Segmental Colectomy Research Articles

Laparoscopic segmental left colectomy for splenic flexure carcinoma: a single institution experience.

There is ongoing debate regarding surgical treatment of splenic flexure cancer. The main points of controversy include the appropriate extent of colon resection, either to the right or to the left, and the appropriate extent of lymph-node dissection. The aim of this study was to review our experience in laparoscopic treatment of splenic flexure cancer cases and to compare our data to the recent literature. Consecutive patients, operated on for splenic flexure colon carcinoma at a single institution between April 2005 and January 2013, were included in the study. Exclusion criteria were a previous history of colorectal cancer, recurrent colonic cancer, emergency cases with an obstructive tumor or a perforated tumor with peritonitis, synchronous cancer, palliative surgery, and a past history of colorectal resection. Patients underwent laparoscopic segmental left colectomy with ligation of the left branch of the middle colic and of the left colic artery.Patient characteristics, operative and postoperative outcomes, and long-term technical, functional, and oncological results from a prospectively maintained database were retrospectively analyzed. After hospital discharge, standardized follow-up was performed at 1month postoperatively, then every 3months during the first 2years, and every 6months thereafter, for a total of 5years. A total of 28 consecutive patients (16 males) with a median age of 71.8years (range 42.5-88.8years) were included. Ninety-day mortality was 3.5% and surgical morbidity was 21.5%with anastomotic leak rate of 10.7%. All survivors experienced good or very good functional results. During a median follow-up period of 50.9months, eight patients (28.5%) presented with a recurrence. The 5-year overall and disease-free survival rates were 46.3% and 39.2%, respectively. Segmental left colectomy for splenic flexure carcinoma is associated with reasonably low morbidity and very good functional results. However, survival rates are low.

Skeletal Muscle Mass Index Predicts Postoperative Complications in Intestinal Surgery for Crohn's Disease

The aim of this study was to evaluate the role of the skeletal muscle mass index (SMI) for major postoperative morbidity in patients with Crohn's disease (CD) and intestinal surgery at a tertiary referral center. A retrospective analysis of the prospectively maintained database for surgical patients with CD at our institution was performed. The cases of all patients operated on between December 2009 and December 2017 with sectional imaging prior to surgery were eligible for this study. A total of 230 patients were included. Major postoperative complications were observed in 32 patients (13.9%). Common intestinal procedures were ileocecal resections (51.7%), segmental small-bowel resections (10%), and colectomy or proctocolectomy (8.3%). In multivariable analysis, SMI (P=.002; odds ratio = 0.914) was the only independent risk factor for major postoperative complications. Both computed tomography (CT) and magnetic resonance imaging (MRI) studies were suitable to determine SMI. The cutoff values for SMI were 31.8 cm2 /m2 for females and 41.5 cm2 /m2 for males. We present the largest published cohort investigating SMI with regard to major postoperative morbidity in surgery for CD. In multivariable analysis, SMI was the only significant risk factor for Clavien-Dindo complications grade ≥III. Lumbar SMI was reliably determined by CT and MRI alike. Because preoperative abdominal imaging with either modality is common for patients with CD, SMI could be a reliable and largely available tool to stratify the risk of postoperative complications.

Alvimopan is associated with decreased length of stay for both open and laparoscopic segmental colectomy

BackgroundAlvimopan has been shown to reduce length of stay after bowel resection. Use remains variable among institutions due to cost and efficacy concerns in laparoscopic surgery. Additionally, alvimopan’s effects have not been isolated from other medications within enhanced recovery protocols. The aim of this study was to distinguish the relationship between alvimopan use, length of stay, and cost in both open and laparoscopic segmental colectomies. MethodsThe Vizient dataset was queried to identify patients undergoing open and laparoscopic colectomies from 2015 to 2017. Patient demographics and treatment details were collected. Primary outcomes of interest included duration of stay and total direct costs. ResultsIn the study, 12,727 patients met inclusion criteria and 3,358 (26.4%) received alvimopan. For both open and laparoscopic groups, alvimopan was associated with decreased length of stay in unadjusted (4.0 vs 6.0 days, P < .01 and 3.0 vs 4.0 days, P < .01, respectively) and adjusted analysis (effect ratio 0.79, P < .01 and 0.85, P < .01, respectively). Alvimopan was associated with a 7% decrease in direct cost after adjustment (effect ratio 0.93, P = .04), with no cost difference in laparoscopic procedures (effect ratio 0.99, P = .71). ConclusionAlvimopan use is associated with decreased length of stay for both open and laparoscopic colon resections, decreased cost in open procedures, and no cost difference for laparoscopic procedures.

Recurrence and Long-Term Survival Following Segmental Colectomy for Right-Sided Colon Cancer in 813 Patients: a Single-Institution Study

BackgroundControversy exists regarding optimal surgical approach to right-sided colon cancer due to increasing complete mesocolic excision outcome data; yet, scarce long-term surgical and oncologic outcome data from high-volume centers following right segmental resections without complete mesocolic excision make comparisons difficult to interpret. We report long-term outcomes following standard mesocolic excision for right-sided colon adenocarcinoma. MethodsA retrospective review of a prospective database was conducted of all consecutive adult patients undergoing surgery for a right-sided colon adenocarcinoma between 2000 and 2007. Demographics, oncologic, operative, and pathologic details are reported. Primary endpoints consisted of overall survival and recurrence. Patients with stage IV and recurrent disease were excluded. ResultsEight hundred thirteen patients were identified. Majority of tumors were stage II (n = 318, 39%). Adjuvant chemotherapy was administered to 228 patients (28%). Recurrence was observed in 97 patients (12%), at median 1.3 years. Recurrence was most commonly distant (n = 73, 9%). At median follow-up 7.3 years, 5- and 10-year overall survival was 72.4%, and 48.6%, respectively. Five- and 10-year disease-free survival was 67% and 45.8%, respectively. Multivariable analysis demonstrated that TNM stage was a significant predictor of recurrence. For disease-free survival, T stage, and N stage were significant on multivariate analysis. Multivariable predictors of overall survival included age, number of lymph nodes removed, N stage, and adjuvant chemotherapy use. ConclusionsExcellent long-term outcomes from a large cohort of patients with non-metastatic, right colon adenocarcinoma treated by segmental colectomy without complete mesocolic excision are reported. The majority of recurrences were distant.

Current Status of Segmental Colectomy in Select Crohn's Disease Patients.

Crohn's disease is a complex disease with a varying clinical and anatomical spectrum. One-third of patients with Crohn's will have disease confined to the colon. In this article, the authors review the surgical treatment options for colonic Crohn's disease including the current status of performing segmental colectomy in colonic Crohn's, the pros and cons of segmental versus subtotal colectomy, and the influence of biologics on recurrence rates following segmental colectomy.

What is the best surgical option for the resection of transverse colon cancer?

Transverse colon is an infrequent localization of colon cancer and it is burdened by a poor prognosis. The principle of oncological radicality includes primary tumor resection with adequate lymphadenectomy. To date, there is still no consensus on which type of surgical resection perform in case of transverse colon cancer (TCC). Lymphatic drainage and vascularization of this section of the colon is highly variable presenting with different anatomical variants. Moreover, mobilization of the transverse colon can be particularly challenging in comparison to other colon tracts. Despite a lack of standardized definitions, three main surgical options are proposed: segmental colectomy of the transverse colon [transverse colectomy (TC)], extended right colectomy (ERC) and subtotal colectomy (STC). The aim of the present review is to describe the outcomes, limitations and advantages of TC, ERC, and STC for TCC in order to identify possible trends in the current literature suggesting which is the best treatment option in both elective and emergency settings.

Curative and Prophylactic Surgery of Young-onset Colorectal Cancer in Inherited Syndromes: A 15-Year Monocentric Retrospective Experience.

Although genoproteomic and clinicopathological knowledge on Lynch syndrome (LS) and familial adenomatous polyposis (FAP) has notably increased during the past two decades and even though surgery represents the mainstay of treatment for both conditions, as of 2019, the surgical choice in terms of timing and procedure still appears controversial in the absence of definitive guidelines. Data were retrospectively analyzed of patients with colorectal cancer (CRC) surgically treated at our Institution between 1st January 2003 and 31st December 2018. Particular attention was given to patients with LS and FAP ≤45 years of age (young-onset CRC); for this category of patients, the surgical procedures performed were compared in terms of benefits and disadvantages. A total of 1,878 primary CRCs were submitted to major surgery; young-onset malignancies accounted for 3.8% of all CRCs. Thirteen young-onset inherited CRCs were surgically removed from 11 patients with LS and two with FAP. Segmental colectomy and restorative proctocolectomy were the procedures most frequently performed in young patients with LS and FAP, respectively. In the light of our retrospective results, we highlight the need for randomized controlled trials comparing the surgical options for LS- and FAP-related CRC developing in young patients. Defining the advantages and risks of each surgical option is of the utmost importance in order to improve prognosis of such patients and establish unanimous recommendations.

Endoscopy, angiography, surgery: diagnostic and therapeutic algorithms for diverticular bleeding

Diverticular bleeding is acomplication of diverticular disease but in contrast to diverticulitis, publications concerning diverticular bleeding are less common. Diverticular bleeding is the cause of approximately 20-50% of cases of lower gastrointestinal bleeding and in rare cases can be life-threatening. The main symptom of diverticular hemorrhage is painless hematochezia and the German guidelines recommend that further diagnostics of suspected diverticular bleeding should be performed in hospital. Interdisciplinary diagnostic and therapeutic algorithms recommend primary endoscopy in acute as well as chronic recurrent diverticular bleeding. If endoscopy fails to provide an exact localization of the origin of bleeding, angiography or computed tomography (CT) angiography can be performed. The 99mTc erythrocyte scintigraphy should only be performed if endoscopy and angiography are unable to identify the localization of the bleeding source. More than 90% of diverticular hemorrhages stop spontaneously; however, it is general agreed that an active diverticular bleeding detected during colonoscopy should be immediately treated endoscopically. Alternative radiological techniques for hemostasis are rarely needed and attention must be paid to the complications. In the rare case of severe bleeding that cannot otherwise be stopped or if the bleeding vessel cannot be located, laparotomy and total colectomy can be recommended. If the diverticular bleeding has definitely been identified or recurrent bleeding causes chronic anemia, segmental or total colectomy may be undertaken; however, the advantages and disadvantages of both types of surgery have to be thoroughly explained to the patient.

Surgical management of obstructive left colon cancer at a national level: Results of a multicentre study of the French Surgical Association in 1500 patients.

Surgical management of obstructive left colon cancer (OLCC) is controversial. The objective is to report on postoperative and oncological outcomes of the different surgical options in patients operated on for OLCC. From 2000-2015, 1500 patients were treated for OLCC in centers members of the French Surgical Association. Colonic stent (n=271), supportive care (n=5), palliative derivation (n=4) were excluded. Among 1220 remaining patients, 456 had primary diverting colostomy (PDC), 329 a segmental colectomy (SC), 246 a Hartmann's procedure (HP) and 189 a subtotal colectomy (STC) as first-stage surgery. Perioperative data and oncological outcomes were compared retrospectively. There was no difference between the 4 groups regarding gender, age, BMI and comorbidities. Postoperative mortality and morbidity were 4-27% (PDC), 6-47% (SC), 9-55% (HP), 13-60% (STC), respectively (P=0.005). Among the 431 living patients after PDC, 321 (70%) patients had their primary tumour removed. Cumulative mortality and morbidity favoured PDC (7-39%) and SC (6-40%) compared to HP (1-47%) and STC (13-50%) (P=0.04). At the end of follow-up definitive stoma rates were 39% (HP), 24% (PDC), 10% (SC), and 8% (STC) (P<0.0001). Five-year overall and disease-free survival was: SC (67-55%), PDC (54-48%), HP (54-37%) and STC (48-49%). After multivariate analysis, SC and PDC were associated with better prognosis compared to HP and STC. In OLCC, SC and PDC are the two preferred options in patients with good medical conditions. For patients with severe comorbidities PDC should be recommended, reserving HP and STC for patients with colonic ischaemia or perforation complicating malignant obstruction.

P327 Segmental colectomy for ulcerative colitis: a new paradigm? A multi-centric study in 72 patients

P327 Segmental colectomy for ulcerative colitis: a new paradigm? A multi-centric study in 72 patients

The dilemmas of the transverse colon cancer: segmental or extended right colectomy, laparoscopic hazards for the inexperienced surgeon

The benefits, efficacy, and safety of laparoscopic surgery for colon and rectal surgery have been previously demonstrated. However, patients with transverse colon cancer were not included in most of the landmark studies. Several reasons have been described for this. Its relatively low frequency and the complexity of performing an adequate laparoscopic lymphadenectomy in the area of the middle colic vessels are among the main reasons. Performing the high ligation of the middle colic vessels is possibly the most challenging and complex step of a laparoscopic transverse colon resection. The proximity of the middle colic vessels to the superior mesenteric artery and vein contribute to the complexity of this step from a technical standpoint, making it challenging for inexperienced surgeons. From a surgical standpoint, transverse colon lesions can be treated by means of a laparoscopic extended right colectomy, a segmental transverse colectomy or a left colectomy.

Solid pseudopapillary neoplasm of the pancreas – A 16 years North Indian tertiary care experience

Introduction: Solid pseudopapillary neoplasm (SPN), an uncommon tumor of the pancreas dominantly affecting young females, is sparsely reported. Herein, we share our experience with presentation, management and outcomes of SPN. Method: A retrospective analysis of a prospectively maintained database on pancreatic tumors over 16 years (January 2003 to December 2018). Result: The inpatients, 30913 in number, included 359 patients with pancreatic tumors (1.16%) - 52 cystic (14.5%) and 25 (48%) of the cystic tumors were SPN. All SPNs (23 females, mean age 32 years) underwent surgery at this center and were analysed.The SPN were located in the head (n=7, 28%), body (n=5, 20%) and tail (n=13, 52%) of the pancreas. Abdominal pain was the most frequent (72%) complain. Mean tumor size was 7.6cm. Panreaticoduodenectomy was performed in 7 patients, central pancreatectomy in 4, and distal pancreaticosplenectomy in 9 (including one with segmental colectomy), spleen preserving distal pancreatectomy in 4 and local wide excision in one patient. The patients with DPS and segmental colectomy presented with recurrence at 29 months. R0 resection was accomplished in 88%. Major morbidity was recorded in 16% cases. There was no mortality. Recurrence free survival was excellent with a median follow up of 34 months. Conclusion: SPN is an indolent tumor with excellent long-term prognosis. Complete surgical excision guided by the location of the tumor remains the treatment of choice.

Curative management of malignant left-sided colorectal obstruction

Left-sided malignant colonic obstruction remains a challenging surgical problem despite recent advances. We aim to provide a concise overview of the relevant surgical options for this condition in the curative setting. A literature search of MedLine, PubMed, and Embase was performed to elucidate the latest evidence in the management of malignant left-sided colorectal obstruction, focusing on the risks and benefits of each approach and the appropriate patient selection. Primary resection and anastomosis are the intervention of choice for low-risk patients in the curative setting. Delayed resection with a bridge to surgery should be considered in unwell patients requiring medical optimization. While stenting has gained popularity, the risk of stent perforation carries a poor prognosis and must be carefully considered. Hartmann's procedure should be considered in high-risk elderly patients. Subtotal colectomy is preferred over segmental colectomy when there is extensive proximal colon damage but results in more frequent bowel actions postoperatively.

The dilemmas of the transverse colon cancer: segmental or extended right colectomy, laparoscopic hazards for the inexperienced surgeon

The dilemmas of the transverse colon cancer: segmental or extended right colectomy, laparoscopic hazards for the inexperienced surgeon

The growing discrepancy between resident training in colonic surgery and the rising number of general surgery graduates.

The decrease in resident operative experience due to working-hour directives and sub-specialization within general surgery is the subject of growing debate. This study aims to examine how the numbers of colectomies used for resident training have evolved since the introduction of working-hour directives and to place these results within the context of the number of new general surgeons. Based on the nationwide database of the Swiss association for quality management in surgery, all segmental colectomies performed at 86 centers were analyzed according to the presence or absence of residents and compared to national numbers of surgical graduates. Of 19,485 segmental colectomies between 2006 and 2015, 36% were used for training purposes. Residents performed 4%, junior staff surgeons 31%, senior staff surgeons 55%, and private surgeons 10%. The percentage performed by residents decreased significantly, while the annual number of graduates increased from 36 to 79. Multivariate analysis identified statutory (non-private) health insurance (OR 7.6, CI 4.6-12.5), right colon resection (OR 3.5, CI 2.5-4.7), tertiary referral center (OR 1.9, CI 1.5-2.6), emergency surgery (OR 1.7, CI 1.3-2.3), and earlier date of surgery (OR 1.1, CI 1.0-1.1) as predictors for resident involvement. Only a low and declining percentage of colectomies is used for resident training, despite growing numbers of trainees. These data imply that opportunities to obtain technical proficiency have diminished since the implementation of working-hour directives, indicating the need to better utilize suitable teaching opportunities, to ensure that technical proficiency remains high.

Combined endo-laparoscopic surgery (CELS) for benign colon polyps: a single institution cost analysis.

Endoscopic removal of benign colon polyps is not always possible, even with advanced endoscopic techniques. Segmental colectomy has been the traditional therapy but is associated with an increased risk of complications and may be unnecessary since fewer than 20% of these polyps harbor malignancy. Combined endo-laparoscopic surgery (CELS) has emerged as an alternative method to address these polyps. While feasibility, safety, and improved short-term patient outcomes have been demonstrated, there has never been an evaluation of cost comparing these two approaches within a single institution. In this observational cohort study, we compared short-term outcomes and costs of 11 patients who underwent CELS for right colon polyps with 11 patients who underwent a laparoscopic right colectomy between April 2014 and November 2017. The cost analysis covered the perioperative period from operating room to hospital discharge. A total of 11 patients underwent an attempted CELS procedure for right colon polyps with a success rate of 90% (10/11). The median length of stay (LOS) for CELS patients was 1day. LOS for patients who underwent a laparoscopic right colectomy at TMC was 3.82days. The median OR time for CELS was 166.73 (± 57.88)min, compared to 204.73 (± 51.49)min for a laparoscopic right colectomy. The calculated total cost for a CELS patient was $5523.29, compared to $12,626.33 for a laparoscopic right colectomy, for a cost-savings of $7103.04 per patient. CELS procedures are associated with good short-term outcomes and are performed at a lower cost compared to traditional laparoscopic colectomy, with the most significant cost saver being shorter hospital LOS. This is the first study to directly compare the cost of CELS to traditional laparoscopic colectomy in the surgical management of benign colon polyps within a single institution.

Changing Autonomy in Operative Experience Through UK General Surgery Training

To determine the operative experience of UK general surgery trainees and assess the changing procedural supervision and acquisition of competency assessments through the course of training. Competency assessment is changing with concepts of trainee autonomy decisions (termed entrustment decisions) being introduced to surgical training. Data from the Intercollegiate Surgical Curriculum Programme and the eLogbook databases for all UK General Surgery trainees registered from August 1, 2007 who had completed training were used. Total and index procedures (IP) were counted and variation by year of training assessed. Recorded supervision codes and competency assessment outcomes for IPs were assessed by year of training. We identified 311 trainees with complete data. Appendicectomy was the most frequently undertaken IP during first year of training [mean procedures (mp) = 26] and emergency laparotomy during final year of training (mp = 27). The proportion of all IPs recorded as unsupervised increased through training (P < 0.05) and varied between IPs with 91.2% of appendicectomies (mp = 20), 40.6% of emergency laparotomies (mp = 27), and 17.4% of segmental colectomies (mp = 15) recorded as unsupervised during the final year of training. Acquisition of competency assessments increased through training and varied by IP. The changing autonomy of trainees through the course of an entire training scheme, alongside formal competency assessments, may provide evidence of changing entrustment decisions made by trainers for different key procedures. Other countries utilizing electronic logbooks could adopt similar techniques to further understanding of competency attainment amongst their surgical trainees.

Impact of omentoplasty on anastomotic leak and septic complications after low pelvic anastomosis: a study from the NSQIP database.

The role of omentoplasty in the prevention of anastomotic leak (AL) in colorectal surgery is controversial. The aim of this study was to evaluate the impact of omentoplasty on AL and septic complications after low pelvic anastomosis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The ACS-NSQIP database was queried for patients who underwent segmental colectomy with low pelvic anastomosis by using 2012 targeted colectomy participant use data file. Patients were divided into two groups according to omentoplasty versus no-omentoplasty formation. AL and surgical site infections (SSIs) within postoperative 30days were compared between the groups. A total of 2891 patients (1447 [50.1%] males) with a mean age of 60.2 ± 13.0years met the inclusion criteria. There were 86 (2.9%) and 2805 (97.1%) patients in the omentoplasty and no-omentoplasty group, respectively. In the multivariate analysis, omentoplasty neither reduced AL (p = 0.83; OR = 0.88, 95% CI, 0.21-2.44) nor organ/space SSIs (p = 0.08; OR = 2.14, 95% CI, 0.91-4.41). Also, this technique did not play any role in reducing AL and organ/space SSI rates regardless of diversion with the exception of its association with higher organ/space SSIs in patients without diverting stoma (9.2% vs 3.8%, p = 0.04). No differences were detected between the groups with respect to the management strategies for AL (p = 0.22). Omentoplasty did not decrease AL and septic complications after low pelvic anastomosis and had no impact on the postoperative management of AL.

Feasibility and Safety of Intraoperative Colonoscopy after Segmental Colectomy and Primary Anastomosis

Patients presenting with near-obstructing colon lesions requiring segmental colectomy may benefit from intraoperative colonoscopy (IOC) after primary anastomosis for a more timely and accurate diagnosis of synchronous lesions. The aim of this study is to demonstrate the feasibility and safety of this technique. A retrospective cohort study of patients undergoing single-stage segmental colectomy and anastomosis at a single tertiary care institution from 2011 to 2013 was performed. One Hundred and sixty-eight consecutive patients underwent segmental colectomy and primary anastomosis of which 78 (46%) were unable to receive preoperative colonoscopy (POC) because of near-obstructing lesions and received IOC after the anastomosis. IOC detected synchronous adenomatous polyps in 24.4 per cent, diverticular disease in 19 per cent, and colitis/proctitis in 2.5 per cent. The IOC group was not significantly different from the POC group with regard to overall morbidity (31% vs 39% P = 0.45), anastomotic leakage (1.3% vs 0%, P = 0.46), or wound infection (5.1% vs 1.1%, P = 0.18). Operation time was 19 minutes longer in the intraoperative group, but overall length of hospital stay was not significantly different (6.4 ± 2.9 days vs 7.3 ± 4.6 days). In patients unable to receive POC because of partial obstruction, IOC after primary anastomosis is both feasible and safe for detecting proximal synchronous lesions.

Efficacy, functional outcome and post-operative complications of total abdominal colectomy with ileorectal anastomosis vs. segmental colectomy in hereditary non-polyposis colorectal cancer.

The primary objective of the present study was to compare the choice of colectomy, i.e. total vs. segmental colectomy, in cases of hereditary non-polyposis colorectal cancer (HNPCC/lynch syndrome), and to assess the efficacy, oncological safety, functional outcome and post-operative complications of total abdominal colectomy with ileorectal anastomosis vs. segmental colectomy in HNPCC. A total of 289 patients who fulfilled the Amsterdam I and II criteria for HNPCC were included in the present study. The criteria for confirmation of the diagnosis were five micro-satellite markers, namely BAT25, BAT26, D2s123, d5S346 and D17S250. Group 1 included those patients who received their diagnosis in the years 2011–2013 and those in group 2 had been diagnosed in the years 2014–2016. The cohort had been subjected to two different types of surgery: i) Standard and extended surgery including total colectomy with ileal pouch anal anastomosis and subtotal colectomy and ii) segmental resection of the colon. Analysis of patient data indicated that in group 1, the extended resection was performed more frequently than in group 2 (68 vs. 34% of cases) and accordingly, segmental resection was less frequent (32 vs. 66%; P<0.001). In conclusion, the extensive rather than the segmental resection has been commonly performed several years ago, but at present, the surgical method of choice in cases of lynch syndrome is segmental resection. Trial registry no. QU/MR2011/CRC5, dated 21 March 2011.