Left Colic Research Articles

Selective approach for splenic flexure mobilization in total mesorectal excision followed by low colorectal anastomoses

To evaluate the results of selective approach for splenic flexure mobilization (SFM) after total mesorectal excision with low colorectal anastomoses. Clinical data were obtained from the multicenter RCT database comparing ileostomy and colostomy in patients with rectal cancer who underwent total mesorectal excision from 2012 to 2017. Our clinic policy is performing paraaortic lymph node dissection with 'low' inferior mesenteric artery ligation, left colic artery preservation and use of sigmoid colon for colorectal anastomosis. SFM was used only in cases of inability to apply above-mentioned procedure (selective approach for SFM). SFM was performed in 15 (13%) out of 115 patients. The most frequent reasons for SFM were sigmoid colon diverticulosis, impaired blood supply or inadequate length of sigmoid colon. There were no differences in intraoperative and postoperative complications between TME without SFM and TME with SFM. Selective SFM in TME followed by advanced paraaortic lymph node dissection and left colic artery preservation is safe and may be considered as a viable option to routine SFM in rectal cancer surgery.

Efficacy and Safety of Transanal Tube Drainage for Prevention of Anastomotic Leakage Following Laparoscopic Low Anterior Resection for Rectal Cancers

Introduction: Laparoscopic surgery is widely used for the treatment of colorectal cancer. But anastomotic leakage is one of the most serious complications following laparoscopic low anterior resection (LAR) for rectal cancer. The purpose of this study was to investigate whether transanal drainage tube placement can reduce anastomotic leakage and avoid re-operation after laparoscopic LAR. Methods: Retrospective assessment was performed on 143 patients with rectal cancers who underwent laparoscopic LAR between April 2009 and March 2016. A diverting stoma was not created in all 143 patients. A transanal drainage tube was placed after anastomosis using a double stapling technique, in 90 patients (group TT). In group TT, a 24 Fr. Silicon catheter was inserted into the anus and was placed approximately 20 - 25 cm in the descending colon. Another 53 patients were operated on without a transanal drainage tube (group NTT). Clinicopathological and operative variables, the frequencies of anastomotic leakage and re-operation after leakage were investigated. Results: Between the two groups (Group TT and NTT), age, gender, body mass index, tumor size, Dukes’ stage, the number of Liniar stapler firings for rectal transaction, and the rate of left colic artery preservation were comparable. Intra-operative blood loss and operation time decreased group TT from group NTT (p < 0.05). The frequency of leakage was 2.8% (2/69) in group TT and was 13.2% (7/53) in group NTT. The rate of leakage was significantly lower in group TT (p = 0.03). Furthermore, the re-operation rate for symptomatic anastomotic leakage was 0% (0/2) in group TT, while in contrast it was 28.5% (2/7) in group NTT. The rate of re-operation was lower in group TT than group NTT (p = 0.07) and all cases with symptomatic leakage in group TT were cured by conservative treatment. There was no side effect of transanal drainage tube (perforation or bleeding of the colon, or deviation of the tube) in Group TT. Conclusions: Transanal drainage tube placement prevents anastomotic leakage after laparoscopic LAR. We regard the transnanal drainage tube to be safe and effective without side effect.

Stable gastric pentadecapeptide BPC 157 in the treatment of colitis and ischemia and reperfusion in rats: New insights.

AIMTo provide new insights in treatment of colitis and ischemia and reperfusion in rats using stable gastric pentadecapeptide BPC 157.METHODSMedication [BPC 157, L-NAME, L-arginine (alone/combined), saline] was bath at the blood deprived colon segment. During reperfusion, medication was BPC 157 or saline. We recorded (USB microscope camera) vessel presentation through next 15 min of ischemic colitis (IC-rats) or reperfusion (removed ligations) (IC + RL-rats); oxidative stress as MDA (increased (IC- and IC + RL-rats)) and NO levels (decreased (IC-rats); increased (IC + RL-rats)) in colon tissue. IC + OB-rats [IC-rats had additional colon obstruction (OB)] for 3 d (IC + OB-rats), then received BPC 157 bath.RESULTSCommonly, in colon segment (25 mm, 2 ligations on left colic artery and vein, 3 arcade vessels within ligated segment), in IC-, IC + RL-, IC + OB-rats, BPC 157 (10 μg/kg) bath (1 mL/rat) increased vessel presentation, inside/outside arcade interconnections quickly reappeared, mucosal folds were preserved and the pale areas were small and markedly reduced. BPC 157 counteracted worsening effects induced by L-NAME (5 mg) and L-arginine (100 mg). MDA- and NO-levels were normal in BPC 157 treated IC-rats and IC + RL-rats. In addition, on day 10, BPC 157-treated IC + OB-rats presented almost completely spared mucosa with very small pale areas and no gross mucosal defects; the treated colon segment was of normal diameter, and only small adhesions were present.CONCLUSIONBPC 157 is a fundamental treatment that quickly restores blood supply to the ischemically injured area and rapidly activates collaterals. This effect involves the NO system.

Evaluation of three-dimensional CT reconstruction on the anatomic variation of inferior mesenteric artery and left colic artery

To demonstrate the clinical applicability of three-dimensional CT angiography by evaluating the anatomic features and variation of inferior mesenteric artery(IMA) and left colic artery(LCA) in order to provide reference to vessel ligation strategy in laparoscopic rectal cancer surgery. Clinical and image data of 123 patients receiving abdominal multislice CT at The Sixth Affiliated Hospital from 2014 to 2015 were retrospectively analyzed. The images were 3D-reconstructed with computer 3D CT angiography and arterial enhancement phase images were chosen for analysis. Linear distances from IMA root to abdominal aortic bifurcation and from LCA at IMA root level to IMA root were measured. Branch types of IMA, coursing pattern of LCA, and association between LCA and inferior mesenteric vein (IMV) site were summarized. Of 123 cases, 80 were males and 43 were females, mean age was (46.8±16.6) years, body weight was (57.7±10.4) kg, and BMI was (21.3±3.6) kg/m2. The average distance from IMA root to abdominal aortic bifurcation was (42.5±7.9) mm, and this distance was closely associated with body weight (OR=4.771, 95%CI: 1.398 to 16.283, P=0.013). Longer distance tended to appear in the heavier patients. LCA and sigmoid artery (SA) originating from same single IMA was found in 61(49.6%) cases; LCA and SA forking at same point in 35(28.5%) cases; LCA and SA coursing together and forking afterwards in 24(19.5%) cases, and LCA disappearing in 3(2.4%) cases. In 71(57.7%) patients, LCA ascended medial to the lateral border of left kidney, while in 16(13.0%) patients, LCA arranged below the inferior border of left kidney. When the LCA site was higher and the distance from LCA to IMA root was closer [distance from LCA to IMA root level was (24.2±9.9) mm, (30.0±15.2) mm and (66.6±12.3) mm, F=83.2, P<0.001]. At the level of IMA root, LCA located medial to IMV in 21(17.1%) cases, located just lateral to IMV in 54(43.9%) cases, and located lateral and ascended far away from IMV in 48(39.0%) cases. 3D-CT angiography is non-invasive, efficient and accurate in evaluating coursing features and variation of IMA and its branches, which can provide important reference to the surgeons, promising laparoscopic surgery smooth and safe.

The long-term survival benefits of high and low ligation of inferior mesenteric artery in colorectal cancer surgery: A review and meta-analysis.

Background:The decision of ligation at the origin of the inferior mesenteric artery (IMA) or below the origin of the left colic artery (LCA) has remained a dilemma for surgeons in colorectal cancer surgery. The available studies are controversial. The objective of this meta-analysis is to compare the predictive significance of high versus low ligation in colorectal cancer surgery.Methods:A literature search done using Medline, EMBASE, GoogleScholar, and references. A meta-analysis was performed to analyze the 5-year overall survival (OS) of the high and low ligation using hazard ratio (HR) and 95% confidence interval (CI). We further analyzed 2 subgroups considering the level of lymph nodes (LNs) extension. That is IMA positive (+ve) and negative (−ve) LNs. Survival differences were analyzed.Results:A total of 3119 patients in 5 cohorts were included in this meta-analysis. The pooled HR results showed significant OS benefit of high ligation than low ligation (HR; 0.77, 95% CI: 0.66–0.89) in the “IMA +ve” group with 33% decreased risk, while there is no statistical significance in the “IMA −ve” (HR 0.66, 95% CI: 0.30–1.46) and the “all cases” group (HR 0.69, 95% CI: 0.41–1.15).Conclusion:The pooled data showed high ligation of IMA has a better survival benefit for the patients with IMA positive LNs. It signifies high ligation should be recommended for the advanced cases or with the suspected high risk of IMA lymphatic metastasis. The limited number of articles demands future high-powered, well-designed randomized controlled trials (RCTs) for the further reliable conclusion.

Strategy of laparoscopic surgery for colon cancer of the splenic flexure: a novel approach.

The splenic flexure (SF) anatomy is complex due to multiple vessels, surrounding organs, layers, and irregular adhesions [1-3]. Our laparoscopic approach involves a lateral-to-medial approach to the left-sided transverse mesocolon (TM), a medial-to-lateral approach to the left mesocolon (LM), and take-down of the remnant SF. First, the omental bursa is opened and its posterior wall and the anterior layer of the TM are dissected along the pancreas, where a gauze is placed. The TM is spread cephalad. A window in the TM is opened in the gauze seen through the TM. If necessary, the middle colic vessels are divided with lymph node (LN) dissection. Then the left colic artery is divided with LN dissection using a medial approach. The LM is widely dissected from the retroperitoneum to reach the TM window. While observing the pancreas through the window, the LM and TM are divided from the pancreas close to the SF. The descending colon is mobilized from its lateral attachment. Finally, the SF is taken down from the spleen by separating remnant structures, including adhesions. Subsequently, functional end-to-end anastomosis was performed extracorporeally. During March 2012-December 2016, 39 patients with left-sided transverse or descending colon cancer underwent this treatment. The mean operative time, blood loss, number of harvested LNs, and hospital stay duration were 283min, 45ml, 15, and 9 days, respectively. No patient needed conversion to open surgery or had organ injury, anastomotic leakage, or Clavien-Dindo III-V complications. There were 7/13/18/1 patients with Stage I/II/III/IV colon cancer, respectively. Nineteen cases had positive LNs. All patients were alive with one local and two distant recurrences at a mean 24-month follow-up. This is a safe and effective surgical strategy for treating colon cancer of the SF, strategically designed to resect the SF after dissecting the surrounding structures.

Clinical study of preserving left colic artery during laparoscopic total mesorectal excision for the treatment of rectal cancer

To evaluate the feasibility, safety, radicality and short-term outcome of preserving left colic artery (LCA) during laparoscopic total mesorectal excision (TME) for the treatment of rectal cancer. From January 2013 to December 2016,136 patients with mid-lower rectal cancer received laparoscopic TME in the Gastrointestinal Surgery Department of Taizhou People's Hospital of Jiangsu Province. Patients with rectal tumor within 10 cm to the anal verge were enrolled into the study. All the enrolled patients had complete data of pathology and follow-up. Those receiving neoadjuvant chemoradiotherapy, with severe base diseases, multifocal tumor, tumor invasion of surrounding tissues, fixation of tumor, recurrent tumor, complications such as acute ileus, bleeding, perforation were excluded. In this study, 72 patients did not undergo preservation of LCA (high ligation group) and 64 patients underwent preservation of LCA (low ligation group). Operative parameters, clinicopathological data and short-term outcome were collected and compared between two groups. The baseline data including gender, age, body mass index, tumor stage, and distance of tumor from anal verge of two groups were comparable (P>0.05). The differences between two groups about the mean time of operation and the operative blood loss were not significant [(164.0±12.6) min vs. (167.3±9.4) min, (30.0±3.6) ml vs. (30.1±3.0) ml, all P>0.05]. There was no operative death in both groups. Differences in the lymph node dissection (13.7±2.6 vs. 13.3±2.1) and the specimen length of proximal resection margin [(16.4±1.9) cm vs. (16.7±2.1) cm] or distal resection margins [(3.9±0.6) cm vs. (4.1±0.9) cm] between high and low ligation groups were not significant (all P>0.05). Compared with high ligation group, the low ligation group had higher rate of sphincter preservation [92.2% (59/64) vs. 79.2% (57/72), χ2=4.580, P=0.032], lower rate of anastomotic leakage [1.6% (1/64) vs. 9.7% (7/72), χ2=4.075, P=0.044], anastomotic stenosis [3.1% (2/64) vs. 12.5%(9/72), χ2=4.006, P=0.045], and voiding and sexual dysfunction [6.3%(4/64) vs. 18.1%(13/72), χ2=4.317, P=0.038]. Mean time of follow-up was 19 months. In high ligation group, the local recurrent rate was 5.56%, distant metastasis rate was 13.89%, overall survival rate was 90.28%, disease-free survival rate was 80.56%, while in low ligation group, the local recurrence rate was 4.69%, distant metastasis rate was 12.50%, overall survival rate was 90.63%, disease-free survival rate was 82.81%, whose differences between two groups were not significant (all P>0.05). Preservation of LCA during laparoscopic TME for the treatment of rectal cancer is safe and feasible, which can reduce the incidence of anastomotic leakage and stenosis, and voiding and sexual dysfunction.

Anatomical and embryological perspectives in laparoscopic complete mesocoloic excision of splenic flexure cancers.

Laparoscopic complete mesocoloic excision (CME) with central vascular ligation for splenic flexure cancer is technically challenging because of its anatomical complexity. Although embryological and anatomical consideration should be helpful to perform CME in colorectal cancer surgery, such studies on the splenic flexure are lacking. The splenic flexure is located embryologically between the terminal portion of the midgut and the beginning of the hindgut, and is supplied by the superior mesenteric and inferior mesenteric arteries. The mesentery of the transverse and descending colon originally is a continuous sheet, although they rotate and partially fuse to each other during development. Our surgical strategy was excision of the transverse and descending mesocolon with ligation of the left colic artery and left branch of the middle colic artery, and extraction of the specimen in an intact package wrapped by the embryological planes. We performed laparoscopic surgery according to our surgical strategy in 17 patients with splenic flexure colon cancer. There were no conversions to open surgery or serious intraoperative complications. Two patients had pathological stage (pStage) I, 5 pStage II, 9 pStage III, and 1 pStage IV disease. No patient had recurrence except for 1 with pStage IV cancer, with a median follow-up of 16months. Our laparoscopic CME technique is feasible for treatment of splenic flexure cancer. Knowledge of anatomy based on embryology is essential to perform this surgery.

Importance of the Moskowitz artery in the laparoscopic medial approach to splenic flexure mobilization: a cadaveric study.

The medial approach in laparoscopic splenic flexure mobilization is based on the entrance to the lesser sac just above the ventral edge of the pancreas (VEOP). The artery of Moskowitz runs through the base of the mesocolon, just above the VEOP. The aim of this study was to assess the incidence of the artery of Moskowitz, its route and its distance from the VEOP. We performed a cadaveric study on 27 human cadavers. The vascular arcades of the splenic flexure were dissected, the number of vascular arches, and the origin and localization of its terminal anastomosis were recorded. The splenic flexure avascular space (SFAS) was defined as the avascular zone in the mesocolon delimited by the VEOP, middle colic artery, ascending branch of the left colic artery and the vascular arch of the splenic flexure nearest to the VEOP and was quantified as the distance between the VEOP and the most proximal arch RESULTS: The artery of Drummond was identified in 100% of the cadavers. In 5 of 27 (18%) Riolan's arch was present, and in 3 of 27 (11%) the Moskowitz artery was found. The mean distance from the VEOP to the artery of Moskowitz was 0.3cm (SD 0.04). This vascular arch travelled from the origin of the middle colic artery to the distal third of the ascending branch of the left colic artery. The SFAS was greater (p=0.001) in cadavers that only presented the artery of Drummond (mean 6.8cm; SD 1.25) than in those with Riolan's arch (mean 4.5cm; SD 0.5) CONCLUSIONS: In the medial approach for laparoscopic mobilization of the splenic flexure, when only one of the arches is present, the avascular area is an extensive and secure territory. If the artery of Moskowitz is present, the area is nonexistent and this would contraindicate the approach due to risk of iatrogenic bleeding. A radiological preoperatory study could be essential for accurate and safe surgery in this area.

Long-term outcomes of laparoscopic low anterior resection of rectal carcinoma with preservation of the left colic artery

To investigate the long-term outcomes of laparoscopic low anterior resection of rectal carcinoma with preservation of the left colic artery(LCA). Clinicopathological and follow-up data of 322 cases with rectal carcinoma undergoing laparoscopic low anterior resection in Department of General Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University from January 2007 to December 2011 were retrospectively analyzed. According to the different surgical methods of inferior mesenteric artery (IMA), cases were divided into the trial group (LCA preservation plus lymph nodes around IMA root dissection, 168 cases) and the control group(origin of IMA ligation, 154 cases). The 5-year rates of disease-free survival(DFS) and overall survival(OS) were compared between two groups. There were no statistically significant differences in the baseline data between the two groups. The follow-up rate was 91.1%(153/168) during 5-60 months in the trial group, and 90.3%(139/154) during 6-60 months in the control group. The number of patients who developed death, local recurrence and metastasis were 49(32.0%), 9(5.9%) and 62(40.5%) in the trial group, and 44(31.7%), 9(6.5%) and 52(37.4%) in the control group, respectively, without significant differences(all P>0.05). The 5-year DFS and OS rates were 57.2% and 69.5% in the trial group, and 59.7% and 70.1% in the control group, and the differences were not significant between the two groups(all P>0.05). After stratification by TNM stage, the 5-year DFS rates of I( stage, II( stage and III( stage were 80.4%, 62.5% and 45.1% in the trial group, and 82.6%, 66.0% and 48.8% in the control group; the 5-year OS rates of I( stage, II( stage and III( stage were 90.2%, 76.2% and 56.7% in the trial group, and 94.4%, 74.3% and 60.5% in the control group, respectively, and the differences were not significant as well (all P>0.05). The long-term outcomes after laparoscopic low anterior resection of rectal carcinoma with preservation of LCA and dissection of lymph nodes around root of IMA are comparable with ligation at origin of IMA.

Anatomical studies on the cranial and caudal mesenteric arteries of the Barbados Black Belly sheep

Abstract Introduction: The Barbados Black Belly is a breed of domestic sheep in the Caribbean island of Trinidad. Anatomical studies on the cranial and caudal mesenteric arteries are necessary to know the pattern of its blood supply to gain information in benefit of experimental surgery. Materials and Methods: The thoracic part of the aorta of five sheep was injected with red latex. Careful gross dissection of the cranial and caudal mesenteric arteries was performed either after embedding in 10% formalin solution for 2-3 days. Results: The cranial mesenteric artery originated from the abdominal aorta, caudally to the celiac trunk, giving caudal duodenal artery, jejunal arteries, ileal arteries, ileocolic artery and middle colic artery. The caudal mesenteric artery arises from the aorta, cranially to the external iliac arteries, originating the left colic and cranial rectal arteries. Conclusion: cranial and caudal mesenteric arteries supplied the small and large intestine of the Barbados Black Belly sheep except caudal part of the large intestine which were supplied by the middle and caudal rectal arteries.

Splenic flexure cancer optimum level of vessel ligation

Background: Incidence of splenic flexure carcinoma is very low in colorectal cancer but often time presented in an advanced stage with high risk of obstruction, contributing poor prognosis. Aim of the study was to investigate the adequacy of vessel ligation in SFC in term of overall survival.Methods: 35 patients diagnosed with splenic flexure carcinoma enrolled and analyzed, patients categorized based on the level of vessel ligation as group-A, left branch of middle colic (LMA) and left colic artery division (LCA) compared, group-B, LCA and marginal of middle colic artery (MMC).Results: CEA marker was not significantly changed post-operatively, as it was within normal range preoperatively at an average of 9-12 µg/ml. There is no significance in staging of tumors in all stages, and recurrence of tumor is present in 5 in group A. Radical margins both proximal and distal ends are not significant. Tumor clearance achieved successfully in both arms in term of proximal margin achieved at 7.9±3.5cm in groups B and 8.3±4.1 cm in group A, p = 0.312. Distal margin reported at 8.7±4.1 cm and 8.9±3.98cm, p = 0.58, respectively. Lymph nodes are positive in group-A and group-B without any significance. Tumor size or diameter ranging from 5.1±3.1 in group-A and 4.76±3.8 in group-B. According to the cell differentiation, majority of the tumor grade turned out to be moderately differentiated cancer, rated at 14 patients (40.1%) in group A and 13 patients (37.1%) in group B. one patients found to be well or poorly differentiated cell tumors in group-A. Overall p-values were insignificant in regards tumor cell differentiation in both groups, p = 0.213. Incidence of lympho-vascular invasion reached only 3 (8.5%) vs. 4 patients (11.2%), p = 0.562, in A and B group.Conclusions: Higher level of vessel ligation has no added significance in overall outcome, but has role to lower the risk of recurrence rate in Splenic flexure carcinoma patients.

Anatomic variations of inferior mesenteric artery and left colic artery evaluated by 3-dimensional CT angiography: Insights into rectal cancer surgery – A retrospective observational study

ObjectiveTo demonstrate the clinical applicability of 3-dimensional CT angiography (3D-CTA) in evaluating the anatomic variations of inferior mesenteric artery (IMA) and left colic artery (LCA), to help make pre-operative strategies of rectal cancer surgery. Methods188 patients with abdominal and pelvic contrast-enhanced CT scan were retrospectively enrolled and 3D-CTA was reconstructed. The origin and branching patterns of IMA, tracking patterns of LCA, intersectional patterns among IMA, LCA and inferior mesenteric vein (IMV) were examined, and their associations with clinical features were analyzed. ResultsThe origin of IMA was located 42.1 ± 7.7 mm above iliac artery bifurcation, 64.4% within the area of the 3rd lumbar vertebra. 47.3% of LCA arose independently from IMA, 27.1% arose at the root of sigmoid artery (SA), 20.7% shared a common trunk with SA while 4.8% of LCA was absent. As for track of LCA before anastomosis with marginal artery, 53.2% went straight upward while medial to the inner border of left kidney (Type A), 27.1% traveled diagonally across left kidney (Type B) and14.9% went infero-laterally to the lower border of left kidney (Type C). Short IMA trunk was independently associated with type A LCA and lower site of IMA origin. At the horizontal level of IMA origin, 29% of the LCA went distant from IMV, while 71% (21% medial, 50% lateral) were mutually close, and the close type was independently associated with type A LCA. ConclusionPreoperative understanding of the vascular variations and the mutual relationship among LCA, IMA and IMV could be obtained by 3D-CTA, which would further help surgeons to set detailed plans for laparoscopic rectal cancer surgery.

Three Different Approaches to the Inferior Mesenteric Artery during Robotic D3 Lymphadenectomy for Rectal Cancer.

In rectal cancer surgery, proximal ligation of the inferior mesenteric artery (IMA) with radical lymphadenectomy is the accepted standard of care.1 Our purpose is to describe three different standardized technical approaches for the management of the IMA during D3 lymphadenectomy.2 METHODS: Operative videos of three robotic D3 lymphadenectomy procedures for rectal cancer were reviewed and annotated with schematic anatomical descriptions for clarification. There are three methods for the management of the IMA during D3 lymphadenectomy for rectal cancer. Standard high ligation is technically the simplest to perform and provides excellent mesenteric length but relies solely on marginal vessel blood supply from the middle colic artery.3 Low ligation with ascending left colic artery preservation is more complex technically but affords excellent vascular supply due to preservation of IMA blood flow, while potentially limiting mesenteric length.4 The central vascular sparing technique is the most complex to perform but allows excellent mesenteric length due to the presence of two separate points of mesenteric division, while also potentially improving blood supply due to decreased vascular resistance and improved collateralization. With each technique, central ligation of the inferior mesenteric vein above the splenic flexure tributary is performed to release the mesentery. The three methods to manage the IMA vary in their technical complexity, preservation of colonic conduit blood supply, and provision of mesenteric length, with associated advantages and disadvantages. The choice of technique is dependent on anatomical and oncological considerations.

Ischemic colitis following left antegrade sclerotherapy for idiopathic varicocele: the role of forensic clinical anatomy

Introduction. The Tauber procedure, i.e. antegrade sclerotherapy for varicocele, can be complicated by ischemic colitis. Its possible pathogenesis is referred to the presence of an atypical kind of portal-systemic communication, which could represent an unfrequently reported anatomic variant. Aim of this study is to solve this anatomical controversy of utmost clinical usefulness. Materials and methods. A computer-aided and hand-checked systematic review of the literature was implemented to identify relevant publications on the topic. Moreover, we reviewed the computed tomography CT-scan of a clinical case with medico-legal implications due to severe vascular complication following Tauber’s procedure. Results. Despite specific References were made on the issue in more dated hardbacks since the 19th century, only a few clinical cases reporting an ischemic colitis following the Tauber’s procedure were found in contemporary literature. By reviewing the CT-scan images of a filed lawsuit we found traces suggestive for the presence of a significant communication between the internal spermatic and the left colic vein, as part of the portal-systemic anastomoses. Conclusions. A significant anatomical finding identified in the past have been under-reported and subsequently underestimated in its clinical value. For the first time we demonstrated its pathophysiological role in a real clinical scenario, coupling the anatomical variation to the clinical complication hence stressing that its knowledge is of utmost importance to raise the scientific awareness and to prevent possible devastating complication in clinical daily practice. Progress in the medical field coupled with increased medical-legal awareness has supported the ripening of clinical anatomy and forensic clinical anatomy, whose multidisciplinary represents the best way to recover and hand down the medical knowledge at risk of being forgotten.

Evaluating distribution of the left branch of the middle colic artery and the left colic artery by CT angiography and colonography to classify blood supply to the splenic flexure.

CT angiography has gained widespread acceptance for preoperative evaluation of blood supply in patients with colorectal cancer. However, there have been few reports that pertain to the splenic flexure, for which surgery is technically difficult. We used preoperative CT angiography and CT colonography to evaluate blood supply to the splenic flexure. We defined the splenic flexure as the junction of the distal third of the transverse colon and the proximal third of the descending colon. We reviewed 191 cases and considered the descending colon as divided into the proximal third and the distal two-thirds; we then determined which part of the descending colon the left colic artery (LCA) entered. We also considered the transverse colon as divided into the proximal two-thirds and the distal third, and evaluated which part of the transverse colon the left branch of the middle colic artery entered. We classified blood supply to the splenic flexure into six types, described by the feeder vessels: type 1, the LCA (39.7%); type 2, the left branch of the middle colic artery (17.8%); type 3, the LCA and the left branch of the middle colic artery (9.9%); type 4, the accessory left colic artery (4.1%); type 5, the LCA and the accessory left colic artery (2.6%); and type 6, the marginal artery (25.6%). We classified blood supply to the splenic flexure into more complex types than previous reports had. Because we dissect the lymph nodes according to the type of blood supply, knowing the type before splenic flexure surgery is crucial.

Laparoscopic anterior resection of rectal cancer with lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery (LAR-LND-PLCA)

Background: Laparoscopic anterior resection of rectal cancer with lymph node dissection around the inferior mesenteric artery (IMA) with preservation of the left colic artery (LAR-LND-PLCA) is a highly difficult operation. According to our rich experiences of laparoscopy surgical techniques recent years, we can proficiently master the surgical techniques and difficulties of LAR-LND-PLCA base on the anatomy of blood vessels and the interfacial space. Methods: A 59-year-old patient who was diagnosed as rectal cancer underwent LAR-LND-PLCA. Combined with this case, we share the surgical technology of LAR-LND-PLCA base on our experience. Results: The length of operation was 120 min with bleeding of about 50 mL. The patient recovered well postoperation and discharged from hospital on the 7th day. Conclusions: LAR-LND-PLCA is effective and safe for the rectal cancer. Because it is too difficult, so it must be done in the rich experienced hospital.

Variations in the branching pattern in inferior mesenteric artery: a series of five cases

Abstract Introduction: Inferior mesenteric artery arises from abdominal aorta just below the third part of duodenum at the level of L3-L4 vertebra. It supplies left colon and rectosigmoid colon through its branches namely- left colic artery, two-three sigmoid arteries and superior rectal artery. The branching pattern of inferior mesenteric artery is of immense use in colon surgery. Material and Methods: The study was carried out in the department of anatomy by dissecting seven embalmed cadavers. The inferior mesenteric artery and its branches were identified; its vertebral level was analysed. The length and diameter of inferior mesenteric artery were measured by vernier callipers. Results: In first case, bifurcation of inferior mesentric artery into common trunk and main artery then trifitrcation of main artery and bifurcation of common trunk belong to anomalous configuration. In second case, this artery gave a tetrafitrcated common trunk and main artery which continued as superior rectal artery. In third case, the same artery trifurcated into left colic, superior rectal artery and bifurcated common trunk. In fourth case, the artery bifurcated into common trunk further dividing into left colic and sigmoid arteries and main artery into superior rectal and sigmoid arteries. In fifth case, this artery trifitrcated into three branches namely, sigmoid, rectosigmoid, and superior rectal arteries. Left colic artery arose from superior mesenteric artery. Conclusion: The knowledge of branching pattern of inferior mesenteric artery will be of paramount importance to colon surgeons during colectomy, to radiologists in avoiding misinterpretation of radiographs and anatomists for new variants.

Evaluation of lymph flow patterns in splenic flexural colon cancers using laparoscopic real-time indocyanine green fluorescence imaging

The treatment of splenic flexural colon cancer is not standardized because the lymphatic drainage is variable. The aim of this study is to evaluate the lymph flow at the splenic flexure. From July 2013 to January 2016, consecutive patients of the splenic flexural colon cancer with a preoperative diagnosis of N0 who underwent laparoscopic surgery were enrolled. Primary outcome is frequency of the direction of lymph flow from splenic flexure. We injected indocyanine green (2.5mg) into the submucosal layer around the tumor and observed lymph flow using the laparoscopic near-infrared camera system in 30min after injection. Thirty-one patients were enrolled in this study. The lymph flow was visualized in 31 patients (100%) without any complications. No case exhibited lymph flow in both the left colic artery (LCA) and left branch of the middle colic artery (lt-MCA) areas. There were 19 cases (61.3%) with lymph flow directed to the area of the root of the inferior mesenteric vein (IMV), regardless of the presence of the left accessory aberrant colic artery. Lymph node metastases were observed in six cases (19.4%), and all of the involved lymph nodes existed in lymph flow areas determined by real-time indocyanine green fluorescence imaging. The findings of the lymph flow pattern of splenic flexure suggest that lymph node dissection at the root of the IMV area is important, and it may be not necessary to ligate both the lt-MCA and LCA, at least in cases without widespread lymph node metastases.

Preservation of left colic artery in laparoscopic radical operation for rectal cancer

To evaluate the clinical significance of low ligation of inferior mesenteric artery (IMA) and preservation of left colic artery in laparoscopic radical operation for rectal cancer. Clinical data of 103 rectal cancer patients undergoing laparoscopic radical operation in Ruijin Hospital from May 2015 to January 2016 were retrospectively analyzed, including 61 cases with preservation of left colic artery (low ligation group, LL group) and 42 cases without preservation of left colic artery (high ligation group, HL group). Clinical conditions during operation and after operation were compared between the two groups. All the patients underwent operation successfully without transferring to laparotomy, intra-operative or post-operative death, and severe intra-operative or anesthetic complications. Age, gender, BMI, ASA score, tumor size and tumor location were not significantly different between the two groups. Four cases(9.5%) in HL group presented ischemic changes in colonic stump during operation, receiving additional colonic resection and no such ischemic changes were found in LL group (P=0.025). The number of harvested lymph node was 16.1±6.8 in HL group and 15.5±7.2 in LL group, number of harvest lymph node in the root of IMA was 4.2±1.7 in HL group with positive rate of 9.5%(4/42) and 4.3±1.7 in LL group with positive rate of 4.9%(3/61), both were not significantly different between the two groups. Lower margin was (2.2±1.4) cm in LL group and (2.8±1.7) cm in HL group, and difference was not significant as well(all P>0.05). There were no significant differences in terms of operation time, blood loss, post-operative complication, recovery of bowel movement and hospital stay. Median follow-up time was 4.5 months(2 to 10 months) and no long-term complications and local recurrence were found. Low ligation of IMA with preservation of left colic artery in laparoscopic radical operation for rectal cancer can provide better blood supply for proximal colon and anastomosis, and can achieve same radical clearance of lymph nodes as high ligation without prolonged operation time, which is worth clinical promotion.