Segmental Left Colectomy Research Articles

Exceptional lymph node recurrence of an unusual ovarian tumor 16 years later: a case report

BackgroundSex cord-stromal tumors with annular tubules are a rare tumor accounting for less than 1% of all ovarian malignancies. However, they are characterized by very late recurrence, which can be as late as 30 years after diagnosis and treatment.Case presentationA 16-year-old female Caucasian patient was treated in our department for a stage IA ovarian sex cord-stromal tumors with annular tubules. She underwent a left salpingo-oophorectomy and ipsilateral pelvic node biopsy with no adjuvant treatment. She was seen for amenorrhea after being lost to follow up for 16 years. The diagnosis of recurrence was made by radiology and the elevation of serum inhibin B level. The patient underwent resection of the tumor, left segmental colectomy, and paraaortic lymphadenectomy because the mass was massively adherent to the left mesocolon. Histology confirmed the diagnosis with no metastatic lymph nodes. No adjuvant therapy was indicated. The patient was lost to follow-up again for 4 years and re-presented for amenorrhea. Serum inhibin B level was high. A second recurrence was suggested, and the patient underwent a laparoscopic surgery. We performed left pelvic and paraaortic lymphadenectomy, and 3 months after surgery the patient was pregnant.ConclusionSex cord-stromal tumors with annular tubules is a slow-growing ovarian tumor with a high potential for recurrence and metastasis. Surgery is the mainstay of treatment. Due to the rarity of these tumors, they are often unsuspected and thus incompletely staged before primary surgery; the diagnosis is made by histological examination. The prognosis of these patients is unknown, and they require long-term follow-up.

Short-term and long-term outcomes of intracorporeal anastomosis in laparoscopic segmental left colectomy for splenic flexure cancer - a multicenter retrospective cohort study of 342 cases.

While intracorporeal anastomosis (IA) has been widely used in totally laparoscopic right colectomy, its application in laparoscopic segmental left colectomy for splenic flexure cancer remains underexplored, particularly in large-scale studies with long-term outcomes. This research aims to assess the technical feasibility and oncological efficacy of IA in treating colonic splenic flexure carcinoma, drawing insights from both short-term and long-term outcomes of a retrospective cohort. A retrospective analysis was conducted on 342 patients diagnosed with colonic splenic flexure carcinoma in three Chinese medical centers. These patients underwent laparoscopic segmental left colectomy between December 2014 and December 2019 across three medical institutions. Comprehensive data encompassing demographics, disease features, pathological characteristics, operative details, and both short-term and long-term outcomes were gathered and scrutinized. Using propensity scores, each patient from the IA cohort was paired with a counterpart from the extracorporeal anastomosis (EA) cohort. IA was performed on 129 patients, while 213 underwent EA. Post-propensity score matching resulted in 129 matched pairs. After matching, many baseline characteristics were balanced. The IA cohort exhibited several advantages, including shorter incision lengths ( P <0.001) and more extensive proximal and distal resection margins ( P =0.003, P <0.001). Additionally, the IA method facilitated a more rapid postoperative recovery as indicated by quicker return of bowel movements (resumption of passing flatus [2.7 (1.0-7.0) days vs. 3.3 (2.0-8.0) days, P <0.001] and defecation [3.7 (1.0-9.0)] days vs. 4.5 (2.0-9.0) days, P <0.001]), faster discharges [6.6 (3.0-15.0) days vs. 8.3 (5.0-20.0) days, P <0.001], and decreased need for rescue analgesics ( P <0.001). The rate of postoperative complications, as rated by the Clavien-Dindo classification, remained consistent across both techniques ( P =0.087). Furthermore, the cosmetic outcome rated by Patient Scar Assessment Questionnaire and Scoring System (PSAQ) was markedly superior in the IA group ( P <0.001). Both approaches demonstrated equivalent 5-year overall (82.7% vs. 82.1%, P =0.419) and disease-free survival (80.9% vs. 78.1%, P =0.476). Subsequent stratification analysis revealed that IA achieved comparable 5-year overall (80.7% vs. 82.0%, P =0.647) and disease-free survival (78.1% vs. 76.4%, P =0.734) in patients with locally advanced colon cancer. Employing IA for laparoscopic segmental left colectomy in cases of splenic flexure carcinoma is not only safe but also offers enhanced cosmetic results and expedited postoperative recovery. Oncologically speaking, IA in left segmental colectomy for splenic flexure carcinoma can yield therapeutic outcomes comparable to those of EA, even in patients with locally advanced colon cancer.

The Comparison of the Quality of Life and Complications in Segmental Colectomy and Subtotal Colectomy as the Treatment for Malignant the Left Colon Tumors

Background: This study was designed to compare postoperative complications, mortality and quality of life associated with the type of surgery (subtotal colectomy vs. segmental colectomy) in patients with left colon tumors. Subtotal colectomy and segmental colectomy are the two most common strategies used for treating the left colon’s malignant tumors. However, each patient’s optimal elective surgical treatment for the left colon’s malignant tumors is unclear. Choosing the optimal treatment for each patient, taking into account the individual conditions and preferences of the patients, with the least chance for occurrence of complications and the highest quality of life can help patients to ultimately return to everyday life. Methods: In this retrospective multi-centric study, patients with left colon tumors who had not received neoadjuvant and have undergone subtotal colectomy or segmental colectomy from 2016 to 2018 were enrolled. Mortality rate, quality of life and postoperative complications such as problems with defecation were assessed as the main outcome measures. Results: In patients with malignant tumors of left colon, both subtotal colectomy and segmental colectomy surgical methods reached the satisfactory results. In fact, there was no significant difference between the two surgical methods except that patients who had undergone subtotal colectomy showed better stool control capability. Conclusion: There was no significant difference between the two surgical procedures regarding postoperative complications and quality of life.

Emergency surgery for splenic flexure cancer: results of the SFC Study Group database

BackgroundThe effectiveness of surgical treatment for splenic flexure carcinomas (SFCs) in emergency settings remains unexplored. This study aims to compare the perioperative and long-term outcomes of different alternatives for emergency SFC resection.MethodThis multicenter retrospective study was based on the SFC Study Group database. For the present analysis, SFC patients were selected if they had received emergency surgical resection with curative intent between 2000 and 2018. Extended right colectomy (ERC), left colectomy (LC), and segmental left colectomy (SLC) were evaluated and compared.ResultsThe study sample was composed of 90 SFC patients who underwent emergency ERC (n = 55, 61.1%), LC (n = 18, 20%), or SLC (n = 17, 18.9%). Bowel obstruction was the most frequent indication for surgery (n = 75, 83.3%), and an open approach was chosen in 81.1% of the patients. A higher incidence of postoperative complications was observed in the ERC group (70.9%) than in the LC (44.4%) and SLC groups (47.1%), with a significant procedure-related difference for severe postoperative complications (Dindo-Clavien ≥ III; adjusted odds ratio for ERC vs. LC:7.23; 95% CI 1.51-34.66; p = 0.013). Anastomotic leakage occurred in 8 (11.2%) patients, with no differences between the groups (p = 0.902). R0 resection was achieved in 98.9% of the procedures, and ≥ 12 lymph nodes were retrieved in 92.2% of patients. Overall and disease-free survival rates at 5 years were similar between the groups and were significantly associated with stage pT4 and the presence of synchronous metastases.ConclusionIn the emergency setting, ERC and open surgery are the most frequently performed procedures. ERC is associated with increased odds of severe postoperative complications when compared to more conservative SFC resections. Nonetheless, all the alternatives seem to provide similar pathologic and long-term outcomes, supporting the oncological safety of more conservative resections for emergency SFCs.

Long-Term Functional Results of a Modified Caudal-to-Cranial Approach in Laparoscopic Segmental Left Colectomy for Diverticular Disease.

A modified caudal-to-cranial approach to perform laparoscopic left colectomy for benign diseases has been recently designed to facilitate the low-tie mesenteric dissection. A chart review has been performed including all consecutive patients with uncomplicated diverticulitis who have been treated by segmental left colectomy with a caudal-to-cranial approach. A total of 34 patients were included in the study. 21 patients were male, mean age was 54.1 ± 11.3, and mean BMI was 26 ± 5.5. Patients with ASA Score I were 7, with ASA II were 9, and with ASA Score III were 5. Incontinence Score (IS) resulted in an average of 5 ± 2, 2 grade of incontinence and the CS score showed an average of 10 ± 3, 2 grade of constipation. Health status, evaluated by Short Form-36 questionnaire, was demonstrated in these patients' great physical function, role, general health, and social function. The anorectal manometry performed 6 months after surgery showed a normal value in terms of the anal resting pressure (47 ± 13 mmHg) and an increased volume to stimulate desire to defecate (197 ± 25 ml). The length of the anal sphincter was normal compared to the reference value (37 ± 5.4 mm). Although further studies are required to obtain definitive conclusions, our results are encouraging to propose low-tie segmental colectomy as the standard procedure for the treatment of uncomplicated diverticulitis, and our modified surgical approach could be considered useful to facilitate the surgical approach.

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

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

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

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

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

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

Elective surgery for tumours of the splenic flexure: a French inter-group (AFC, SFCD, FRENCH, GRECCAR) survey.

In an elective setting, there is no consensus regarding the type of colectomy that is best for patients with tumors of the splenic flexure: segmental left colectomy (or splenic flexure colectomy), left hemicolectomy or subtotal colectomy (or extended right hemicolectomy). In the United Kingdom, extended right hemicolectomy is preferred by surgeons. The aim of the present survey was to report on the practices in France for this particular tumor location. Between 15/07/17 and 15/10/17, members of two French surgical societies [the French Association of Surgery (AFC) and the French Society of Digestive Surgery (SFCD)] and two French surgical cooperative groups [the French Federation of Surgical Research (FRENCH) and the French Research Group of Rectal Cancer Surgery (GRECCAR)] were solicited by email to answer an online anonymous questionnaire. A total of 190 out of 420 surgeons participated in this study (response rate 45%). The preferred procedure was splenic flexure colectomy (70%), followed by left hemicolectomy (17%) and subtotal colectomy (13%). The most used surgical approach was laparoscopy (63%), followed by laparotomy (31%) and hand-assisted laparoscopy (6%). Lymph node dissection was extended to the middle colic artery in 29% of splenic flexure colectomies and in 33% of left hemicolectomies. Twenty-nine percent of responders thought that tumors of the splenic flexure had a worse prognosis in comparison with other colonic sites, because of insufficient lymph node dissection (73%) or a more advanced stage (50%) at diagnosis. However, this opinion did not change the type of colectomy performed. There is a strong consensus in France to operate tumors of the splenic flexure with a splenic flexure colectomy and lymph node dissection limited to the left colic artery.

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.

Similar length of colon is removed regardless of localization in right‐sided colonic cancer surgery

Colorectal cancers represent a heterogenous group of tumours. While left segmental colectomy is an accepted and oncologically safe practice for left-sided colonic cancer (CC), some authors suggest that limited segmental resection of right-sided cancer should be debated in order to preserve length of the resected colon. To our knowledge, caecum and ascending CC have not been analysed as different groups of tumours. The objective of this study was to assess if, retrospectively, surgical treatment of caecal cancer differed from ascending CC. A review of all consecutive patients with right colonic resection for cancer admitted to the University hospital of Grenoble from January 2005 to August 2016 was performed. Length of resected colon was compared between caecal primary and ascending CC. Other technical and pathological aspects were analysed such as minimal invasive surgery and number of harvested lymph nodes from anatomic specimens. Among operated patients, tumour was localized pre-operatively on caecum in 110 cases and on the right ascending colon in 119 cases. Pre-operative localization had no effect on resected colon length (mean 24.5 cm, 24 ± 10.34 versus 25 cm ± 7.28, P = 0.95), on the number of harvested lymph nodes with a mean of 15 (±7.6) nodes in the caecal group versus 15.2 (±7.3) (P = 0.72). We noticed 15 cases of discordance between pre- and post-operative localization (4 versus 11, P = 0.08). Length of resected colon does not differ depending on localization of tumour in our center.

Acute intussusception on a lipoma of the left colon: report of a case

Introduction: Lipomas of the colon are rare benign tumors. Colo-colonic intussusception caused by colonic lipoma is more rare. Case report: We report a case of a 52-year-old patient presenting with recurrent colonic obstruction which occurred in recent days. Colonoscopy revealed a large submucosal mass having benign appearance. Abdominal computed tomography scan diagnosed colo-colonic intussusception due to a large lipoma of the sigmoid colon. Diagnosis was confirmed during operative reduction and resection. He had segmental left colectomy. The postoperative course was uneventful. Conclusion: Computed tomography scan and colonoscopy seem important for diagnosing both lipoma and intussusception. The treatment may be surgical or endoscopic.

Large benign submucosal lipoma presented with descending colonic intussusception in an adult

Patient: Female, 34Final Diagnosis: Lipoma of the large intestineSymptoms: Abdominal pain • bloating • blood in stool • constipation • lose of appetite • nauseaMedication: —Clinical Procedure: —Specialty: SurgeryObjective:Rare diseaseBackground:Lipoma of the large intestine is rare, account for only 5% of all gastrointestinal tumors. Lipomas are usually asymptomatic but rarely may cause bleeding, obstruction and intussusception. We present a case of a giant colonic lipoma causing descending-colonic intussusception.Case Report:34 yo F presented with the intermittent left lower quadrant abdominal pain for 3 weeks. The pain initially was associated with bloating and constipation and for the last several days frank blood in stool, nausea and decreased appetite. CT scan of the abdomen revealed descending colonic obstruction by a 5.3 cm colonic lipomatous mass with resultant intussusception. Patient initially underwent colonoscopy that revealed polypoid lesion at 3–40 similar to lipoma with intussusception that was reduced. Patient subsequently underwent laparoscopic segmental left colectomy for the descending colonic intussusception due to large colonic lipomatous mass. Pathology confirmed the histology of lipoma.Conclusions:Adult bowel intussusception is a rare but challenging condition to diagnose in a timely manner. Preoperative diagnosis is usually missed or delayed because of nonspecific and often subacute symptoms. Lipoma is a rare cause of the intussusception. A high index of suspicion and appropriate investigations (abdominal ultrasound, CT scan and colonoscopy) can result in prompt diagnosis. Lipoma of the large intestine is very rare. Submucosal lipomas are usually asymptomatic but may cause bleeding, obstruction, intussusception, or abdominal pain. Accurate preoperative diagnosis is difficult and lipoma is often mistaken for adenomatous polyp or carcinoma. Treatment usually requires formal resection of the involved bowel segment due to high suspicion for malignancy and subsequent complications due to obstruction.

Prevalence of and Risk Factors for Morbidity After Elective Left Colectomy

Independent risk factors for postoperative morbidity after colectomy are most likely linked to disease characteristics. Retrospective analysis. Twenty-eight centers of the French Federation for Surgical Research. In total, 1721 patients (1230 with colon cancer [CC] and 491 with diverticular disease [DD]) from a databank of 7 prospective, multisite, randomized trials on colorectal resection. Elective left colectomy via laparotomy. Preoperative and intraoperative risk factors for postoperative morbidity. Overall postoperative morbidity was higher in CC than in DD (32.4% vs 30.3%) but the difference was not statistically significant (P = .40). Two independent risk factors for morbidity in CC were antecedent heart failure (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.42-6.32) (P = .003) and bothersome intraluminal fecal matter (2.08; 1.42-3.06) (P = .001). Three independent risk factors for morbidity in DD were at least 10% weight loss (OR, 2.06; 95% CI, 1.25-3.40) (P = .004), body mass index (calculated as weight in kilograms divided by height in meters squared) exceeding 30 (2.05; 1.15-3.66) (P = .02), and left hemicolectomy (vs left segmental colectomy) (2.01; 1.19-3.40) (P = .009). Patients undergoing elective left colectomy for CC or for DD constitute 2 distinct populations with completely different risk factors for morbidity, which should be addressed differently. Improving colonic cleanliness (by antiseptic enema) may reduce morbidity in CC. In DD, morbidity may be reduced by appropriate preoperative nutritive support (by immunonutrition), even in patients with obesity, and by preference of left segmental colectomy over left hemicolectomy. By decreasing morbidity, mortality should be lowered as well, especially when reoperation becomes necessary.

Minimally Invasive Colorectal Resection Is Associated With a Transient Increase in Plasma Hepatocyte Growth Factor Levels Early After Surgery for Colon Cancer

Surgery's impact on blood levels of hepatocyte growth factor (HGF), a potent angiogenic factor, is unknown. Preoperative (PreOp) HGF blood levels are elevated in patients with colorectal cancer (CRC) and correlate with disease stage and prognosis. This study's purpose was to determine plasma HGF levels after minimally invasive colorectal resection (MICR) in patients with CRC. Clinical and operative data were collected. Blood samples were obtained in all patients PreOp and on postoperative day (POD) 1 and 3; in some, samples were taken during weeks 2 and 3 after MICR. Late samples were bundled into 7-day time blocks. HGF levels were determined via enzyme-linked immunosorbent assay in duplicate. Student's t test was used to analyze the data (significance, P < .0125 after Bonferroni correction). A total of 28 CRC patients who underwent MICR were studied. Most had right, sigmoid, or left segmental colectomy. The mean plasma HGF level was higher on POD 1 (2417 ± 1476 pg/mL, P < .001) and POD 3 (2081 ± 1048 pg/mL, P < .001) when compared with PreOp levels (1045 ± 406 pg/mL). Plasma levels were back to baseline by the second (1100 ± 474 pg/mL, P = .64) and third postoperative weeks (1010 ± 327 pg/mL, P = .51). MICR for CRC is associated with a 1.9- to 2.3-fold increase in plasma HGF levels during the first 3 PODs after which levels normalize. This transient increase may briefly promote angiogenesis and the growth of residual tumor cells.

Isolated primary schwannoma arising on the colon: report of two cases and review of the literature

Primary schwannoma of the large intestine is an extremely rare neoplasm. Here, we report two cases of colonic schwannoma confirmed pathologically after laparoscopic resection. A 52-year-old female and a 59-year-old female were referred by their general practitioners to our coloproctologic clinic for further evaluation and management of colonic submucosal masses. Colonoscopies performed in our institution revealed round submucosal tumors with a smooth and intact mucosa in the mid-ascending and descending colon, respectively. Computed tomography (CT) scans showed an enhancing soft tissue mass measuring 2 × 2 cm in the right colon and well-defined soft tissue nodule measuring 1.5 × 1.7 cm in the proximal descending colon, respectively. We performed laparoscopic right hemicolectomy and segmental left colectomy under the preoperative impression of gastrointestinal stromal tumors. Two cases were both diagnosed to be benign schwannoma of the colon after immunohistochemical stains (S-100 (+), smooth muscle actin (-), CD117 (-), and CD34 (-)).

The controversy regarding hand-assisted colorectal resection

The technique of hand-assisted colectomy was introduced in the 1990s but initially was not widely embraced by the minimally invasive community [1, 2]. However, in the past 4–6 years the popularity of hand-assisted methods has increased considerably. One reason for the surge in interest was the publication of the Clinical Outcomes of Surgical Therapy (COST) findings, which suggested that laparoscopic colectomy for cancer was associated with comparable oncological outcome and improved short-term results [3]. Many surgeons who had not been performing laparoscopic colectomy now felt it was safe to do so and, thus, began utilizing minimally invasive methods. Another important reason for the increased utilization of handassisted methods in recent years was the introduction of secondand third-generation devices that are far easier to use and are more versatile than the initial devices. As the use of hand-assisted techniques has increased, a rift has developed in the minimally invasive world regarding the appropriateness and need for hand-assisted methods. Strong proponents believe that hand-assisted methods are appropriate for all left-sided colorectal resections whereas others feel strongly that, for an experienced minimally invasive surgeon, there is no need for hand-assisted methods at all. Until recently, the relatively sparse published literature on the subject has been insufficient to settle the dispute. However, the recent multicenter randomized study presented at the 2007 American Society of Colon and Rectal Surgeons (ASCRS) meeting sheds further light on the subject. This study suggested that handassisted colectomy is associated with time savings of 33 and 57 min for left segmental colectomy and total abdominal colectomy, respectively. Importantly, the shortterm clinical outcomes of hand-assisted procedures were comparable to those obtained using straight laparoscopic methods [4]. The mean incision length for the hand-assisted group was 8.2 cm as opposed to 6.1 cm for the laparoscopic group. Despite these findings, the controversy continues. Laparoscopic ‘‘purists’’ believe that there is little or no place for hand-assisted methods because the straight laparoscopic approach results in a smaller final incision. Since the whole point of laparoscopy is to minimize abdominal wall trauma, they can find no acceptable rationale for ‘‘giving back’’ incision length to accommodate hand methods. Some feel that the abdominal wall trauma incurred with hand-assisted operations more resembles an open rather than a minimally invasive operation. They maintain that, with the proper skills and training, straight laparoscopic resections are feasible and clearly preferable to hand-assisted approaches. Straight laparoscopic proponents also worry that surgeons who exclusively learn handassisted methods will never master the two-handed technique and are not likely to cross the bridge to straight laparoscopic resection. Thus, a cadre of hand-assisted surgeons is likely to arise who will be doing a second best type of resection. Hand-assisted proponents believe that, clinically, for the majority, the recovery and morbidity of hand-assisted patients is very close to if not the same as patients that undergo straight laparoscopic resection. Further, they point out that the difference in overall incision size between the two approaches is not that great. Supporters also believe S. Stein New York Presbyterian Hospital, New York, NY, United States

CANCER COLIQUE ET GROSSESSE

We are reporting a case of colonic adenocarcinoma in a 18 weeks pregnant woman aged 42 years. We realised a left segmental colectomy completed by an adjuvant chemotherapy after a normal delivery. For months later, a bilateral ovarian metastasis were diagnose. Therfore, an hysterectomy and a bilateral ablation of annexes with an omentectomy was done. The ovulation was good without recurrence for four months later. Discussion : The adivised therapeutical attitude is to stop pregnancy before intervention during the first trimester, in the second trimester surgical treatment is indicated regardless pregnancy, in the thied trimester, it is necessary to wait until full pulmonary maturity of the foetus is seached, then intervene by a caesarian section and a curative surgical treatment at the some time. The diagnosis of cancer colon associated with pregnancy is difficult and needs a strong multidisciplinary collaboration. The prognosis of cancer colon is aggravted in pregnant women. It can not be emproved except with an early diagnosis.

Crohn's Colitis: Experience with Segmental Resections; Results in A Series of 84 Patients

Colonic Crohn's disease can be treated surgically by total colonic resection or by segmental colonic resection. The aim of this study was to analyze the outcomes of patients treated by segmental colectomy for colonic Crohn's disease. Among 413 patients undergoing operations for Crohn's disease, 84 had a segmental colectomy (cases of terminal ileitis with limited cecal involvement were not included). Postoperative complications, mortality, recurrence, and functional results were studied. Eighty-four patients (51 women, 33 men), with a mean age of 34 years, underwent operation (right segmental colectomy: 55%; left segmental colectomy: 40%; associated right and left colectomy: 5%). A stoma was established in 27 patients (32%). Operative mortality was zero. Twelve patients (14%) had postoperative complications (including six cases of anastomotic leakage). The mean and median followup times were 111 and 104 months, respectively (range: 15 to 276 months) for the 82 patients with followup available. Thirty-six patients had to undergo reoperation, and the mean time to reoperation was 4.5 years. Twenty-six of these patients suffered colonic recurrence and were treated by total colectomy (n = 9) or new segmentary resection (n 17). The only factor that correlated with the risk of recurrence was youth. At the end of the study, 13 patients still had a stoma. Seventy-five percent of the patients without stoma had less than three bowel movements per day, and 80% were fully satisfied or satisfied, There is no evidence of a higher risk of postoperative complications, surgical recurrence, or the requirement of a permanent stoma in patients suffering from colonic Crohn's disease who are treated according to a "bowel-sparing policy" compared with patients treated with more extensive resections published in the literature. Prospective randomized studies are needed to validate this observation.

Curative resection for left colonic carcinoma: Hemicolectomy vs. Segmental colectomy

PURPOSE: This study was developed to compare median and actuarial survival after left hemicolectomyvs.left segmental colectomy. METHODS: Between January 1980 and January 1985, 270 consecutive patients (133 males and 137 females; mean age, 64±12 (range, 18-91) years with left colonic carcinoma located between the left third of the transverse colon and (but not, including) the colorectal juncture were randomly allotted to undergo either left hemicolectomy or left segmental colectomy. Left hemicolectomy removed the entire left colon along with the origin of the inferior mesenteric artery and the dependent lymphatic territory. Left segmentai colectomy removed a more restricted segment of the colon and left the origin of the inferior mesenteric artery unmolested. RESULTS: After elimination of 10 patients for protocol violation, 131 patients with left hemicolectomy and 129 with left segmental colectomy were analyzed. Both groups were similar with regard to preoperative risk factors (age, sex, obesity, weight loss, anemia, diabetes, cirrhosis, kidney failure, steroid therapy or radiation therapy performed for any cause other than cancer), pathology findings (size, degree of differentiation, Dukes stage, invasion of lymph nodes at the origin of the inferior mesenteric artery), and associated lesions. Only the length of tumor-free margins of colon removed was significantly longer in left hemicolectomy. The number of early postoperative abdominal and extra-abdominal complications was similar in both groups. Overall, early postoperative mortality was 4 percent higher, but not significantly in left hemicolectomy (eight deaths, 6 percent) than in left segmental colectomy (three deaths, 2 percent). Median survival was 10 years and nearly equivalent in both groups. The two actuarial survivai curves were similar. Bowel movement frequency was significantly increased after left hemicolectomy during the first postoperative year. Our results suggest that survival after left segmental colectomy is equivalent to that of left hemicolectomy. Notwithstanding the observation of other carcinologic rules, left segmental colectomy rather than left hemicolectomy may theoretically be performed under laparoscopy without compromising the carcinologic outcome.