75% (95% CI: 69–81%) sensitivity and 83% (95% CI: 77–88%) specificity in the validation cohort for the prediction of ASA-PS. ConclusionPreoperative chest-abdomen-pelvis CT thoroughly and wisely read is highly accurate to differentiate patients with ASA-PS I/II from those with ASA-PS III/IV before left colectomy.

Una experiencia de integración de la Formación Sanitaria Especializada con la Universitaria de Posgrado: Entrenamiento por etapas en cirugía laparoscópica.

Antecedentes: Diseño de un modelo de simulación para formación en cirugía laparoscópica. Métodos: Dentro del Máster Anatomía Aplicada a la Clínica se implementaron tres etapas de formación progresiva en médicos residentes. La etapa 1 se realizó en simulador con material no biológico: manejo de objetos, disección con pinza y tijera, y sutura laparoscópica. La etapa 2 utilizó material biológico (tubo digestivo en fresco) en simulador, para la práctica de sección intestinal y anastomosis intracorpórea. En la etapa 3 se realizaron técnicas laparoscópicas en cadáver en fresco (apendicectomía, colecistectomía, apertura de la transcavidad epiploica, hemicolectomías derecha e izquierda). Se añadió una encuesta de satisfacción a los participantes de la actividad. Resultados: El programa se impartió a 6 residentes de Cirugía General. Todos completaron los ejercicios de las etapas 1 y 2. En la etapa 3 se pudo realizar el neumoperitoneo sin dificultad y los tejidos presentaron una textura adecuada. Los residentes de primer año completaron la apendicectomía y la colecistectomía, pero procedimientos más complejos requirieron residentes con más experiencia. Los participantes encuestados reflejaron que el programa es adecuado y útil para el entrenamiento en laparoscopia. Conclusiones: El modelo propuesto es reproducible y adecuado en adquisición de competencias básicas en cirugía laparoscópica. Background: Design of a simulation model training in laparoscopic surgery for surgical residents. Methods: Three stages of progressive training were programmed within a Postgraduate Degree in Clinical Anatomy. Stage 1 was performed in a box-trainer with synthetic materials: managing small objects, dissection with clamp and scissors, and laparoscopic intracorporeal suture. Stage 2 used biological material (fresh digestive tract from a human corpse) in box-trainer, practicing section and intracorporeal anastomosis. In stage 3, laparoscopy was performed on a fresh corpse (appendectomy, cholecystectomy, lesser sac opening, right and left colectomy). A satisfaction survey was carried out to the participants. Results: Some six General and Digestive Surgery residents took the program. All of them completed the stage 1 and 2 exercises. In stage 3, the pneumoperitoneum could be performed without any complications, and tissues presented an adequate texture. First-year residents completed appendectomy and cholecystectomy, but more complex procedures required more experienced residents. The participants reflected that the program is adequate and useful to gain basic skills in laparoscopy. Conclusions: The proposed model is reproducible and adequate in acquisition of basic skills in laparoscopic surgery.

Total laparoscopic left colectomy intracorporeal anastomosis

Laparoscopic left colectomy (LLC) has been widely performed for treating patients with left hemicolon cancer. For less invasion, totally laparoscopic left colectomy intracorporeal anastomosis (TLC/IA) has been increasingly attempted and proposed. Up to now, there is no standard for intracorporeal anastomosis. Authors list various types of intracorporeal anastomosis in terms of technical details and postoperative complications. According to the literatures, side to side anastomosis with linear laparoscopic stapler is the mainstream method. Surgeons should make flexible choices based on personal technical characteristics, colon conditions and objective economic conditions of patients. An individualized anastomosis method is acceptable.

Initial clinical experience with Single-Port robotic (SP r) left colectomy using the SP surgical system: description of the technique.

The daVinci Single-Port (SP) robot is a new robotic platform designed to overcome the challenges of Single-Incision Laparoscopic Surgery. The objective of this study is to demonstrate the feasibility and technical aspects of SP robotic (SP r) left colectomy using the SP platform. Under Institutional Review Board approval and registration on ClinicalTrials.gov, we performed SP rLeft colectomy using the daVinci SP surgical system on four patients. The primary end-point of this study was to report and describe the technical feasibility to perform SP rLeft colectomy. The secondary end-points included perioperative metrics and outcomes. Four patients underwent successful SP rLeft colectomy for diverticulitis through a single incision (average size: 4.4cm) without intraoperative complications or conversions. The robot was docked 2.7 times on average (range 2-4). The average docking time was 8.4min (range: 3-33min). The mean estimated blood loss was 91mL (range: 20-250mL). There were no morbidities or mortalities. Patients were discharged on POD 2 and 3. We demonstrated in this initial clinical series the SP rLeft colectomy to be feasible and safe to perform in select patients. The SP robot's single-arm design and flexible instruments have shown to provide excellent visualization and retraction with minimal collisions. We predict that the SP robot will be widely utilized in the field of colorectal surgery as it becomes available to colorectal surgeons. Further experience and larger studies are needed to define the advantages and identify the problems with the SP rLeft colectomy.

Estended right colectomy, left colectomy or segmental left colectomy for splenic flexture carcinomas ? A European multicentric study including 399 patients

This study aims to compare short and long term outcomes of extended right (ERC), left (LC), or segmental left colectomy (SLC) and laparoscopy or open surgery performed for curative-intent elective surgery in a patient affected by splenic flexure carcinomas (SFCs).

“Stent in Stent” Procedure for Treatment of Extreme Strictures of Colorectal Cancer – Case Series in a Single Center: How to Do it

Background: Since 1990’s the use of self-expanding metal stent has been known. Initially, this kind of technique has been debated in literature. Actually, is a widely used technique for treatment of bowel neoplastic obstruction. This procedure is important to restore bowel canalization but is feasible performed by expert endoscopists and a dedicated anesthesiologist team. More difficult seems to be the treatment of strictures longer than 9 cm of large bowel or synchronous very close stenosis of rectal-sigmoid junction and rectum. This technical note demonstrated how SEMS positioning can be performed for treatment of long and extreme large bowel obstruction. Methods: In this case series we have treated all patients admitted in our department with diagnosis of extreme bowel neoplastic obstruction, with “stent in stent” technique, in deep sedation. Results: From January to August 2019 we admitted in our Surgical and Endoscopic Unit two patients, a 90- year-old for bowel obstruction by synchronous colorectal cancer and a 80-year-old female for 15 cm large bowel neoplastic obstruction. Patients were submitted to “Stent-in-Stent” technique. No complications and perforation were observed with restore of bowel canalization after few hours from SEMS positioning. Both patients had no signs of bowel obstruction at abdomen X-Ray control, after 48 hours. 80-year-old female patient was submitted to left colectomy after 6 days without complications, while 90-year-old was discharge after 3 days. Conclusion: This study demonstrated how is possible to perform endoscopic SEMS positioning to treat longer than 15 cm neoplastic large bowel obstruction and synchronous colorectal cancer with “Stent-inStent” technique. Our technical note describes, point by point, all passages of this procedure and suggests as is possible to treat synchronous sigmoid-rectal neoplastic obstruction using two different kind of metal stent.

Segmental Diffuse Inflammatory Pseudopolyps Associated With Diverticulitis

Abstract Introduction/Objective Inflammatory pseudopolyps (IPs) often develop in response to chronic active inflammation in patients with inflammatory bowel disease (IBD). IPs can be diffuse and numerous in severe IBD. IPs can also occur from other chronic active injuries, such as ulcers, persistent infection, ischemic colitis, anastomotic site and diverticulitis. IPs arising from diverticulitis is uncommon and generally few in numbers. We report a rare case of a patient with segmental diffuse IPs associated with diverticulitis in the absence of IBD. Methods A 59-year-old male patient with a history of sigmoid diverticulitis presented with abdominal pain and was treated with antibiotics. Three months later he had severe recurrent diverticulitis. CT scan showed wall thickening of the sigmoid colon and multiple sigmoid diverticula. Colonoscopy showed extremely severe inflammatory colitis in the area of diverticulitis between 25.0 and 35.0 cm from the anal verge. Biopsies revealed cryptitis, crypt abscesses, crypt architecture distortion and Paneth cell metaplasia. The patient underwent laparoscopic left colectomy. Results The rectosigmoid colon specimen is 18.0 cm in length and 6.0 cm in diameter. There was a 7.5 cm segment with numerous polyps. Multiple diverticula with diverticulitis were also identified in this region. The rest of the colon was unremarkable. Microscopic examination revealed numerous IPs and multiple diverticulitis. No evidence of IBD was identified. Conclusion To our knowledge, this is the first time that segmental and diffuse IPs are described with associated diverticulitis in the absence of IBD. The pathogenesis of IPs in non-inflammatory bowel disease is not well described. Previously, it was reported that diverticulosis and subsequent diverticulitis has no significant impact on the development of IPs, and IPs may arise independent of location and time of diverticulitis. Sporadic IPs may also appear without any underlying pathology. In the current case, there were multiple diverticula and diffuse diverticulitis, which may have contributed to the diffuse IPs. Further clinical inquiries revealed no clinical signs and symptoms of IBD.

A rare case of metachronous neuroendocrine tumor after a colorectal adenocarcinoma: qualitative critical review of synchronous and metachronous gastrointestinal NET

Gastrointestinal neuroendocrine tumor (NET) associated with a metachronous intestinal adenocarcinoma is rare. We report the case of a 71-year-old man with an ileal NET. Patient has previously undergone a left colectomy for sigmoid cancer. We report a complete review both of the metachronous and synchronous NET. A comprehensive systematic literature search in PubMed, EMBASE, and MEDLINE identified a total of 35 relevant studies. This study includes an analysis of review articles, case reports, case series, retrospective studies and population-based studies. In the English literature to date, there are 21 case reports (19 synchronous cases and 2 metachronous cases), 3 case series and 3 review articles, and less than 10 retrospective studies or population-based studies. A total of 31 patients in 24 articles were included in the study: 28 patients with a synchronous gastrointestinal NET and colorectal adenocarcinoma and 3 patients with metachronous gastrointestinal NET and colorectal adenocarcinoma. The incidence of synchronous cancer (particularly for colorectal and gastric cancer) with a gastrointestinal NET ranges from 10 to 50%, while for the metachronous ones it is still unclear. This is the third metachronous case report and the first descriptive case of gastrointestinal NET diagnosed 2 years after a colorectal adenocarcinoma. An endoscopic follow-up program for gastrointestinal NET patients and/or for first-degree relatives of NET patients appears recommendable.

Leiomyosarcoma of the transverse colon with lymph node metastasis and malignant transformation: a case report

BackgroundThe concept of GIST was established in 1998, clearly differentiating between gastrointestinal leiomyosarcoma and GISTs among gastrointestinal mesenchymal tumors. Lymph node metastasis is extremely rare in true gastrointestinal leiomyosarcoma, and there are no reports of malignant transformation from leiomyoma.Case presentationThe patient was an old woman who had undergone endoscopic mucosal resection for an Is polyp on the left side of the transverse colon at the age of 73. She was diagnosed with leiomyoma with positive surgical margins. Subsequently, she presented to our institution with a sensation of pressure in the upper abdominal region as a chief complaint at the age of 76 years. Abdominal computed tomography and colorectal endoscopy showed a tumor lesion with invagination of the intestines in the transverse colon, the same site as that of the previously resected leiomyoma. A biopsy suggested a smooth muscle tumor, and we performed partial left transverse colectomy and lymph node dissection under a diagnosis of recurrence and enlargement of the previously incompletely resected leiomyoma. Histopathological examination revealed spindle-shaped tumor cells, and the mitotic activity was 30–40/10 high-power field. Tumor cells were immunohistologically positive for α-smooth muscle actin and h-caldesmon; partially positive for desmin; negative for c-kit, CD34, DOG-1, and the S-100 protein; and showed a Ki-67 labeling index of 70–80%. She was diagnosed with leiomyosarcoma malignantly transformed from leiomyoma. Metastasis was found in 1 of the 14 resected lymph nodes. The patient did not undergo adjuvant chemotherapy, but has survived with no recurrence at 2 years after the surgery.ConclusionsWe have reported a case of leiomyosarcoma of the transverse colon with lymph node metastasis that was malignantly transformed from a leiomyoma.

The role of tibial nerve stimulation for enhanced postoperative recovery after colorectal surgery: a double-blind, parallel-group, randomized controlled trial.

Postoperative ileus (POI) is the most common cause of prolonged hospital stay following abdominal surgery, despite an optimized enhanced recovery after surgery (ERAS) program. The aim of the study was to evaluate the role of postoperative transcutaneous electrical tibial nerve stimulation (TTNS) in the recovery of bowel function and in shortening hospital stay after colonic resection. Patients having elective laparoscopic colonic surgery within an ERAS program at our institution between June 2016 and June 2019 were enrolled and randomly assigned to a treatment protocol with TTNS or sham electrical stimulation. The primary endpoint was the time of recovery of gastrointestinal motility, measured as the first passage of stool. Secondary endpoints included: first passage of flatus, length of hospital stay, and complication rate related to the use of TTNS. One hundred and seventy patients who had right hemicolectomy (median age 71years (range 43-89years); 47.5% women) and 170 patients who had left colectomy (median age 67years range (37-92years); 41.5% women) were enrolled. The only factor significantly affected by TTNS was time to first passage of flatus after right hemicolectomy (reduced from 46 to 33h, p = 0.04). However, if only patients with low compliance to early oral nutrition (63 of 340; 18.5%) were considered, a statistically significant difference in time until first flatus (p < 0.01) and first bowel movement (p < 0.0001) and a shorter time until discharge (median 5 vs 7days) were found in both left and right colectomies groups, respectively. TTNS may have a positive effect on gastrointestinal tract motility and recovery from POI after colorectal surgery in a selected group, who has low compliance with an ERAS program, without increasing the risk of complications.

Segmental Colonic Resection Is a Safe and Effective Treatment Option for Colon Cancer of the Splenic Flexure: A Nationwide Retrospective Study of the Italian Society of Surgical Oncology-Colorectal Cancer Network Collaborative Group.

Global experience with splenic flexure cancer is limited because of its low incidence. Both limited (segmental) and extended resections are performed, because agreement on which is the adequate procedure has not been reached. The purpose of this study was to investigate whether segmental resection is as safe and effective as extended resection. This nationwide retrospective cohort study included all consecutive resections of splenic flecure cancer between January 2006 and December 2016 using data from the National Colorectal Cancer Network of the Italian Society of Surgical Oncology following the guidelines set out in the STROBE statement. Data were obtained for 31 Italian Referral Centers for Colorectal Surgery. A total of 1304 patients were submitted to resection of the splenic flexure (n = 791, 60.7%) or extended procedures (extended right and left colectomies; n = 513, 39.3%). We evaluated Clavien-Dindo ≥3 postoperative complications and oncological (number of lymph nodes removed, length of free proximal and distal margins, rate of R0 resections) and survival outcomes. The 2 arms were well balanced in regard to sex, BMI, ASA and Eastern Cooperative Oncology Group scores, and disease stage. Limited resection was performed more frequently using a minimally invasive approach (62.1% vs 50.9%, p < 0.001) and with shorter operation times than extended procedures (165 vs 189 minutes, p < 0.001), but the same Clavien-Dindo ≥3 postoperative complications (6.44% vs 6.43%, p = 0.99), 30-day mortality (0.63% vs 0.38%), oncological outcomes, and survival rates (5-year overall survival 0.84 vs 0.83, 5-year progression-free survival 0.85 vs 0.84). There are limitations inherent to the retrospective nature of the study and a potential lack of consistency in treatment across centers over time. Indications as to why a specific operation was chosen were based mostly on surgeons' beliefs. Segmental resection is a safe and effective treatment option for cancer of the splenic flexure. See Video Abstract at http://links.lww.com/DCR/B307. LA RESECCIÓN DE COLON SEGMENTARIA ES UNA OPCIÓN DE TRATAMIENTO SEGURA Y EFICAZ PARA EL CÁNCER DE COLON DE LA FLEXIÓN ESPLÉNICA: UN ESTUDIO RETROSPECTIVO A NIVEL NACIONAL DE LA SOCIEDAD ITALIANA DE ONCOLOGÍA QUIRÚRGICA - GRUPO COLABORATIVO RED DE CÁNCER COLORRECTAL: La experiencia global con el cáncer de flexión esplénica es limitada debido a su baja incidencia. Se realizan resecciones limitadas (segmentarias) y extendidas, ya que no se ha llegado a un acuerdo sobre cuál es el procedimiento adecuado.El propósito de este estudio fue investigar si la resección segmentaria es tan segura y efectiva como la resección extendida.Este estudio de cohorte retrospectivo a nivel nacional incluyó todas las resecciones consecutivas de cáncer de flecura esplénica entre enero de 2006 y diciembre de 2016 utilizando datos de la Red Nacional de Cáncer Colorrectal de la Sociedad Italiana de Oncología Quirúrgica siguiendo las pautas establecidas en la declaración STROBE.Se obtuvieron datos para 31 centros de referencia italianos para cirugía colorrectal.Un total de 1304 pacientes fueron sometidos a resección de la flexión esplénica (n = 791, 60.7%) o procedimientos extendidos (colectomías extendidas derecha e izquierda; n = 513, 39.3%).Evaluamos Clavien-Dindo ≥3 complicaciones postoperatorias y oncológicas (número de ganglios linfáticos extirpados, longitud de márgenes proximales y distales libres, tasa de resecciones R0) y resultados de supervivencia.Los dos brazos estaban bien equilibrados en cuanto a sexo, IMC, ASA y puntajes ECOG, y etapa de la enfermedad. La resección limitada se realizó con mayor frecuencia utilizando un enfoque mínimamente invasivo (62.1% versus 50,9%, p < 0.001) y con tiempos de operación más cortos que los procedimientos extendidos (165 min versus 189 min, p <0.001), pero el mismo Clavien-Dindo ≥3 complicaciones postoperatorias (6,44% versus 6,43%, p = 0.99), mortalidad a los 30 días (0,63% versus 0,38%), resultados oncológicos y tasas de supervivencia (5-y OS 0,84 versus 0,83, 5-PFS 0,85 versus 0,84).Existen limitaciones inherentes a la naturaleza retrospectiva del estudio y una posible falta de consistencia en el tratamiento entre centros a lo largo del tiempo. Las indicaciones de por qué se eligió una operación específica se basaron principalmente en crieterios de los cirujanos.La resección segmentaria es una opción de tratamiento segura y efectiva para el cáncer de la flexión esplénica. Consulte Video Resumen en http://links.lww.com/DCR/B307. (Traducción-Dr. Adrian Ortega).

Emergent management of complicated paraesophageal hernia due to distal gastrointestinal obstruction: three-case series

Background: The aim of this study is to describe the diagnostic evaluation and treatment in patients with complicated paraesophageal hernia (PEH) and distal gastrointestinal (GI) obstruction. Methods: Three cases with known PEH in the Department of Surgery of the General Hospital of Nea Ionia ‘’Constantopoulion-Patission’’, I woman 78 yrs, II man 88 and III man 78, underwent emergent open surgery for complicated PEH and GI obstruction. Cardiorespiratory distress in all and sepsis in I, were encountered. Case I had coexistent incarcerated abdominal hernia, II had a prepyloric lesion revealed by gastroscopy and III chronic constipation. X-rays and CT scan helped diagnosis. Operative findings: In case I, we found viable incarcerated bowel, gastric fundus and body strangulated in mediastinum, fundus ruptured, and antrum ischemic; total gastrectomy with esophageal and duodenal stapling were performed. In case II, the stomach with an obstructive prepyloric lesion was volvulized in mediastinum; distal gastrectomy, gastrojejunostomy, cruroraphy and fundopexy were performed. In case III, strangulation of the dolichosigmoid was the prominent feature, moreover, incarceration of gastric fundus and transverse colon in PEH sac were also found; reduction of PEH contents, limited resection of thick congenital bands, extended left colectomy, cruroraphy, fundopexy and caecopexy were performed. Results: Case I and II were transferred intubated to ICU. Case I was never stabilized, died after 50 hours; histology confirmed gastric necrosis. Case II was extubated on day 4, discharged on day 28; histology revealed antral ischemia and prepyloric pT2 adenocarcinoma. Case III had uneventful outcome; histology revealed dolichosigmoid ischemia. Follow-up of cases II and III (32 and 30 months respectively) has been uneventful. Conclusion: Obstructive conditions distal to large PEHs may lead to acute complications in hernia contents and emergent surgery is challenging. Obstructive conditions distal to large PEHs may lead to acute complications in hernia contents and emergent surgery is challenging.

Effect of Enhanced Recovery After Surgery Protocol Implementation on Cost and Outcomes by Type of Colectomy Performed.

Enhanced recovery after surgery (ERAS) protocols are widely utilized for elective colorectal surgery to improve outcomes and decrease costs, but few studies have evaluated the impact of ERAS protocols on cost with respect to anatomic site of resection. This study evaluated the impact of ERAS protocol on elective colon resections by site and longitudinal impact over time. A single-center retrospective cohort study of 598 consecutive patients undergoing elective colorectal resection before and after implementation of ERAS protocol from 2013 to 2017 was performed. The primary outcomes were length of stay (LOS) and cost. Comparative and multivariate inferential statistics were used to assess additional outcomes. A total of 598 patients (100 pre-ERAS vs 498 post-ERAS) were evaluated with an overall median LOS of 4 days for right and left colectomies and 3 days for transverse colectomies. When comparing type of resection before and after ERAS protocol introduction, an increased LOS for left hemicolectomies from 3.09 to 4.03 days (P = .047) was noted, with all other comparisons failing to reach statistical significance. Over time, an initial decrease in LOS for MIS approach after protocol introduction was observed; however, this effect diminished in the ensuing years and had no significant effect overall. Total cost of care was significantly increased post-ERAS for all cohorts except transverse colectomies. No further statistically significant differences were found. After an initial improvement in outcomes, continued utilization of ERAS protocols demonstrated no improvement in LOS compared to pre-ERAS data and increased cost overall for patients regardless of site of resection.

Simultaneous Sigmoid Colectomy, Bilobar Liver Resection and Lung Metastasectomy via a Transdiaphragmatic Approach for Stage IV Colonic Adenocarcinoma

Current evidence supports the curative resection of colorectal cancer and synchronous liver and lung metastases in selected patients.1,2 This video shows simultaneous left colectomy, bilobar liver resection, and lung metastasectomy via a transdiaphragmatic approach for stage IV colorectal cancer.3 PATIENT: A 57-year-old man with a stage IV colonic adenocarcinoma was considered for simultaneous resection of primary, liver, and lung metastases without thoracic incision. The tumor mutational status was KRAS, NRAS, and BRAF wild-type, and the patient underwent preoperative chemotherapy. After performing a midline laparotomy, atypical liver resection of segments 8/4a was performed under the guidance of intraoperative ultrasonography and intermittent Pringle maneuver using the two-surgeon's technique. A small capsular lesion in segment 3 also was intraoperatively detected and resected. Lung metastasectomy of the right lower lobe was performed via a transdiaphragmatic approach using an endoscopic stapler. Sigmoid colectomy with transanal circular-stapled anastomosis was performed. Duration of surgery and blood loss were 358min and 400ml, respectively. Histopathological examination showed metastatic colonic adenocarcinoma with negative surgical margins and final stage was T3N2aM1b. The patient was discharged on postoperative day 6without complication. He was alive and free of disease at 90-day follow-up. Simultaneous colon, liver, and lung resection via a transdiaphragmatic approach is a feasible and safe surgical strategy in selected patients with peripheral lung metastases and favorable tumor biology.4 This surgical strategy avoids thoracic incision, multiple operations, and may reduce the healthcare costs and the recovery time to early implement postoperative therapy.

Single-port laparoscopic Deloyers procedure for tension-free anastomosis after extended left colectomy or subtotal colectomy: A 6-patient case series.

Right colon-to-rectal anastomosis is performed in relatively rare conditions, including after subtotal colectomy or extended left hemicolectomy. One technique of tension-free anastomosis is the Deloyers procedure that includes cranio-caudal rotation of the right colon. As with other colon surgeries, the laparoscopic approach has been adapted for the Deloyers procedure. Nevertheless, due to its rare indications and technical specificity, only a small case series have been reported. Here, we report our experience with single-port laparoscopic (SPL) Deloyers procedures.Between June 2013 and March 2018, 6 patients underwent SPL Deloyers procedures. Three patients underwent SPL subtotal colectomy with ascending colon-to-rectal anastomosis for sigmoid colon cancer with chronic ischemic colitis, sigmoid colon cancer with left colon ischemia, and synchronous transverse and sigmoid colon cancer, respectively. The other 3 patients underwent SPL Hartmann reversal using the Deloyers procedure technique for 2 transverse colon end colostomies and 1 ascending colon end colostomy state, which were the result of a previous extended left hemicolectomy and subtotal colectomy, respectively. A commercially available single port was used with conventional straight and rigid laparoscopic instruments. The surgical procedures were similar to those performed during conventional laparoscopic surgery. For the anastomosis, the mobilized remaining ascending colon was rotated 180° counter-clockwise around the axis of the ileocolic pedicle. Tension-free colorectal anastomosis was then performed between the well-vascularized ascending colon and the rectal stump.The SPL Deloyers procedure was successful in all patients. No additional incisions for trocars or conversions to open surgery were necessary. The operative time and postoperative length of stay were 210 to 470 min and 8 to 21 days, respectively. No intraoperative complications were noted. There were 3 minor postoperative complications without anastomotic leakage. All patients had 2 to 3 bowel movements per day, and 1 patient regularly took loperamide at 6 months after surgery.The SPL Deloyers procedure was feasible and allowed patients to achieve good bowel movements. This operation may be considered an additional surgical option for experienced SPL surgeons in selected patients.

Short-term efficacy of totally laparoscopic left colon cancer radical resection with overlapped delta-shaped anastomosis technique

Objective: To evaluate the safety, feasibility and short-term efficacy of totally laparoscopic left colectomy for left colon cancer by using overlapped delta-shaped anastomosis technique for digestive tract reconstruction. Methods: A retrospective cohort study was conducted to collect the clinical data of 86 patients with left colon cancer who underwent laparoscopic surgery in Cancer Hospital of Chinese Academy of Medical Sciences from October, 2017 to February, 2019. The patients were divided into totally laparoscopic left-sided colectomy (TLLC) (treatment group, n=25 cases) and laparoscopic-assisted left-sided colectomy (LALC) (control group, n=61 cases). The intraoperative and postoperative data were compared between the two groups. Results: There were no surgical-related deaths in both groups. All the patients in the TLLC group underwent laparoscopic resection, while one patient in the LALC group transfer to open surgery. The operation time in TLLC group and LALC group were (164.5±42.3) min and (171.0±43.1) min, respectively, without statistically significant difference (P=0.516). However, the intraoperative blood loss of patients in the TLLC group was (36.4±22.7) ml, which was significantly less than (52.9±32.2) ml in the LALC group (P=0.026). The anastomosis time in the TLLC group was (39.1±6.5) min, which was significantly longer than (24.9±5.4) min in the LALC group (P<0.001). Postoperative exhaust time in the TLLC group was (2.6±0.5) days, which was significantly shorter than (3.3±0.8) days in the LALC group (P<0.001). The incision length in the TLLC group was (4.2±2.2) cm, significantly shorter than (7.0±2.5) cm in the LALC group (P<0.001). The length of the resected bowel was (21.0±7.3) cm in the TLLC group, which was significantly longer than (17.5±5.4) cm in the LALC group (P=0.037). The length of hospital stay in the TLLC group was (6.2±1.9) days, which was significantly shorter than (7.9±1.5) days in the LALC group (P<0.001). The incidences of postoperative complications in the TLLC group and LALC group were 0 and 4.9% (3/61), respectively, without statistically significant (P=0.553). No anastomotic complications occurred in both groups. During the follow-up period, neither group of patients was hospitalized again, and no tumor metastasis or recurrence occurred. Conclusions: It is safe and feasible to apply the TLLC with overlapped delta-shaped anastomosis in patients with left colon cancer. It has better short-term effects such as shorter incisions, faster recovery, and shorter postoperative hospital stays, and is worthy of further promotion.

Cirugía Robótica Colorectal, en un Hospital de Comunidad Cerrada. Experiencia Inicial

Introducción: La introducción del sistema Da Vinci, ha revolucionado el campo de la cirugía mínima invasiva en el cual el cirujano tiene control de la cámara 3D y los instrumentos son de gran destreza y confort ergonómico, acortando la curva de aprendizaje quirúrgica.Objetivo: Describir nuestra experiencia inicial de cirugía robótica colorectal en un hospital de comunidad cerrada de la Ciudad Autónoma de Buenos Aires.Materiales y Método: Estudio retrospectivo descriptivo sobre una base prospectiva de cirugías colorectales robóticas realizadas por el mismo equipo quirúrgico desde mayo de 2016 a abril de 2019.Resultados: Se operaron 41 pacientes. Trece de ellos fueron colectomías derechas, 17 colectomías izquierdas y 11 cirugías de recto. El tiempo quirúrgico promedio fue de 170 minutos (90-330), la estadía hospitalaria de 4 días (3-30), la tasa de conversión de 7,31% (3/41 pacientes) y la tasa de dehiscencia anastomótica del 9,75% (4/41 pacientes). Morbilidad global del 19.5% (8/41 pacientes).Conclusión: Hemos repasado los resultados iniciales de nuestra experiencia en cirugía robótica colorectal en un número reducido de casos, pero suficiente para evaluar la seguridad y reproducibilidad del método al comienzo de una curva de aprendizaje.