Postoperative Diarrhea Research Articles

Postoperative Use of Antibiotics in Adults with Non-perforated Appendicitis Subjected to Open Appendectomy

Acute appendicitis is the most common cause of acute abdominal pain necessitating appendicectomy. The aim of this study was to determine the role of postoperative antibiotics in non-perforated appendicitis regarding; superficial site infections (SSIs), deep site infections (DSIs), complications and the length of hospital stay. This prospective study was carried out on 112 patients diagnosed as acute appendicitis at the Emergency Hospital, General Surgery Department, Tanta University Hospital from March 2014 to April 2016. The patients classified into two groups: Group 1: patients who received postoperative antibiotics, these included 55 patients and Group 2: patients who did not receive postoperative antibiotics and these included 57 patients. The patients subjected to open appendectomy through a standard Grid-Iron incision. The patients' characteristics, ultrasound findings, antibiotics regimen, operative diagnosis, length of hospital stay, wound infection, complications and histopathological findings were analysed using SPSS V 20. Out of 112 patients, 72 patients were male and 40 patients were female. The patients' age ranged from 18 to 55 years with a mean age of 26 years. There is no significant difference regarding patient's age, sex, medical comorbidities, fever, radiologic findings or operative time between the two groups. Treatment with postoperative antibiotics did not significantly reduce the risk of developing superficial SSIs, DSIs. The patients received postoperative antibiotics were significantly more likely to sustain urinary tract infection (P=0.03) a postoperative diarrhea (P = 0.02), increased risk of Clostridium difficile infection (P =0.01) with higher rates of both readmission (P= 0.08) and reoperation (P = 0.07) with a significantly longer hospital stay (2.6 vs 1.4 days, P = 0.001). The use of postoperative antibiotic treatment for nonperforated appendicitis did not reduce the infectious complications while increasing postoperative morbidity and increase the length of hospital stay.

Transanal Endoscopic Microsurgery Combined with Laparoscopic Colectomy for Synchronous Colorectal Tumors: A Word of Caution.

The incidence of malignant synchronous colorectal tumors (SCRT) is between 2% and 5%, and the association of synchronous adenomatous polyps in colon cancer has been reported to be 15%-50%. Surgical resection is the primary treatment option for SCRT not amendable to endoscopic resection. Lesions in adjacent segments are usually treated with more extensive resection; however, there is still some controversy on how to best treat synchronous lesions in separate segments, especially when the rectum is involved. In this study, we aimed to report the outcome of patients with SCRT treated by laparoscopic colectomy combined with Transanal Endoscopic Microsurgery. Data pertaining patients undergoing combined colectomy and Transanal Endoscopic Microsurgery (TEM) between 2004 and 2014 were retrospectively collected. 141 TEM performed in the study period, 9 (6.5%) with combined laparoscopic colectomy were included. Mean age was 69.1 ± 10.6 years. There were 6 (66%) right, 2 (22%) left, and one (11%) sigmoid colectomy. All rectal lesions were benign adenomas, with mean tumor size 2.5 cm, and distance from the verge 9 ± 2.5 cm. Lesions were located in lateral rectal wall in 4, posterior in 4, and anterior in one case. Seven patients had the colectomy before TEM, and 2 had the TEM first. Mean operative time was 245 minutes (range 185-313) for the combined procedures. Median time of hospitalization was 6 days (range 4-11). Six patients (66%) had prolonged postoperative diarrhea. The final rectal pathology reports were adenoma with high-grade dysplasia (HGD) in 5 patients and adenoma with low-grade dysplasia in four cases. The colon pathology was T1 N0 in 3, T2 N0 in one, T3 N1 in one, adenoma with HGD in 2, and no residual tumor in 2 patients. Two patients underwent re-TEM for recurrent adenoma of rectum at 14 and 18 months postoperatively. The combination of TEM with laparoscopic colectomy is feasible and should be kept in mind as an alternative procedure in case of SCRT. However, more strict selection criteria should be considered and the disadvantages should be discussed with the patient.

The role of single-shot metronidazole in the prevention of Clostridium difficile infection following ileostomy reversal surgery

Symptomatic infection with Clostridium difficile is strongly linked to antibiotic use and rates are higher for colorectal surgery. In February 2015, trust policy for antibiotic prophylaxis of ileostomy reversal surgery was changed from three doses of metronidazole plus cefuroxime to single-dose metronidazole, in a bid to reduce rates of Clostridium difficile infection. A retrospective cohort study was conducted at a single, large hospital trust between February 2014 and February 2016, before and after change in antimicrobial policy. Theatre data, clinical notes and pathology results were all reviewed. Outcome data, patient age, gender, length of operation and hospital stay were extracted. One hundred three patients underwent ileostomy reversal surgery between February 2014 and February 2015. All received cefuroxime together with metronidazole at induction of anaesthesia followed by two further post-operative doses as operative prophylaxis. Ninety-six patients underwent ileostomy reversal surgery between February 2015 and February 2016. All received single-dose metronidazole at induction as prophylaxis. Post-operative diarrhoea was significantly reduced in patients given single-dose metronidazole compared with patients managed with multiple dose, dual antibiotic therapy (32 vs 12.5%, P 0.001). Rates of CDI were also significantly reduced in patients given single-dose metronidazole (6.8 vs 1%, P 0.038). Single-dose, pre-operative metronidazole is effective at reducing post-operative diarrhoea and CDI in ileostomy reversal surgery compared with multiple-dose cefuroxime plus metronidazole. Metronidazole may be effective as a prophylactic antibiotic against CDI in colonic surgery.

THE ROLE OF ANTIBIOTIC PROPHYLAXIS IN PREVENTION OF INTESTINAL STOMAS CLOSURE

AIM. To evaluate the effectiveness of antibiotic prophylaxis in closure of preventive intestinal stomas. MATERIALS AND METHODS. In a main (I-first) group included 99 patients who did not undergo antibiotic prophylaxis (ABP). In the control (II-second) group were 96 patients who underwent ABP by a single intravenous injection of 1,2 g of amoxycillin / clavulanic acid in 30 minutes before the operation. RESULTS. The overall incidence of complications in the main and control groups was 23 (23,3 %) and 27 (27,9 %), respectively (p=0,53). Among them, the surgical site infection (SSI) was the first place in the frequency of complications: in group I in 12 (12,2 %) in group II in 11 (11,4 %) patients (p=0,35 ). Postoperative diarrhea with frequency of stools 5 or more times per day in second place infrequency, but has evolved into two less in the main than in the control group - in 4 (4,0 %), and 8 (8.3 %) patients, respectively (p=0,212). Febrile fever was detected more frequently in the first group than in the second - 6 (6,1 %) and 1 (1,0 %) cases, respectively (p=0,06). Other complications were the paresis of gastrointestinal tract (p=0,76), bleeding from the formed anastomosis area (p=0,149), pneumothorax (p=0,324), cystitis (p=0,309) and lobar pneumonia (p=0,309). There were no statistically significant complications associated with one of two groups. CONCLUSION. The results of the study not prove the effectiveness of the ABP in patients undergoing closure preventive intestinal stoma. This does not allow us to recommend its routine use. The question of prophylactic antibiotics should be taken individually, considering all the possible risks.

Distal Pancreatectomy With En Bloc Celiac Axis Resection for Locally Advanced Pancreatic Cancer

Although distal pancreatectomy with en bloc celiac resection (DP-CAR) is used to treat locally advanced pancreatic cancer, the advantages and disadvantages of this surgical procedure remain unclear. The purpose of this study was to evaluate its clinical safety and efficacy.Studies regarding DP-CAR were retrieved from the following databases: PubMed, EMBASE, Web of Science, Cochrane Library, and Chinese electronic databases. Articles were selected according to predesigned inclusion criteria, and data were extracted according to predesigned sheets. Clinical, oncologic, and survival outcomes of DP-CAR were systematically reviewed by hazard ratios (HRs) or odds ratio (OR) using fixed- or random-effects models.Eighteen studies were included. DP-CAR had a longer operating time and greater intraoperative blood loss compared to distal pancreatectomy (DP). A high incidence of vascular reconstruction occurred in DP-CAR: 11.53% (95%CI: 6.88-18.68%) for artery and 33.28% (95%CI: 20.45-49.19%) for vein. The pooled R0 resection rate of DP-CAR was 72.79% (95% CI, 46.19-89.29%). Higher mortality and morbidity rates were seen in DP-CAR, but no significant differences were detected compared to DP; the pooled OR was 1.798 for mortality (95% CI, 0.360-8.989) and 2.106 for morbidity (95% CI, 0.828-5.353). The pooled incidence of postoperative pancreatic fistula (POPF) was 31.31% (95%CI, 23.69-40.12%) in DP-CAR, similar to that of DP (OR = 1.07; 95%CI, 0.52-2.20). The pooled HR against DP-CAR was 5.67 (95%CI, 1.48-21.75) for delayed gastric emptying. The pooled rate of reoperation was 9.74% (95%CI, 4.56-19.59%) in DP-CAR. The combined 1-, 2-, and 3-year survival rates in DP-CAR were 65.22% (49.32-78.34%), 30.20% (21.50-40. 60%), and 18.70% (10.89-30.13%), respectively. The estimated means and medians for survival time in DP-CAR patients were 24.12 (95%CI, 18.26-29.98) months and 17.00 (95%CI, 13.52-20.48) months, respectively. There were no significant differences regarding postoperative 1-, 2-, and 3-year survival rates between DP-CAR and DP, whereas DP-CAR had a better 1-year survival rate compared to palliative treatments. The pooled HR for overall survival between DP-CAR and DP was 1.36 (95%CI: 0.997-1.850); the pooled HR favoring DP-CAR was 0.38 (95%CI: 0.25-0.58) for overall survival compared to palliative treatments. The rate of cancer-related pain relief from DP-CAR was 89.20% (95%CI, 77.85-95.10%). The pooled incidence of postoperative diarrhea was 37.10% (95%CI, 20.79-57.00%); however, most diarrhea was effectively controlled.DP-CAR is feasible and acceptable in terms of its survival benefits and improved quality of life. However, it should be performed with caution due to its high postoperative morbidity.

Effect of elevated intra-abdominal pressure on acute gastrointestinal injury in laparoscopic colorectal surgery: a prospective study

Effect of elevated intra-abdominal pressure on acute gastrointestinal injury in laparoscopic colorectal surgery: a prospective study

The Role of Laparoscopic Total Colectomy in Treatment of Slow- Transit Constipation: A Prospective Study

Background: Patients with intractable chronic constipation should be evaluated with physiologic tests after structural disorders, and extracolonic causes have been excluded. Conservative treatment options should be tried excessively. If surgery is indicated, subtotal or total colectomy with ileorectal anastomosis is the treatment method of choice. Patients and methods: In this prospective study, 7 patients were reviewed including patient demography, clinical manifestations, preoperative investigations, operative procedure, intraoperative and postoperative complications, and postoperative follow up. All patients enrolled in the study underwent laparoscopic total colectomy (LTC), with ileorectal anastomosis (IRA). Average age of the patients was (35±15.8 years), average operative time was (80±30 min), average blood loss was (75±30 ml), average hospital stay was (6±2.5 days). Results: 7 patients in our study were diagnosed to have slow-transit constipation via history, clinical examination, colonoscopy and barium enema to rule out structural disorders, colonic motility study, anorectal manometry, colonic transit time, and defecography. All patients underwent LTC with IRA after failure of conservative treatment. 3 patients(42.8%) had postoperative diarrhea which resolved spontaneously after 2 weeks, 1 patient (14.2%) had wound infection, 1patient(14.2%) had minor anastomotic leak which subsided on conservative treatment.2 patients had abdominal pain and bloating which improved gradually,1 patient had recurrent constipation which was improved on laxatives, median number of motions/day was 3, with median satisfaction and success rate of about 82%. Conclusion: Laparoscopic treatment of slow-transit constipation seems to be safe, feasible, and effective procedure with satisfactory results, with minimal postoperative complications, short hospital stay, with a faster return to social activity, along with a better cosmetic results and good functional results.

Postoperative diarrhea and high ostomy output impact postoperative outcomes after elective colon and rectal operations regardless of Clostridium difficile infection

BackgroundWe aimed to review and compare outcomes of patients with and without Clostridium difficile infection (CDI) after elective colorectal operations. MethodsRetrospective cohort study of patients with CDI after elective colon and rectal operations from 2007 to 2012 (Group A) was conducted. Outcomes were compared with patients with a negative C. difficile toxin assay performed for postoperative diarrhea or high stoma output (Group B) and matched controls (Group C). ResultsForty-four patients (median age 53 years) developed CDI postoperatively (Group A). Fourteen patients (32%) had surgical site infections. Both Group A and Group B patients received ertapenem as preoperative antibiotic prophylaxis significantly more often than matched controls (P < .0001), and also had significantly more surgical site infections (P = .004), longer hospital stays (P = .003), and more readmissions (P = .02) compared with Group C patients. ConclusionsIn this study, postoperative CDI was uncommon, of low morbidity, and no mortality. Postoperative diarrhea and high stoma output, whether in patients who are C. difficile positive or not, appear to impact postoperative outcomes.

Effects of the combination therapy of the West and Taditional Chineses Medicine for 59 acute appendicitis patients with postoperative diarrhea

Objective To find out the efficacy of the combination therapy of the West and Taditional Chineses Medicine for acute appendicitis patients with postoperative diarrhea. Methods According to the digital table, 109 acute appendicitis patients with postoperative diarrhea were randomly divided into 59 cases of the treatment group and 50 cases of the control group. The control group were given with the conventional therapy and Western medicine therapy, and the treatment group were given with the Traditional Chinese Medicine based on the control group. Test results of stool specimens pathogen, the efficacy and the occurrence of adverse drug reactions were observed. Results 96 pathogens were detected in stool specimens of the two groups of patients, the four pathogens with the largest constituent ratios were Vibrio, Shigella, Aeromonas and Proteus,and the constituent ratio were respectively 36.5%,22.9%,18.8% and 11.5%.The remarkable effective rate and total efficiency of the treatment group was 83.1%,96.6%,respectively, which were significantly higher than 58.0%,84.0% of the control group(χ2= 8.426,4.598,all P 0.05). Conclusion The efficacy of the combination therapy of the West and Waditional Chineses Medicine for acute appendicitis patients with postoperative diarrhea was significant effect, and the incidence of adverse drug reactions was less. Key words: Appendicitis; Postoperative Complications; Diarrhea; Medicine,Chinese Traditional

Lanreotide Autogel in the Treatment of Persistent Diarrhea following a Total Colectomy.

Diarrhea is one of the most common complications following colectomy in patients with slow transit constipation (STC). Early postoperative diarrhea is usually treated with opioid agonists; however, to date, published data on the management of persistent diarrhea after colectomy for STC are scarce. Here, we report a case of severe diarrhea after a total colectomy with ileorectal anastomosis. One year after the surgery, the patient presented with persistent diarrhea. Treatment with a long-acting somatostatin analogue, lanreotide Autogel, was initiated. One month after the first injection of lanreotide Autogel the diarrhea was resolved. The patient's stool transit was markedly improved (type 4 or type 5 according to the Bristol Stool Chart compared to type 7 before the treatment), positively affecting the patient's quality of life (mean score of 2.1 on the Irritable Bowel Syndrome Quality of Life questionnaire compared to 3.9 before the treatment). This case report describes a successful use of lanreotide Autogel in a patient with persistent diarrhea after a total colectomy.

Complications after Loop Ileostomy Closure: A Retrospective Analysis of 132 Patients

Background: Closure of a loop ileostomy is a relatively simple procedure although many studies have demonstrated high morbidity rates following it. Methods to reduce the number of complications, such as timing of closure or different surgical closure techniques, are investigated. The aim of this study was to evaluate the experience of the Abdominal Surgery Center at Vilnius University Hospital (VUH) ‘Santariskiu klinikos' to review the complications after closure of loop ileostomy and to identify potential risk factors for postoperative complications. Methods: Data from 132 patients who underwent closure of loop ileostomy from 2003 to 2013 at the Abdominal Surgery Center of VUH were collected, including demographics, causes of ileostomy formation, additional diseases, time from creation to closure of ileostomy, anastomotic technique, duration of the operation, postoperative complications, and hospital stay after surgery. The operations were performed by 15 surgeons with varying experience assisted by surgical residents. Experience in ileostomy closure was defined by the number of procedures performed. Results: Complications occurred in 24 patients (18.2%), with 20 of them having surgical complications: bowel obstruction (9 (6.8%)), wound infection (4 (3.0%)), peritonitis due to anastomotic leak (3 (2.3%)), intra-abdominal abscess (2 (1.5%)), anastomotic leak with enterocutaneous fistula (1 (0.76%)), and bleeding (1 (0.76%)). 4 patients had non-surgical complications: postoperative diarrhea (2 (1.5%)), urinary retention (1 (0.76%)), and deep vein thrombosis (1 (0.76%)). Most complications were classified as group II according to the Clavien-Dindo classification. 2 patients died (1.5%). The anastomotic technique used did not affect the outcome. The experience of the surgeon as judged by the frequency of the procedure was the main factor affecting postoperative morbidity significantly (p = 0.03). Conclusion: Our study revealed that the rate of postoperative complications and a smooth postoperative course after the closure of ileostomy was influenced by surgical experience.

Sa1112 Pre-Operative Diarrhea and Length of Distal/Terminal Ileal Resection Do Not Predict Post-Operative Diarrhea in Crohn's Disease Patients

6 in operated patients (ns). Length of strictures was 5.6±3.4 cm at surgery, 5.7±4.1 cm at SICUS (n.s). Pre-stenotic dilatation was present in 49/81(60%) and 15/37(40.5%) strictures in non-operated and operated patients, respectively (n.s). The length and lumen diameter of strictures were 5±5 cm and 6±1 mm in non-operated and 6.6±5 cm and 5.2±1.8 mm in operated patients (n.s), respectively. There was no significant difference in the stricture site and location of CD at diagnosis, between operated and non-operated patients . Conclusions. Site, length, and degree of luminal narrowing of stricture do not differ between CD patients requiring and not requiring surgery. Severity of stricture does not appear to be the only factor of obstructive symptoms requiring surgery. It is likely that other factors contribute with stricture to indicate surgery. 1) Cosnes J et al IBD 2002; 2) Pallotta N et al IBD 2011

Clostridium difficile is Common in Patients With Postoperative Diarrhea after Hip and Knee Arthroplasty

Clostridium difficile is an antibiotic-associated gastrointestinal infection that has detrimental consequences. We sought to determine the incidence of C. difficile in TJA patients with postoperative diarrhea, to determine risk factors for C. difficile infection, and to establish the incidence of C. difficile-related complications. Our institutional protocol includes screening for C. difficile in all patients with diarrhea after TJA. We identified 121 such patients over four years with twenty-eight (23%) testing positive for C. difficile. Revision arthroplasty and prolonged postoperative antibiotic use were risk factors for C. difficile infection. With our protocol of screening and immediate treatment of C. difficile positive patients, we found no C. difficile-associated complications.

Long-term outcome after laparoscopic bowel resections for deep infiltrating endometriosis: a single-center experience after 900 cases.

Background. Laparoscopic bowel resections for endometriosis are safe and effective but only short-term follow-up has been evaluated. In the present study long-term outcome in terms of intestinal and urinary function, fertility, chronic pain, and recurrence was assessed. Materials and Methods. From January 2002 to December 2010 nine hundred patients underwent laparoscopic bowel resection for endometriosis, and on 774 (86%) a questionnaire was administered. Patients were divided into 3 groups on the strength of the operation date. Postoperative diarrhea, constipation, rectal bleeding, tenesmus, dyschezia, dysuria, dyspareunia, fertility, and recurrence of disease were assessed. Results. The median follow-up was 54 months (range 1–120). All the evaluated symptoms significantly improved over time, with P = 0.0001 for dyspareunia, constipation, and pelvic pain and P = 0.004 for diarrhea. Nonsignificant improvement was reported for dysuria and rectal bleeding (with P = 0.452 and P = 0.097, resp.). Conclusions. The present results confirm that bowel resections for endometriosis are correlated with an acceptable complication rate even at long-term follow-up and that symptoms significantly improve over time, except for rectal bleeding and dysuria, the latter associated with a neurological damage.

Postoperative Clostridium difficile infection with PCR ribotype 078 strain identified at necropsy in five Thoroughbred racehorses

Clostridium difficile is an important cause of acute enterocolitis in horses. We describe five cases of C difficile infection occurring postoperatively in Thoroughbred racehorses. Following diarrhoea or colic accompanied by...

Extended Lymphadenectomy in Patients With Pancreatic Cancer Is Debatable

Lymph node staging is one of the most important factors in determining the prognosis after resection of pancreatic ductal adenocarcinoma. Despite ongoing efforts to further refine lymph node staging, the debate on the extent of lymphadenectomy during pancreaticoduodenectomy is still open. The purpose of this review was to summarize the evidence about performing standard lymphadenectomy during curative resection of pancreatic cancer. All four prospective randomized controlled trials published concluded that extended lymphadenectomy does not contribute to better oncologic outcome for patients with adenocarcinoma of the pancreatic head. Indeed, one major drawback of extended lymphadenectomy is the higher risk of persistent postoperative diarrhea. No prospective randomized studies could be found on the role of extended lymphadenectomy in patients with adenocarcinoma of the corpus and tail. Based on current evidence there is no indication that extended lymphadenectomy should be performed routinely during resection of pancreatic cancer.

Risk factors for the development ofClostridium difficilecolitis in a surgical ward

PurposeClostridium difficile colitis (CDC) is a nosocomial infection. We attempted to discover the risk factors for the development of CDC in patients admitted to our surgical ward.MethodsWe conducted a retrospective chart review of all patients admitted to our surgical ward between January 2010 and July 2011. CDC was confirmed when toxin A/B or toxin B polymerase chain reaction was detected in the stool and clinical symptoms, such as diarrhea, were present. We divided patients into the CDC and non-CDC groups, and compared the clinical features between the two groups.ResultsThe rate of CDC occurrence was 0.4% (19/4,720 patients). Univariate analysis showed that colectomy (P < 0.001), hospital stays longer than 10 days (P < 0.001), aged over 55 years (P < 0.001) and transfer from medical ward (P = 0.009) were significant parameters for CDC. Multivariate analysis showed that colectomy (P < 0.001; odds ratio [OR], 8.405; 95% confidence interval [CI], 2.927 to 24.132) and hospital stays longer than 10 days (P = 0.035; OR, 10.253; 95% CI, 1.176 to 89.392) were high risk factors for CDC occurrence in the surgical ward.ConclusionThe risk factors for CDC in a surgical ward could be colectomy and a long duration of hospitalization. Therefore, clinicians should consider the possibility of CDC when patients undergo colectomy, are admitted for a long time, and have postoperative diarrhea.

Postoperative Antibiotics Correlate with Worse Outcomes after Appendectomy for Nonperforated Appendicitis

Acute appendicitis remains the most common cause of acute abdominal pain necessitating operative intervention. Although postoperative antibiotics are universally used for perforated appendicitis, no consensus exists on whether postoperative antibiotics are beneficial for preventing surgical site infections (SSIs) in nonperforated cases. We set out to determine how postoperative antibiotic therapy affects outcomes after appendectomy for nonperforated appendicitis. The medical records of 1,000 patients undergoing appendectomy for nonperforated appendicitis at The Mount Sinai Medical Center from January 2005 through July 2010 were retrospectively reviewed. In total, 728 cases contained sufficient follow-up data for analysis; 334 of these patients received postoperative antibiotics and 394 did not. There were no significant differences in patient demographics, medical comorbidities, American Society of Anesthesiologists (ASA) class, admission temperature, preoperative antibiotic treatment, operating room time, estimated blood loss, appendiceal diameter, or intraoperative transfusion between the two groups, although WBC was higher for patients receiving postoperative antibiotics (12.3 vs 14 cells/mm(3), p = 0.001). Postoperative antibiotics did not alter the incidence of superficial SSIs, deep SSIs, or organ space SSIs (all p = 0.1), but did correlate with higher rates of Clostridium difficile infection (p = 0.02), urinary tract infection (p = 0.05), postoperative diarrhea (p < 0.001), and longer length of stay (LOS) (1.1 vs 2.4 days, p < 0.001). Patients receiving postoperative antibiotics also showed trends toward higher readmission and reoperation rates (both p = 0.06). Postoperative antibiotic treatment for nonperforated appendicitis did not reduce infectious complications and prolonged LOS while increasing postoperative morbidity. Therefore, postoperative antibiotics likely increase the treatment cost for nonperforated appendicitis while not adding an appreciable clinical benefit and, in some cases, actually worsening outcomes.

Reply to: Right hemicolectomy with central vascular ligation in colon cancer

We thank Doctors Weber and Hohenberger for their kind comments [1]; however, we would like to stress some points of interest. The variance of colon arterial anatomy is an established fact and has been well pointed out that it can be due to definitions used, population examined, or methodology [2]. The numbers are not crucial; it is more important that the surgeon be aware of the individual variants, especially those that can complicate surgical procedures. We also have had the impression that the right colic artery is not found at surgery as often as with radiology. On occasion, a right colic artery seen at preoperative MDCT angiography was of such a small caliber that it could be successfully cauterized at surgery. However, this does not imply that there are no lymph nodes or vessels in its vicinity. Moreover, there are data in the literature about metastasis in cecal and ascending colon cancer to the central ileocolic, right colic, and middle colic nodes at rates of 11.1, 5.0, and 6.1%, respectively [3]. This becomes even more important in light of recent data suggesting that patients with micrometastasis and isolated cancer cells within harvested lymph nodes (found in 5–26% of negative nodes) have lower survival rates [4]. This is why we have started a randomized controlled trial (ClinicalTrials.gov) to study safe D3 resection in right-sided colon cancer through the help of preoperative MDCT angiography. Our operative technique for D3 resection (or CME) differs somewhat from that of Hohenberger et al. [5]. A medial approach is generally preferred in Norway. Dissection begins by dividing the visceral peritoneum over the terminal ileal vein and opening the vascular sheath of the superior mesenteric vein (SMV). The dissection continues toward the left-hand side of the superior mesenteric artery, and then cranially, following it to the level of the gastrocolic trunk. This is simultaneously followed (in the operating room) by a 3D reconstruction of the vessels using the Osirix software mentioned in our article (Fig. 1). The fatty tissue is dissected from the SMV toward the patient’s right side; the ileocolic and right colic arteries are found (when present) and divided at their origin. The middle colic artery is not divided, but the fatty tissue around the origin of the middle colic artery is removed, dissecting it toward the right side of the patient and keeping the specimen intact and en bloc. The right branch of the middle colic artery is divided. The arteries are drawn toward the right-hand side of the SMV anterior or posterior depending on their position, and the right colic vein is divided at its confluence with the gastrocolic trunk. We have a vascular surgeon present in this segment of the procedure (SK). Lateral mobilization of the devascularized specimen is then performed. If the dissection is done in this manner, one will notice a gutter toward the vena cava that is lifted together with the mesocolon. The resection of the vascular sheath posterior to the SMV is performed last. Finally, we would like to say that postoperative diarrhea was not an issue in patients who underwent a D3 resection at our institution, possibly because of the much lower extent of dissection than what Hohenberger et al. [5] describe. Furthermore, we are very glad that we agree that the right mesocolon is not clearly defined at its medial aspect, since this should lead to a resolution.

Right hemicolectomy with central vascular ligation in colon cancer

We read with interest the report by Spasojevic et al. [1] describing the origin of the right colic artery and the implications for oncologic resection of the ascending colon. Using computed tomographic (CT) angiography, the authors demonstrated a right colic artery arising from the superior mesenteric artery in 54% of patients, with this vessel passing posterior to the superior mesenteric vein in only 7.4% of cases. Contrary to the authors’ suggestion, we did not fail to report the described variations in our series of extended lymphadenectomy for right colon cancer [2]. Rather, it is our surgical experience that a true right colic artery is rarely seen. Our finding of a true right colic artery in approximately 15% of patients is consistent with that of previous reports [3, 4]. Perhaps the discrepancy between our experience and that of Spasojevic et al. [1] is partly a matter of definition. We and others have observed, for example, that the middle colic artery has many variations. VanDamme and Bonte [5] described two or more middle colic arteries with separate origins in 25% of their patients. When performing a complete mesocolic excision for right-sided colon cancer, we do not routinely divide such middle colic vessels centrally because lymph node metastases are not seen in this distribution. When, however, a true right colic artery originating from the superior mesenteric artery and passing posterior to the superior mesenteric vein is identified, then a central ligation should be performed. By rotating the fully mobilized colon in a clockwise direction, the origin of both the right colic artery (when present) and the ileocolic artery may be fully exposed to allow true central ligation [2]. Thus, an arterial stump with potentially involved lymph nodes is never missed. In the procedure, the autonomic nerve plexus enveloping the superior mesenteric artery must be preserved to avoid postoperative diarrhea. As correctly observed by Spasojevic et al. [1], the right mesocolon is not clearly defined at its medial aspect. When a complete mesocolic excision for right-sided colon cancer is performed, the fascia on both sides of the mesocolon, including the contained ileocolic artery (and the right colic artery when present) must be actively divided in a plane parallel to the mesenteric root. In this way the excision of the mesocolon and its mesocolic lymph nodes is maximized.