Splenic Flexure Research Articles

S2431 Ulcerative Colitis Flare-Ups Following mRNA COVID-19 Vaccination

Introduction: Ulcerative colitis (UC) is an autoimmune disease commonly managed with immunosuppressants. However, its put UC patients at a higher risk for infections. Therefore, vaccination is an important part of management. Messenger RNA (mRNA) vaccine is a new type of vaccine only widely used against COVID-19. The effect of mRNA vaccines on UC patients on immunomodulatory treatement is relatively unknown. Here, we present the first case of UC flare-up after receiving the SARS-CoV-2 mRNA vaccine. Case description/methods: A 36-year-old female with past medical history of ulcerative colitis, autoimmune pancreatitis presented with intermittent lower abdominal pain and diarrhea for 2 weeks with fever for 1 day. Her last flare-up was 3 years ago before she was put on Tofacitinib. She never required hospitalization. Her symptoms started the second day after she received the second dose of Pfizer COVID-19 vaccine. She had daily 5-10 times of non-bloody diarrhea and abdominal cramps. Her symptoms subsided after 7 days of initial onset. On day 11, she started to have daily up to 15 times bloody bowel movements, along with nausea, vomiting, unable to maintain oral intake. Day 17 after vaccination, patient went to ED after fever of 100.5F. On presentation, she is afebrile, WBC 11.9, CRP 61.8, calprotectin 1840, Clostridioides difficile negative, GI Panel negative. CT showed severe colitis involving the left colon from splenic flexure to rectum. Colonoscopy showed erythematous, granular, hemorrhagic, and ulcerated mucosa in the entire examined colon. Terminal ileum, cecum, ascending, transverse, descending, sigmoid and rectum biopsies were negative for CMV, showed chronic active colitis. Patient received intravenous Methylprednisolone, then transited to oral Prednisone taper and resumed her Tofacitinib. Her symptoms gradually improved. Discussion: To our best knowledge, no report has shown the association of mRNA vaccine and UC flare-up. In general, non-live vaccines are safe for UC patients regardless of immunosuppressants usage. Live vaccines are also contraindicated Tofacitinib users like our patient. In the Pfizer COVID-19 vaccine trial, patients on immunosuppressive therapy were excluded. Given the temporal relationship between the vaccine and her flare-up in the setting of long-term remission history, we are concerned that the stress induced by the mRNA vaccine may increase the risk of flare-up. More studies need to be done to evaluate the safety profile of mRNA vaccine for UC patients on immunosuppressants.Figure 1.: A: Nodular mucosa in second portion of duodenum. B: Multiple ulcers in terminal ileum. C and D: 1.7 cm segment of terminal ileum circumferential bowel wall thickening with mucosal hyperenhancement and submucosal edema.

S1588 Extra Pancreatic Pseudocyst (EPP) as an Initial Presentation in an Alcoholic Woman With No Previous Medical History

Introduction: Pseudocyst of pancreas is the most common complication of Acute and chronic pancreatitis. Pseudocysts can be intrapancreatic, peripancreatic and extra pancreatic. EPP in liver is a rare complication of Acute and chronic pancreatitis and only 26 cases have been reported so far. Here we are presenting a case of extra Pancreatic Pseudocyst located in the gall bladder fossa. Case Description/Methods: A 59-year-old female with history of Chronic alcohol use presented with severe abdominal pain of 10 days duration. The pain was sudden in onset, sharp, constant located diffusely throughout her abdomen but was noted to be worse on the right upper (RUQ), radiating to her lower back and right shoulder. She drinks at least 2 glasses of wine daily for several years. Vital signs are stable on admission. On physical exam, the abdomen was soft, rigid with rebound tenderness in RUQ. Labs showed an elevated C-Reactive Protein 20.6, Sedimentation Rare 123, WBC 18.2, platelets 637, lipase 906. Ultrasound showed hepatic steatosis with complex fluid collection adjacent to the gallbladder in the right hepatic lobe. Computed Tomography scan demonstrated a severe colitis along with 4.8 cm x 3.3 cm complex fluid collection in the gallbladder fossa and an enlarged pancreatic head with loss of adjacent fat planes and tracking of fluid into the mesentery, and a 7 mm fluid collection within the pancreatic head. Patient was started on IV antibiotics along with continuous IV fluids for sepsis and questionable pancreatitis due to fever spikes (102.3F) and Interventional radiology (IR) placed a drain. The appearance of the fluid with elevated enzymes (Fluid Lipase and Amylase: 5104 and 605) was consistent with pancreatitis. MRI/MRCP showed a 2.7 cm fluid collection in the pancreaticoduodenal groove and marked inflammatory changes around hepatic flexure of the colon and a persistent fluid collection posterior to the gallbladder. IR drained collection regional to the liver and gallbladder. Resolution of the fluid collection following drainage was noticed. All cultures were negative, antibiotics were discontinued. Patient improved clinically. Discussion: Most common location for EPP is lesser sac and least common site is Liver. Pathophysiology behind it is inflammatory disruption causing leakage of pancreatic fluid that migrates along hepatogastric, hepatoduodenal or by digesting tissue in the hepatic parenchyma. EPP are important to identify and surgical drainage would be mainstay of treatment to prevent severe complications.Figure 1.: CT scan showing collection in Gall Bladder fossa.

S1536 A Retained Gallstone Post-Cholecystectomy Presenting as Abdominal Pain and Bloody Diarrhea

Introduction: Retained gallstones is a complication of cholecystectomy which can lead to the formation of intra-abdominal abscesses. In the following case, we describe a patient who developed abdominal pain and bloody stools post-cholecystectomy, found to have a retained gallstone and abscess eroding into the liver parenchyma and colon. Case Description/Methods: A 69-year-old male with a past medical history significant for prostate cancer status post radiation and hormone therapy, hypertension, hyperlipidemia, and diabetes presented to the gastroenterology clinic for evaluation of bloody diarrhea and right lower quadrant abdominal pain of three weeks duration. He described the pain as constant and endorsed decreased appetite and three-pound weight loss over the same time period. Surgical history was significant for a laparoscopic cholecystectomy five months prior for gangrenous cholecystitis. A colonoscopy performed three years prior revealed radiation colonopathy and a tubular adenoma, but no other significant findings. Physical exam was unremarkable with no abdominal tenderness. Stool cultures and giardia were negative, and calprotectin was 8 mcg/g. Computed tomography of the abdomen and pelvis was subsequently performed, revealing a 3.5 × 2 cm peritoneal abscess with a 14 mm retained gallstone and gallstone fragments eroding into the liver parenchyma and the hepatic flexure of the colon. Given these findings, the patient was advised to present to the emergency department. He subsequently underwent a diagnostic laparoscopy with removal of the stone and drainage of the surrounding abscess. A Jackson Pratt drain was placed, and fluid cultures subsequently grew Escherichia coli. The patient was discharged with antibiotics on post-operative day two. On two-week follow up, the patient reported feeling well with complete resolution of his abdominal pain. Discussion: Gallstone spillage and subsequent abscess formation is a known risk of cholecystectomy. This most frequently occurs when laparoscopic cholecystectomy is complicated by gallbladder perforation. Symptoms of retained stones can present months to years after cholecystectomy. Definitive treatment generally requires both drainage of the abscess and removal of the retained gallstone to eliminate infection and prevent future repeat infection.Figure 1.: Computed tomography of the abdomen and pelvis (coronal view) demonstrating a 3.5 x 2 cm peritoneal abscess with a 14 mm retained gallstone (arrow) and gallstone fragments eroding into the liver parenchyma.

What Is the Optimal Elective Colectomy for Splenic Flexure Cancer: End of the Debate? A Multicenter Study From the GRECCAR Group With a Propensity Score Analysis.

The optimal elective colectomy in patients with splenic flexure tumor is debated. This study aimed to compare splenic flexure colectomy, left hemicolectomy, and subtotal colectomy for perioperative, histological, and survival outcomes in this setting. This is a multicenter retrospective cohort study. Patients diagnosed with nonmetastatic splenic flexure tumor who underwent elective colectomy were included. Between 2006 and 2014, 313 consecutive patients were operated on in 15 French Research Group of Rectal Cancer Surgery centers. Propensity score weighting was performed to compare short- and long-term outcomes. The primary end point was disease-free survival. Secondary end points included overall survival, quality of surgical resection, overall postoperative morbidity, surgical postoperative morbidity, and rate of anastomotic leakage. The most performed surgery was splenic flexure colectomy (59%), followed by subtotal colectomy (23%) and left hemicolectomy (18%). Subtotal colectomy was more often performed by laparotomy compared with splenic flexure colectomy and left hemicolectomy (93% vs 61% vs 56%, p < 0.0001), and was associated with a longer operative time (260 minutes (120-460) vs 180 minutes (68-440) vs 217 minutes (149-480), p < 0.0001). Postoperative morbidity was similar between the 3 groups, but the median length of hospital stay was significantly longer after subtotal colectomy (13 days (5-56) vs 10 (4-175) vs 9 (4-55), p = 0.0007). The median number of harvested lymph nodes was significantly higher after subtotal colectomy compared with splenic flexure colectomy and left hemicolectomy (24 (8-90) vs 15 (1-81) vs 16 (3-52), p < 0.0001). The rate of stage III disease and the number of patients treated by adjuvant chemotherapy were similar between the 3 groups. There was no difference in terms of disease-free survival and overall survival between the 3 procedures. The study was limited by its retrospective design. In the elective setting, splenic flexure colectomy is safe and oncologically adequate for patients with nonmetastatic splenic flexure tumor. However, given the oncological clearance after splenic flexure colectomy, it seems that the debate is not completely closed. See Video Abstract at http://links.lww.com/DCR/B703. ANTECEDENTES:La colectomía electiva óptima en pacientes con tumores del ángulo esplénico continua en debate.OBJETIVO:Comparar la colectomía de ángulo esplénico, hemicolectomía izquierda y colectomía subtotal para los resultados perioperatorios, histológicos y de supervivencia en este escenario.DISEÑO:Estudio de cohorte retrospectivo multicéntrico.ESCENARIO:Se incluyeron pacientes diagnosticados de tumores del ángulo esplénico no metastásicos que se sometieron a colectomía electiva.PACIENTES:Entre 2006 y 2014, 313 pacientes consecutivos fueron intervenidos en 15 centros GRECCAR.INTERVENCIONES:Se realizó una ponderación del puntaje de propensión para comparar los resultados a corto y largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la supervivencia libre de enfermedad. Los criterios de valoración secundarios incluyeron la supervivencia general, la calidad de la resección quirúrgica, la morbilidad posoperatoria general, la morbilidad posoperatoria quirúrgica y la tasa de fuga anastomótica.RESULTADOS:La cirugía más realizada fue la colectomía del ángulo esplénico (59%), seguida de la colectomía subtotal (23%) y la hemicolectomía izquierda (18%). La colectomía subtotal se realizó con mayor frecuencia mediante laparotomía en comparación con la colectomía de ángulo esplénico y la hemicolectomía izquierda (93% frente a 61% frente a 56%, p <0.0001), y se asoció con un tiempo quirúrgico más prolongado (260 min [120-460] frente a 180 min [68-440] frente a 217 min [149-480], p <0.0001). La morbilidad posoperatoria fue similar entre los tres grupos, pero la duración media de la estancia hospitalaria fue significativamente más prolongada después de la colectomía subtotal (13 días [5-56] frente a 10 [4-175] frente a 9 [4-55], p = 0.0007). La mediana del número de ganglios linfáticos extraídos fue significativamente mayor después de la colectomía subtotal en comparación con la colectomía del ángulo esplénico y la hemicolectomía izquierda (24 [8-90] frente a 15 [1-81] frente a 16 [3-52], p <0.0001). La tasa de enfermedad en estadio III y el número de pacientes tratados con quimioterapia adyuvante fueron similares entre los 3 grupos. No hubo diferencias en términos de supervivencia libre de enfermedad y supervivencia general entre los 3 procedimientos.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo.CONCLUSIONES:En un escenario electivo, la colectomía del ángulo esplénico es segura y oncológicamente adecuada para pacientes con tumores del ángulo esplénico no metastásicos. Sin embargo, dado el aclaramiento oncológico tras la colectomía del ángulo esplénico, parece que el debate no está completamente cerrado. Consulte Video Resumen en http://links.lww.com/DCR/B703.

Robotic Soave pull-through procedure for Hirschsprung's disease in children under 12-months: long-term outcomes.

To describe the long-term outcomes of the robotic Soave pull-through (RSPT) procedure for Hirschsprung's disease (HSCR) in children younger than 12months. A prospective observational study was conducted on HSCR patients under 12months of age who underwent RSPT at our institution between 2011 and 2020. Data regarding demographics, clinical features, technical details, operative time, hospital stay, postoperative complications, and long-term outcomes were prospectively collected. A total of 15 patients (9 male; 6 female) were included, with a median age at surgery of 4months (interquartile range 3-6), and a mean weight of 6.8 ± 1.3kg. Twelve patients suffered from rectosigmoid aganglionosis and three from long HSCR (extending up to the hepatic flexure). The mean total operative time was 240 ± 72min. The median hospital stay was 3days (interquartile range 3-4). Partial anastomosis dehiscence was observed in one patient, requiring reoperation on the 4th postoperative day. With a median follow-up of 79months (interquartile range 45-115), no fecal incontinence or mild soiling were observed. Constipation occurred in two patients and mild enterocolitis in one case. RSPT procedure for Hirschsprung's disease in children younger than 12months is a safe and effective procedure, with few complications and satisfactory long-term continence outcomes.

Surgical management of splenic flexure colon cancer: a retrospective propensity-matched study comparing open and minimally invasive approaches using the national cancer database

Minimally invasive resection of colon cancer at the splenic flexure can be technically challenging with concerns for a suboptimal oncologic outcome. We aimed to compare open and minimally invasive approaches following curative resection. The National Cancer Database was queried for patients with non-metastatic colon adenocarcinoma at the splenic flexure who underwent resection from 2010 to 2016. Cohorts were separated into open and minimally invasive approaches, and demographic and clinicopathologic variables were compared. Propensity-score matching (PSM) was utilized to balance potential confounding covariates between cohorts to elucidate the independent association between surgical approach and outcomes. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival. Secondary outcomes were analyzed by way of logistic regression or Mann-Whitney U test. After matching, 842 patients were compared between approaches. Patients who underwent minimally invasive surgery had no significant difference in regional nodes ≥ 12 examined, positive margins, negative circumferential margins, unplanned 30-day readmission, or time from surgery to initiation of chemotherapy when compared to patients who underwent open surgery. Minimally invasive surgery was significantly associated with decreased odds of 30-day mortality, 90-day mortality, and decreased mortality hazard for 5-year overall survival compared to open surgery. The optimal approach for surgical management of splenic flexure colon cancer has not been standardized given its rarity and exclusion from randomized controlled trials. Our retrospective review suggests that minimally invasive resection of splenic flexure colon cancers in carefully selected patients is associated with equivalent oncologic outcomes as well as improved short and long-term survival compared to an open approach.

Real-time fluorescence image-guided gastrointestinal oncologic surgery: Towards a new era.

Technological improvements are crucial in the evolution of surgery. Real-time fluorescence-guided surgery (FGS) has spread worldwide, mainly because of its usefulness during the intraoperative decision-making processes. The success of any gastrointestinal oncologic resection is based on the anatomical identification of the primary tumor and its regional lymph nodes. FGS allows also to evaluate the blood perfusion at the gastrointestinal stumps after colorectal or esophageal resections. Therefore, a reduction on the anastomotic leak rates has been postulated as one of the foreseeable benefits provided by the use of FGS in these procedures. Although the use of fluorescence in lymph node detection was initially described in breast cancer surgery, the technique is currently applied in gastric or splenic flexure cancers, as they both present complex and variable lymphatic drainages. FGS allows also to perform intraoperative lymphograms or sentinel lymph node biopsies. New applications of FGS are being developed to assist in the detection of peritoneal metastases or in the evaluation of the tumor resection margins. The present review aims to provide a general overview of the current status of real-time FGS in gastrointestinal oncologic surgery. We put a special focus on the different applications of FGS, discussing the main findings and limitations found in the contemporary literature and also the promising near future applications.

Colonic Volvulus

Colonic volvulus accounts for 3 to 5% of bowel obstructions in the United States. Current data reveal sigmoid volvulus as the most common colonic volvulus, followed by volvulus of the cecum, transverse colon, and splenic fixture. Despite a low incidence in the United States, diagnosis, management, and patient outcome depend on an appropriate index of suspicion and adherence to the proposed algorithm highlighting the approach to the patient with colonic volvulus. This review outlines the definition, pathogenesis, and epidemiology of colonic volvulus, as well as its clinical evaluation and treatment. Tables review the demographics of colonic volvulus in the United States, the differential diagnosis of and risk factors for colonic volvulus, important radiographic findings in colonic volvulus, and nonoperative management of sigmoid volvulus. Figures show the types of ileosigmoid knot; plain radiographs of cecal, sigmoid, transverse, and splenic flexure volvulus; contrast enema of cecal, transverse, splenic flexure, and sigmoid volvulus; cross-sectional abdominal imaging of cecal, sigmoid, and transverse colon volvulus and ileosigmoid knot; endoscopic evaluation in sigmoid volvulus; use of an esophageal overtube for placement of a rectal tube; necrotic cecum and transverse colon volvulus in the operating suite; and sigmoid volvulus in an elderly gentleman. This review contains 14 figures, 13 tables, and 165 references Keywords: Colonic volvulus, colonic obstruction, endoscopy, surgical intervention, ileosigmoid knot, splenic flexure volvulus, sigmoid volvulus, transverse colon volvulus, cecal volvulus

Proper surgical extent for clinical Stage I right colon cancer.

Purpose:Pre-operative evaluation identifying clinical-stage affects the decision regarding the extent of surgical resection in right colon cancer. This study was designed to predict a proper surgical resection through the prognosis of clinical Stage I right colon cancer.Patients and Methods:We included patients who were diagnosed with clinical and pathological Stage I right-sided colon cancer, including appendiceal, caecal, ascending, hepatic flexure and proximal transverse colon cancer, between August 2010 and December 2016 in two tertiary teaching hospitals. Patients who underwent open surgeries were excluded because laparoscopic surgery is the initial approach for colorectal cancer in our institutions.Results:Eighty patients with clinical Stage I and 104 patients with pathological Stage I were included in the study. The biopsy reports showed that the tumour size was larger in the clinical Stage I group than in the pathological Stage I group (3.4 vs. 2.3 cm, P < 0.001). Further, the clinical Stage I group had some pathological Stage III cases (positive lymph nodes, P = 0.023). The clinical Stage I group had a higher rate of distant metastases (P = 0.046) and a lower rate of overall (P = 0.031) and cancer-specific survival (P = 0.021) than the pathological Stage I group. Compared to pathological Stage II included in the period, some of the survival curves were located below the pathological Stage II, but there was no statistical difference.Conclusion:The study results show that even clinical Stage I cases, radical resection should be considered in accordance with T3 and T4 tumours.

Colonic leiomyoma mimicking a liver tumor: an unusual diagnosis after en-block robotic resection.

Colonic leiomyomas are rare. Their clinical presentation ranges from asymptomatic polyps detected on endoscopy to large symptomatic abdominopelvic masses. Imaging findings are usually non-specific, and percutaneous biopsy might help with differential diagnosis. However, radical surgery with negative margins is ultimately needed to rule out malignancy. We describe an uncommon presentation of a colonic leiomyoma mimicking a right hepatic lobe tumor on preoperative imaging. The robotic approach allowed a precise abdominal exploration with confirmation of colonic and hepatic infiltration and subsequent oncological en-block resection. Surgeons operating on hepatic tumors close to the right colic flexure should be aware of this diagnosis.

V11-09 ROBOTIC MODIFIED BALLOON-LESS RETROPERITONEAL APPROACH FOR POSTERIOR RENAL MASSES

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-09 ROBOTIC MODIFIED BALLOON-LESS RETROPERITONEAL APPROACH FOR POSTERIOR RENAL MASSES Thomas Lowrey, Jacob Allen, Daniel Parker, Andrew McIntosh, and Sanjay Patel Thomas LowreyThomas Lowrey More articles by this author , Jacob AllenJacob Allen More articles by this author , Daniel ParkerDaniel Parker More articles by this author , Andrew McIntoshAndrew McIntosh More articles by this author , and Sanjay PatelSanjay Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video demonstration will describe an efficient modified robotic retroperitoneal approach for posterior renal masses, avoiding the need for balloon dilation and extensive defatting in the traditional approach. METHODS: The patient is placed in the 90 degree flank position. A 5 mm laparoscope is placed 4 cm superior to the umbilicus at the midclavicular line, which will aid in visualizing placement of the working robotic ports. The reflection of the peritoneum at the white line of Toldt is identified in order to mark the robotic camera port site 2 fingerbreadths above the iliac crest. Two medial 8-mm robotic ports are placed 2 fingerbreadths above the iliac crest and 8 cm apart using the robotic camera port as reference. Next, with laparoscopic scissors and Kittner Dissector, the lateral side wall attachments to the colon are taken down creating space to safely place the camera port and lateral most trocar. Using a 30 degree upward scope, the peritoneum along white line of Toldt and lateral kidney attachments are incised up to the splenic flexure or hepatic flexure. Complete incision of the peritoneum allows the kidney to naturally flop medially thereby doubling the working space as compared to the traditional approach. Once the white line of Toldt is mobilized, the 4th arm lifts the kidney to place the hilum on traction. After Gerota’s fascia is incised and the hilum identified, standard partial nephrectomy is performed. RESULTS: A total of 15 patients underwent this new technique without any Clavien 1-4 complications. The technique allows for efficient port placement without the need for: blind finger entry, balloon dilation, tedious dissection and sweeping of the peritoneum required for port placement, and extensive defatting of the pararenal fat to create the retroperitoneal space. The port location in this technique is the same as the traditional retroperitoneal approach, thus affording the same view with increased working space and improved visualization of landmarks. Insufflation is also more consistent given less air leaks from inadvertent peritoneal tears and from the balloon dilating port site. CONCLUSIONS: This modified retroperitoneal approach allows for quick, efficient, and safe port placement resulting in larger working space and excellent visualization of anatomical landmarks without the need for complicated retroperitoneal balloon dilation, sweeping of peritoneum for port placement, and defatting of the pararenal fat. Since the development of this technique, we have abandoned the traditional robotic retroperitoneal approach with balloon dilation at our institution. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e860-e860 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Lowrey More articles by this author Jacob Allen More articles by this author Daniel Parker More articles by this author Andrew McIntosh More articles by this author Sanjay Patel More articles by this author Expand All Advertisement Loading ...

IMPACT OF RETROFLEXED VIEW ON THE DETECTION OF LESIONS IN THE PROXIMAL COLON: ASSESSMENT OF 393 PATIENTS IN A PRIVATE TERTIARY HOSPITAL.

The gold standard test for colorectal cancer screening the colonoscopy. Although this is the test of choice, colonoscopy misses a significant number of lesions, mainly in the proximal colon. With the purpose of reducing the number of lesions missed, new techniques have been studied, amongst them, retroflexed view in the right side of the colon and the second direct forward view. Assessing the safety of the retroview in the proximal colon (cecum and ascending colon), its impact on the detection of lesions in the proximal colon and its advantage over the double right forward view using adenoma detection rate and adenoma miss rate. Three hundred and ninety-three patients who came to Hospital Mater Dei to undergo colonoscopy from March to July 2017, prospectively. Out of these, 372 were included in the study based on the following exclusion criteria: being under 18 years of age, inadequate bowel preparations (Boston scale <7), history of colectomy, inflammatory bowel disease or polypoid diseases. First, an endoscopist inserted the colonoscope into the cecum and examine the cecum and the ascending colon with a forward view twice. In the third insertion into the cecum, retroflexed view was performed, cecal mucosa was examined until the hepatic flexure in search of polyps missed on forward view. All lesions found were resected and sent for histological analysis. In 334 (89.8%) patients, retroflexed view was performed successfully, 65.8% of failures were attributed to the loops of the device which prevented the maneuver. The direct view identified 175 polyps in the proximal colon in 102 people. Retroflexed view detected 26 polyps missed by the direct view in 24 (6.5%) people, with a missing rate of 12.9% in the test with only the forward view. Out of the 26 polyps found in retroview, 21 (80.76%) were adenomas, one of them with a high-grade dysplasia. Eleven patients had polyps seen only in retroflexed view. Retroview has increased the polyp detection rate from 27.41% to 31.72% and the adenoma detection rate from 21.77% to 25%. The adenoma miss rate by the double direct view was 12.8%. Without the retroview, one polyp in every 13.91 colonoscopies would be missed (number needed to treat - NNT=13.91). There was no adverse event. The retroflexed view technique in the proximal colon was shown to be safe, fast and feasible in most cases. It increased the adenoma detection rate and was shown to be advantageous in this study wit benefit beyond the double direct view.

Options for Low Rectal Cancer: Robotic Total Mesorectal Excision.

Low rectal cancers (LRCs) may offer a difficult technical challenge even to experienced colorectal surgeons. Although laparoscopic surgery offers a superior exposure of the pelvis when compared with open approach, its role in rectal cancer surgery has been controversial. Robotic platforms are well suited for difficult pelvic surgery due to its three-dimensional visualization, degree of articulation of instruments, precise movements, and better ergonomics. The robot may be suitable especially in the anatomically narrow pelvis such as in male and obese patients. Meticulous dissection in critical steps, such as splenic flexure takedown, nerve-sparing mesorectal excision, and distal margin clearance, are potential technical advantages. In addition, robotic rectal resections are associated with lower conversion rates to open surgery, less blood loss, and shorter learning curve with similar short-term quality of life outcomes, similar rates of postoperative complications, and equivalent short-term surrogate outcomes compared with conventional laparoscopy. Robotic surgery approach, if used correctly, can enhance the skills and the capabilities of the well-trained surgeon during minimally invasive procedures for LRC.

Management of postoperative complications after laparoscopic left hemicolectomy: an approach in modern times after incorporation of indocyanine green and full mobilization of the splenic flexure.

The aim of this study was to report our experience in the management of complications after laparoscopic left hemicolectomy (LLH) after the incorporation in our clinical practice of intraoperative indocyanine green (ICG) fluorescence angiography (FA). In our last period after incorporation of ICG-FA, 277 unselected consecutive patients underwent laparoscopic colorectal surgery with this technology. Ninety-seven (35%) right hemicolectomy, 19 segmental resection of the splenic flexure (6.9%), 54 anterior resection of the rectum (19.5%) and 107 LLH (38.6%) were performed. Complications were graded according to Clavien-Dindo classification, and anastomotic leakages (AL) were graded according to Clavien-Dindo classification and to International Study Group of Rectal Cancer (ISGRC) classification. Eight surgical and one medical complications (8.4%) were observed. Two AL occurred (1.9%). One drained spontaneously by drainage placed intraoperatively (Clavien-Dindo I, ISGRC A) and one treated by laparoscopic peritoneal lavage, leakage suture and ileostomy (Clavien-Dindo III-b, ISGRC C). Other complications were: wound infection (Clavien-Dindo II) (2); postoperative anemia caused by rectorrhagia (Clavien-Dindo II) (2); pelvic abscess between bladder and uterus (Clavien-Dindo III-a) (1); hemoperitoneum secondary to inferior mesenteric artery bleeding treated with peritoneal lavage and hemostasis (Clavien-Dindo III-b) (1); atrial fibrillation (Clavien-Dindo II) (1). All complications have been resolved. The complication rate after LLH after the incorporation of ICG-FA is low, since the number of AL have dramatically decreased in comparison to our previous experience. The management of these patients proved to be safe and effective due to in all cases the complication has been resolved. Further studies are required to standardize the management of these patients.

Submucosal Giant Lipoma of the Colon as an Unusual Cause of Partial Intestinal Occlusion: Report on Seven Consecutive Cases.

Colonic lipomas begin to be symptomatic when they reach a certain size, although the presentation can vary. In this study, we aimed to evaluate our experiences with the management of patients who presented with symptomatic giant colonic lipomas. The data of 7 patients with single colonic lipoma were retrospectively reviewed. The following data were evaluated: age, gender, clinical and diagnostic findings, American Society of Anesthesiologists (ASA) score, operative findings, postoperative complications, mortality, hospital stay duration, and hospital readmission. The diagnosis of colonic lipoma was established by computed tomography (CT). In this study, 4 (57.1%) of 7 patients with colonic lipoma were female, and 3 (42.9%) were male. The mean age was 56.7 years (range, 45-69). The main symptoms were abdominal pain (100%), and constipation (71.4%). The findings of intestinal occlusion detected on CT confirmed the diagnosis in all patients. Colon lipoma was located in the ascending colon in 2 patients, in the hepatic flexure in 2 patients, in the transverse colon in 2 patients, and in the cecum in 1 patient. The surgical procedure was uneventful in all patients. Four (57.1%) patients underwent laparoscopic colonic resection, while in the remaining 3 (42.9%) patients, a laparotomy was performed. The mean operating time was 185.7 min (150-210). Length of stay was 7.1 days (6-10), with no mortality. The mean diameter of the lesions was 7.4 cm (6-9). At a 6-month follow-up, all patients were asymptomatic with no signs of recurrence. Although colon lipomas are rare, they are of great importance because they can be symptomatic and can be confused with colon malignancies in the differential diagnosis. Being able to make a definitive preoperative diagnosis will change the surgical strategy. A minimally invasive surgical approach should be employed to resect symptomatic colonic lipomas with an experienced surgical team in eligible patients whenever possible.

Arterial supply to the rat colon.

Rats are often used as animal models in studies such as on intestinal transplantation and anastomosis healing, which require colectomy. Although detailed information regarding arterial supply is important to establish accurate and reproducible experimental procedures, this has not been studied in the rat colon. Therefore, we analysed the detailed arterial distribution pattern and its individual variations in the colon of 34 rats. The rat colon received colic branches of the ileocolic artery, and the right, middle and left colic arteries. The single left colic artery constantly arose from the caudal mesenteric artery and was distributed to the descending colon, whereas the others showed variations in number and distribution. The ileocolic artery gave rise to one (12%) or two (88%) colic branches supplying the proximal ascending colon, and these branches formed rich, mesh-like anastomoses along the initial portion of the ascending colon. One (74%) or two (26%) right colic arteries originated from the cranial mesenteric artery and supplied the ascending colon and right colic flexure. Moreover, one (38%), two (56%) or three (6%) middle colic arteries emerged from the cranial mesenteric artery and were distributed to the transverse colon, left colic flexure and proximal descending colon. In total, we categorized the individual variations in arterial branching and anastomosis into 11 patterns. Arterial supply to the rat colon showed a specific pattern and frequent individual variations. These findings thus provide essential information for establishing reproducible models of rat colic surgery.

A 60 Years Old Man with Adenocarcinoma of Colon and Lung with an Isolated Adrenal Metastasis: A Case Report

The incidence of synchronous colorectal and lung cancer associated with adrenal metastasis is relatively rare. We report of patient with tumour located in the right colic flexure adjoining ascending colon, mid and partly upper lobe of right lung. Pathological examination showed the colorectal and lung cancer were poorly differentiated adenocarcinoma. Right adrenal mass was adrenocortical metastatic carcinoma. Surgical treatment and postoperative adjuvant chemotherapy for the lung cancer were different from those for colorectal cancer with pulmonary metastasis. If possible, radical resection should be performed for each cancer when synchronicity is found.&#x0D; CBMJ 2020 January: Vol. 09 No. 01 P: 30-37

28139 A case of IgA vasculitis associated with underlying cytomegalovirus colitis

A 62-year-old Caucasian female with history of treated hepatitis C virus (HCV) infection in remission, secondary liver cirrhosis, and idiopathic CD4 deficiency presented for admission with hematochezia and gastrointestinal discomfort. She also endorsed a 2-week history of petechial rash on her feet. A colonoscopy revealed ulcerated, friable mucosa at the hepatic flexure with a biopsy confirming CMV colitis. The patient was promptly started on IV valgalanyclovir. Dermatology was consulted for the rash with examination revealing numerous scattered purpuric macules and papules on the legs and feet. A punch biopsy revealed leukocytoclastic vasculitis, while a direct immunofluorescence (DIF) assay demonstrated 2+ granular staining in superficial dermal vessels for IgA, IgM, IgG, C3, and fibrinogen. The patient’s hospital course was complicated by worsening renal function, hematuria, and Staphylococcus epidermidis bacteremia treated with IV daptomycin. The patient was felt to have IgA vasculitis, but given her concurrent infections systemic immunosuppression was not recommended. Her cutaneous lesions, hematochezia, hematuria and renal function all ultimately improved with treatment of the patient’s underlying colitis. To our knowledge, this is the third case of IgA vasculitis as a complication of underlying CMV infection of the gastrointestinal tract.

Vascular anatomy of the splenic flexure: a review of the literature.

Surgical treatment of the transverse colon is difficult because of the many variations of blood vessels. We reviewed the patterns of vascular anatomy and the definition of the vessels around the splenic flexure. We searched the PubMed database for studies on the vascular anatomy of the splenic flexure that were published from January 1990 to October 2020. After screening of full texts, 33 studies were selected. The middle colic arteries were reported to arise independently without forming a common trunk in 8.9-33.3% of cases. The left colic artery was absent in 0-7.5% of cases. The accessory middle colic artery was present in 6.7-48.9% of cases and was present in > 80% of cases without a left colic artery. The reported frequency of Riolan's arch was 7.5-27.8%. The frequency was found to vary widely across studies, partially due to the ambiguous definition of Riolan's arch. A comprehensive preoperative knowledge of the branching patterns of the middle colic artery and left colic artery and the presence of collateral arteries would be helpful in surgery for colon cancer in the splenic flexure.

Intracholecystic Papillary-Tubular Neoplasms (ICPNs): A Pathology Report

We presented a 60-year-old man who underwent a colonoscopy examination of a polypoid mass with a wound surface of 1.1 cm in hepatic flexure. An adenocarcinoma of intestinal type was diagnosed based on the biopsy report, and patient was referred to the hospital for colectomy. In colonoscopy and biopsy, the polypoid mass was completely removed, and despite different sections of the whole specimen in the colectomy specimen, any mass was not found, while only one out of three identified lymph nodes were involved. In laboratory tests, CBC had anemia: (Hb: 10.8 mg/ dl), elevated CEA tumor marker (range: 18 ng/ml), and lipid profile disorder together with high cholesterol (300 mg/dl), indicating colon cancer manifestation.