Splenic Flexure Research Articles

A comprehensive evaluation of 80 consecutive robotic low anterior resections: impact of not mobilizing the splenic flexure alongside low-tie vascular ligation as a standardized technique.

Rectal cancer surgery represents challenges due to its location. To overcome them and minimize the risk of anastomosis-related complications, some technical maneuvers or even a diverting ileostomy may be required. One of these technical steps is the mobilization of the splenic flexure (SFM), especially in medium/low rectal cancer. High-tie vascular ligation may be another one. However, the need of these maneuvers may be controversial, as especially SFM may be time-consuming and increase the risk of iatrogenic. The objective is to present the short- and long-term outcomes of a low-tie ligation combined with no SFM in robotic low anterior resection (LAR) for mid- and low rectal cancer as a standardized technique. A retrospective observational single-cohort study was carried out at Reina Sofia University Hospital, Cordoba, Spain. 221 robotic rectal resections between Jul-18th-2018 and Jan-12th-2023 were initially considered. After case selection, 80 consecutive robotic LAR performed by a single surgeon were included. STROBE checklist assessed the methodological quality. Histopathological, morbidity and oncological outcomes were assessed. Anastomotic stricture occurrence and distance to anal verge were evaluated after LAR by rectosigmoidoscopy. Variables related to the ileostomy closure such as time to closure, post-operative complications or hospital stay were also considered. The majority of patients (81.2%) presented a mid-rectal cancer and the rest, lower location (18.8%). All patients had adequate perfusion of the anastomotic stump assessed by indocyanine green. Complete total mesorectal excision was performed in 98.8% of the patients with a lymph node ratio < 0.2 in 91.3%. The anastomotic leakage rate was 5%. One patient (1.5%) presented local recurrence. Anastomosis stricture occurred in 7.5% of the patients. The limitations were small cohort and retrospective design. The non-mobilization of the splenic flexure with a low-tie ligation in robotic LAR is a feasible and safe procedure that does not affect oncological outcomes.

Comparison of Long-term Outcomes between Hirschsprung's Disease Patients after Soave Procedure and Duhamel Procedure Based on the Paediatric Incontinence and Constipation Scoring System: A Retrospective Cohort Study

Introduction: Hirschprung's disease is a congenital disease that causes intestinal motility disorders. Hirschprung's disease is still the most common condition that causes intestinal obstruction in children. The incidence of Hirschprung's disease is 1:5000 live births. The incidence ratio of this disease is around 4:1 between men and women, with a higher percentage of men 1,3,4. Approximately 75% of cases of Hirschprung's disease occur in the rectosigmoid colon area, 17% in the splenic flexure or transverse colon and 8% along the colon and terminal ileum. The Duhamel technique still remains a popular procedure most surgeons especially for long segment treatment and redo procedures.28, 30 The advantage of the Duhamel Procedure is that it is easy to perform, reduces the risk of damage to surrounding structures such as genitourinary innervation, but has the possibility of complications of anastomotic leakage which causes fistulas and abscesses.&#x0D; Materials and Methods: Total subjects of this study was 441 patients with Hirschprung's disease who were treated with the Soave procedure and the Duhamel procedure at Dr. Moewardi General Hospital in Surakarta, Central Java, Indonesia for the period January 2017 - January 2022. This type of research is descriptive analytics with a retrospective cohort.&#x0D; Results: The results of the study can be concluded that patients with HAEC increases the risk of constipation. Congenital abnormalities predispose to fecal incontinence. Differences in surgical techniques do not significantly influence or increase the risk of constipation and fecal incontinence based on statistical tests. However, the increased risk of constipation and fecal incontinence is higher in patients undergoing the Duhamel surgical procedure.&#x0D; Conclusion: Conclusions that can be drawn from research regarding the comparison of long-term outcomes of Hirschsprung disease patients after Soave and Duhamel operations based on the Pediatric Incontinence and Constipation Scoring System at Dr. Moewardi General Hospital in Surakarta, Indonesia for period January 2017 – January 2022, it can be concluded that there is no significant difference in the outcome of patients who underwent the Soave or Duhamel procedures. The Duhamel procedure has a higher prevalence of complications of constipation and fecal incontinence compared to the Soave procedure. The presence of HAEC before the surgical procedure increases the risk of constipation, significantly in the Soave and Duhamel procedures.

Bispectral index monitoring for sedation in scheduled adult colonoscopy: A randomized controlled trial

BackgroundPatients should be closely monitored during procedures under sedation outside the operating room, but it is unclear which type of monitoring is best. We investigated the efficacy and safety of BIS monitoring vs conventional monitoring for sedation during colonoscopy. MethodsWe performed a double-blind clinical trial in 180 patients undergoing elective colonoscopy. Patients were randomized to 1) the BIS group or 2) a control group, in which sedation was monitored with a BIS monitor or the Ramsay Sedation Score, respectively. The primary outcome was the rate of sedation-induced adverse events in both groups. Secondary outcomes were the characteristics of patients who developed adverse events, and time during colonoscopy when these events occurred, propofol and remifentanil dosage, and patient satisfaction. ResultsUnivariate analysis showed fewer cardiopulmonary complications in the BIS group (41.11% vs 57.78% in controls; p = 0.02). Multivariate analysis found a significantly higher risk of adverse events in older patients (95% CI, 1.013–1.091; p = 0.0087) and in men (95% CI, 1.129–7.668; p = 0.0272). These events were observed at the hepatic flexure. No significant differences between propofol or remifentanil dosage, use of rescue medication, and patient satisfaction were observed between groups. ConclusionsOur data suggest that BIS monitoring during sedation in scheduled colonoscopies reduces adverse respiratory events. Although its routine use in sedation does not appear to be warranted, clinicians should take steps to identify patients with a higher risk of complications who might benefit from this type of monitoring.

Audit of hemostatic clip use after colorectal polyp resection in an academic endoscopy unit.

Background and study aims Prophylactic closure of endoscopic resection defects reduces delayed hemorrhage after resection of non-pedunculated colorectal lesions ≥ 20 mm that are located proximal to the splenic flexure and removed by electrocautery. The risk of delayed hemorrhage after cold (without electrocautery) resection is much lower, and prophylactic clip closure after cold resection is generally unnecessary. The aim of this study was to audit clip use after colorectal polyp resection in routine outpatient colonoscopies at two outpatient centers within an academic medical center. Patients referred for resection of known lesions were excluded. Patients and methods Retrospective chart analysis was performed as part of a quality review of physician adherence to screening and post-polypectomy surveillance intervals. Results Among 3784 total lesions resected cold by 29 physicians, clips were placed after cold resection on 41.7% of 12 lesions ≥ 20 mm, 19.3% of 207 lesions 10 to 19 mm in size, and 2.8% of 3565 lesions 1 to 9 mm in size. Three physicians placed clips after cold resection of lesions 1 to 9 mm in 18.8%, 25.5%, and 45.0% of cases. These physicians accounted for 8.1% of 1- to 9-mm resections, but 69.7% of clips placed in this size range. Electrocautery was used for 3.1% of all resections. Clip placement overall after cold resection (3.9%) was much lower than after resection with electrocautery (71.1%), but 62.4% of all clips placed were after cold resection. Conclusions Audits of clip use in an endoscopy practice can reveal surprising findings, including high and variable rates of unnecessary use after cold resection. Audit can potentially reduce unnecessary costs, carbon emissions, and plastic waste.

First worldwide report on rectal resections with Hugo™ surgical system: description of docking angles and tips for an effective setup.

Rectal robotic surgery gained momentum in the last decade, but it is still associated with not-negligible costs. In order to reduce costs, recently different robotic systems have received approval for clinical use. This study aims to present the first case series of rectal resection with the novel cost-effective platform Robotic Assisted Surgery (RAS) Hugo™. Tips for effective set up of the system and detailed configuration of tilt and docking angles are also provided. Three cases of rectal resection with Hugo RAS™ system are reported. After the first two cases of resection with partial mesorectal excision in which surgeries were performed with the setup proposed by the vendor company, in the third case we tested a novel setup that allowed a full robotic low rectal resection performing vascular ligations, TME and colonic splenic flexure mobilization without the need of any de-docking. Our first three robotic rectal resections with the Hugo RAS™ system were completed without complications with a median docking time of 12 min (range 8-15) and a median console time of 345 minutes (range 271-475). In the first two cases, hybrid robotic and laparoscopic surgeries were performed to obtain an adequate haemostasis and traction during the pelvic phase. In the third case, a full robotic TME was successfully accomplished. Our experience demonstrates that a full robotic low rectal resection with TME with Hugo™ RAS system is feasible, safe and associated with satisfactory postoperative outcomes.

Abstract 3467: Tumor immune and microbial characteristics of colorectal cancer according to age at diagnosis and detailed anatomical location

Abstract Background: Colorectal cancer is a heterogeneous disease, exhibiting spectra of tumor characteristics that vary across age at diagnosis and anatomical location. We hypothesized that tumor immune and microbial characteristics of colorectal cancer might change with age at diagnosis and detailed anatomical location. Methods: We utilized a pooled dataset of colorectal cancer cases (N= 958 to1413 depending on variables) with available immune cell density or microbial data in the Nurses' Health Study, Health Professionals Follow-up Study, and Ontario Familial Colon Cancer Registry. We examined whether there were statistically significant trends in tumor immune and microbial according to age at diagnosis and detailed primary tumor location (cecum, ascending, hepatic flexure, transverse, splenic flexure, descending, sigmoid, rectosigmoid, rectum) using Spearman’s correlation test. The densities of immune cells were determined by using multiplex immunofluorescence, including T cells (CD3, CD4, CD8, CD45RA, CD45RO, FOXP3) and macrophages (CD68, M1-like, and M2-like) in tumor intraepithelial and stromal regions. We conducted stratified analyses by microsatellite instability (MSI) status. Results: The density of memory (both CD4+ and CD8+) T cells in tumor epithelial areas continuously increased as age at diagnosis increased (P for trend &amp;lt;0.005). Compared to later-onset colorectal cancer, early-onset colorectal cancer had a lower density of memory T-cells. With respect to tumor site, CD3+CD4+ and CD3+CD8+ T densities in tumor epithelial areas were highest in the cecum compared to other subsites, and there was a statistically significant decreasing trend from the cecum to rectum (P for trend &amp;lt;0.005). We also observed significant decreasing trends for CD68+, M1-like, and M2-like macrophage densities in combined tumor (intraepithelial and stromal) regions from the cecum to rectum (P for trend &amp;lt;0.005). The proportion of F. nucleatum-positive colorectal cancers gradually decreased from the cecum to rectum (P for trend &amp;lt;0.005). Similar trends were observed in separate analyses in non-MSI-high cases. Conclusions: This study suggests that certain tumor immune and microbial characteristics in the tumor microenvironment, specifically T cell and macrophage densities and Fusobacterium nucleatum positivity, change gradually according to age at diagnosis and/or detailed anatomical location. Age and anatomical location spectra in tumor immune and microbial characteristics will shed light on the etiology of colorectal cancer (including early-onset colorectal cancer), leading to better-personalized cancer prevention and treatment. Citation Format: Tomotaka Ugai, Yasutoshi Takashima, Yuxue Zhong, Juha P. Väyrynen, Daniel Buchanan, Jeroen Huyghe, Li Hsu, Conghui Qu, Sushma Thomas, Claire Thomas, Steve Gallinger, Robert Grant, Ulrike Peters, Amanda I. Phipps, Jonathan Nowak, Shuji Ogino. Tumor immune and microbial characteristics of colorectal cancer according to age at diagnosis and detailed anatomical location [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3467.

Transduodenal robotic ampullectomy: tips and tricks and strategies for postoperative duodenal fistula management (with video).

Transduodenal Ampullectomy (TA) is a procedure for resecting low-malignancy ampullary tumors, with postoperative fistula as a notable complication. This study aims to clarify the indications for TA, outline the surgical robotic technique, and emphasize the importance of comprehensive complication management alongside the surgical approach. This multimedia article provides a detailed exposition of the robotic TA surgical technique, including the most important steps involved in exposing and reimplanting biliary and pancreatic ducts. The procedure encompasses the mobilization of the hepatic flexure of the colon, an extensive Kocher maneuver for duodenal mobilization, and ampulla exposure through a duodenal incision. Employing retraction loop sutures enhances surgical field visibility. Reconstruction involves securing pancreatic and biliary ducts to the duodenal mucosa, each tutored with a silicon catheter, and suturing for ampullectomy completion. The total operative time was 380min. Final histopathology disclosed high-grade dysplasia with an isolated focus of adenocarcinoma (pT1), accompanied by clear resection margins. A postoperative duodenal fistula occurred, managed successfully through conservative treatment, utilizing subcutaneous drainage. Despite accurate robotic TA execution, complications may arise. This study underscores the importance of a comprehensive approach, incorporating meticulous surgical technique and effective complication management, to optimize patient outcomes.

Surgical approach to splenic flexure adenocarcinoma of the colon: Less is more?

IntroductionDue to the watershed vasculature and lymphatic drainage of splenic flexure (SF) neoplasms, and their exclusion from large clinical trials, optimal management remains debated. This study evaluated extent of resection and surgical approach for SF adenocarcinoma and their respective outcomes. MethodsAdults with stage I-III splenic flexure adenocarcinoma were identified in the National Cancer Database (2004–2020) and categorized by surgical management. ResultsOf 7412 patients, 4264 (58%) underwent extended colectomy (EC). The cohorts were overall similar, though more patients with stage I disease were managed with segmental colectomy (SC) (24% vs. 20%, p < 0.01). Those undergoing EC had longer hospital stays (LOS) and greater odds of readmission. Use of robotic-assisted surgery was higher in SC (9% vs. 7%, p < 0.01) and increased from 1% in 2010 to 24% in 2020. This approach was independently associated with a shorter LOS than open surgery. Despite a higher number of lymph nodes examined (median 18 vs. 16), EC and SC had similar nodal (both 37%, p = 0.95) and margin involvement (both 4%, p = 0.39). Five-year survival after EC and SC was similar (75% vs. 76%, p = 0.6). Patients undergoing robotic surgery had significantly lower odds of positive surgical margins and experienced an improved prognosis. ConclusionsEC and SC were performed at similar rates for SF adenocarcinoma, while the use of robotic surgery increased over time. Neither extent of resection nor surgical approach significantly impacted oncologic outcomes. These data indicate that surgical decision-making should be balanced between tumor- and patient-specific considerations, morbidity of extended colectomy, and surgeon preference. SynopsisIn a national cohort of splenic flexure cancers, segmental and extended colectomy were associated with comparable rates of negative margins, nodal involvement, and survival. Robotic assist increased over time without impacting oncologic outcomes. Surgical procedure and approach should thus be tailored to clinical condition and surgeon preference.

Quantification of surgical workflow during robotic proctectomy.

Surgical workflow assessments offer insight regarding procedure variability. We utilised an objective method to evaluate workflow during robotic proctectomy (RP). We annotated 31 RPs and used Spearman's correlation to measure the correlation of step time and step visit frequency with console time (CT) and total operative time (TOT). Strong correlations were seen with CT and step times for inferior mesenteric vein dissection and ligation (ρ=0.60, ρ=0.60), lateral-to-medial splenic flexure mobilisation (SFM) (ρ=0.63), left rectal dissection (ρ=0.64) and mesorectal division (ρ=0.71). CT correlated strongly with medial-to-lateral (ρ=0.75) and supracolic SFM visit frequency (ρ=0.65). TOT correlated strongly with initial exposure time (ρ=0.60), and medial-to-lateral (ρ=0.67) and supracolic SFM visit frequency (ρ=0.65). This study correlates surgical steps with CT and TOT through standardised annotation, providing an objective approach to quantify workflow.

Monitorización del índice biespectral para sedación en colonoscopias electivas de pacientes adultos: ensayo controlado aleatorizado

BackgroundPatients should be closely monitored during procedures under sedation outside the operating room, but it is unclear which type of monitoring is best. We investigated the efficacy and safety of BIS monitoring vs conventional monitoring for sedation during colonoscopy. MethodsWe performed a double-blind clinical trial in 180 patients undergoing elective colonoscopy. Patients were randomized to 1)the BIS group or 2)a control group, in which sedation was monitored with a BIS monitor or the Ramsay Sedation Score, respectively. The primary outcome was the rate of sedation-induced adverse events in both groups. Secondary outcomes were the characteristics of patients who developed adverse events, and duration of colonoscopy when these events occurred, propofol and remifentanil dosage, and patient satisfaction. ResultsUnivariate analysis showed fewer cardiopulmonary complications in the BIS group (41.11% vs 57.78% in controls; P=.02). Multivariate analysis found a significantly higher risk of adverse events in older patients (95%CI: 1.013-1.091; P=.0087) and in men (95%CI: 1.129-7.668; P=.0272). These events were observed at the hepatic flexure. No significant differences between propofol or remifentanil dosage, use of rescue medication, and patient satisfaction were observed between groups. ConclusionsOur data suggest that BIS monitoring during sedation in scheduled colonoscopies reduces adverse respiratory events. Although its routine use in sedation does not appear to be warranted, clinicians should take steps to identify patients with a higher risk of complications who might benefit from this type of monitoring.

Comparative long-term outcomes of natural orifice specimen extraction surgery and conventional laparoscopic colectomy for left-sided colorectal cancer: a propensity score-matched analysis.

Natural orifice specimen extraction surgery (NOSES) is currently widely used in left-sided colorectal cancer. Some clinical comparative studies have been conducted, providing evidence of its safety and oncological benefits. However, these studies are typically characterized by small sample sizes and short postoperative follow-up periods. Consequently, in this research, the authors adopt the propensity score matching method to undertake a large-scale retrospective comparative study on NOSES colectomy for left-sided colorectal cancer, with the goal of further augmenting the body of evidence-based medical support for NOSES. This retrospective study involved patients who underwent NOSES colectomy and conventional laparoscopic (CL) colectomy for left-sided colorectal cancer between January 2014 and April 2021. In the NOSES group, specimens were extracted through the anus with the help of a Cai tube (homemade invention: ZL201410168748.2). The patients were matched at a ratio of 1:1 according to age, sex, BMI, tumor diameter, tumor location (descending and splenic flexure colon/ sigmoid colon/ middle and upper rectum), tumor height from anal verge, ASA grade, previous abdominal surgery, clinical pathologic stage, preoperative CEA. After matching, 132 patients in the NOSES group and 132 patients in the CL group were eligible for analysis. Compared with CL group, NOSES group was associated with decreased postoperative maximum pain score (2.6±0.7 vs. 4.7±1.7, P=0.000), less additional analgesia required (6.8 vs. 34.8%, P=0.000), faster time to passage of flatus (2.3±0.6 days vs. 3.3±0.7 days, P=0.000), less wound infection (0.0 vs. 6.1%, P=0.007), and longer operative time (212.5±45.8min vs. 178.0±43.4min, P=0.000). No significant differences were observed in estimated blood loss, time to resume regular diet, postoperative hospital stay, conversion to open surgery or conventional minilaparotomy, total morbidity, readmission, mortality, pathologic outcomes, and Wexner incontinence score between groups. After a median follow-up of 63.0 months, the 5-year overall survival rates were 88.3 versus 85.0% (P=0.487), disease-free survival rates were 82.9 versus 83.6% (P=0.824), and the local recurrence rates were 4.4 versus 4.0% (P=0.667) in the NOSES and CL groups, respectively. This study suggests that NOSES colectomy using a Cai tube for left-sided colorectal cancer is a safe and feasible option with better cosmetic results, less pain, faster recovery of gastrointestinal function, and comparable long-term clinical and oncologic outcomes to CL colectomy.

The Complexities of Colorectal Cancer: A Case Report

Background: Colorectal cancer (CRC) is a malignancy that originates from the colon tissue (ascending, transverse, descending, sigmoid colon) and rectal tissue. Colorectal cancer is the fourth most common cancer in the world, and the second leading cause of cancer death. In Indonesia (2020), colorectal cancer was ranked sixth of the all malignancy diagnoses with a total of 17,368 new cases (4,4%).&#x0D; Case presentation: a case of colon cancer (mucinous adenocarcinoma) in a 70 year old woman. Diagnosis was based on anamnesis of the presence onf intermitten abdominal pain, a mass in the right iliac region of the abdomen, and defecation accompanied by blood. On physical examination, there was tenderness and a mass in the right iliac region, and a positive Carnett’s sign. computer tomography (CT) of the urinary tract without contrast was performed and revealed a mass was found in the right abdomen, suspicious for the ascending colon and hepatic flexure of the colon, a cyst with a diameter of ± 3cm in the right kidney.&#x0D; Conclusion: Anatomical patology (microscopic) results showed mucinous adenocarcinoma. The treatment for this patient was exploratory laparotomy, right hemicolectomy, and end to end anastomosis.&#x0D;

SF-CORNER (splenic flexure colorectal cancer): an international survey of operative approaches and outcomes for cancers of the splenic flexure.

The optimum surgical approach to splenic flexure cancers (SFCs) remains uncertain. The aim of this survey was to explore the opinions of an international surgical community on the management and outcomes of SFC. A questionnaire was constructed comprising five sections (information about respondents; definition and prognosis of SFC; operative approach; approach in specific scenarios; outcomes) and circulated through an international dissemination committee and social media. The survey received 576 responses over 4 weeks across 50 countries. There was no consensus regarding the definition of the splenic flexure, whilst the proportion of respondents who did and did not think that patients with SFC had a worse outcome was equal. The overall preferred operative approach was left hemicolectomy [203 (35.2%)], followed by segmental resection [167 (29%)], extended right hemicolectomy [126 (21.9%)] and subtotal colectomy [7 (12%)]. The stated pedicles for ligation varied between resection types and also within the same resection. One hundred and sixty-six (28.8%) respondents thought a segmental resection was associated with the worst survival and 190 (33%) thought it was associated with the best quality of life. This survey confirms a lack of consensus across all aspects SFC treatment. The differing approaches described are likely to represent different beliefs around the variable anatomy of this region and the associated lymphatic drainage. Future studies are required to address such inconsistencies and identify the optimum surgical strategy, whilst also incorporating quality-of-life metrics and patient-reported outcomes. A one-size-fits-all approach is probably not appropriate with SFC, and a more bespoke approach is required.

Colonic intussusception from pedunculated colonic lipoma at hepatic flexure: A case report and review of current literature

Colonic lipomas are a benign tumor that can present in multiple ways, including; incidentally, abdominal pain, change in bowel habit, bleeding, intestinal obstruction and intussusception. We present the case of a 48-year-old gentlemen who presented to the emergency department with a 3 day history of abdominal pain and was found to have a 5 cm intramural ischemic pedunculated colonic lipoma causing intussusception and large bowel obstruction. He received initial management with emergency laparoscopic exploration, reduction of intussusception, colotomy and lipoma excision. He made a full recovery. The current approaches to management of colonic lipomas are conservative, endoscopic or surgical. This case highlights the potential consequences of untreated colonic lipomas. In our review of the literature, we highlight that there is a lack of clear consensus on appropriate management of these patients.

Virtual Monoenergetic Images Facilitate Better Identification of the Arc of Riolan During Splenic Flexure Takedown.

This study aimed to investigate whether virtual monoenergetic images (VMIs) can aid radiologists and surgeons in better identifying the arc of Riolan (AOR) and to determine the optimal kilo electron volt (keV) level. Thirty-three patients were included. Conventional images (CIs) and VMI (40-100 keV) were reconstructed using arterial phase spectral-based images. The computed tomography (CT) attenuation and noise of the AOR, the CT attenuation of the erector spinal muscle, and the background noise on VMI and CI were measured, respectively. The signal-to-noise ratio, contrast-to-noise ratio (CNR), and signal intensity ratio were calculated. The image quality of the AOR was evaluated according to a 4-point Likert grade. The CT attenuation, noise, CNR, and signal intensity ratio of the AOR were significantly higher in VMI at 40 and 50 keV compared with CI ( P < 0.001); VMI at 40 keV was significantly higher than 50 keV ( P < 0.05). No significant difference in signal-to-noise ratio, background noise, and CT attenuation of the spinal erector muscle was observed between VMI and CI ( P > 0.05). virtual monoenergetic image at 40 keV produced the best subjective scores. Virtual monoenergetic image at 40 keV makes it easier to observe the AOR with optimized subjective and objective image quality. This may prompt radiologists and surgeons to actively search for it and encourage surgeons to preserve it during splenic flexure takedown.

A modified method for precise anastomosis during laparoscopic low anterior resection for rectal cancer: the first clinical experience and application

BackgroundThere is no criterion to guide and evaluate the anastomosis of laparoscopic low anterior resection (LAR). We developed a new technique for precise anastomosis. This study endeavored to evaluate the effectiveness and safety of this new technology.MethodsPatients with mid-low rectal cancer who underwent laparoscopic LAR in our department were enrolled retrospectively between January 1, 2021 and July 1, 2023. During the LAR, the distance between the sacral promontory and the rectal stump was measured and used to determine the length of the sigmoid colon, which was preserved for anastomose. The demographic characteristics and short-term outcomes were analyzed.ResultsForty-nine patients (26 men, 23 women) with low and middle rectal cancer were retrospectively enrolled in the study. The distance of the tumor from the anal verge was 6.4 ± 2.7 cm. The operative time was 193 ± 42 min. All patients underwent precise anastomosis, among which 12 patients underwent freeing of the splenic flexure of the colon. According to our criteria, there was no redundant or tense state of the colon anterior to the sacrum after the anastomosis. Only one patient had a postoperative anastomotic leak (Grade B). All 15 patients receiving neoadjuvant chemoradiotherapy underwent terminal ileostomy. No postoperative death occurred within 30 days of the surgery. The median follow-up time in our study was 12 months. One patient developed a single metastasis in the right lobe of the liver in the eighth month after surgery and underwent microwave radiofrequency ablation, which did not recur in the four months of postoperative follow-up, and the rest of the patients survived disease-free without recurrence of metastasis.ConclusionsPrecise measurement of the proximal colon of the anastomosis can ensure accurate and convenient colorectal anastomosis and this may be a technique worthy of clinical application. However, its effectiveness needs to be further verified in a multicenter clinical trial.

Splenic Flexure Mobilization: A Subinferior Mesenteric Vein Approach in a Patient With a Large Renal Cyst.

Splenic Flexure Mobilization: A Subinferior Mesenteric Vein Approach in a Patient With a Large Renal Cyst.

Mucinous Colorectal Adenocarcinoma on a 21-Year-Old Female. Case Report and Literature Review

Colon and rectal cancer is now the third most diagnosed in the West. About 40% of cases are diagnosed after age 75, and the incidence increases with age. Mucinous colorectal adenocarcinoma is a subtype of colon cancer. The effect of diet on the development of colon and rectal cancers is unclear. The clinical picture divides the colon into 2: Right-sided colon (cecum, ascending colon, hepatic flexure) versus the left-sided colon (splenic flexure, descending colon, sigmoid, rectosigmoid) and rectum. Arbitrarily, two-thirds of the transverse colon is on the right side. Patients are usually asymptomatic for the most part, when symptoms exist, they present as transrectal bleeding, changes in intestinal habits, anemia, or abdominal pain. In younger patients, additional factors are used to identify those at higher risk for colorectal cancer. (e.g., having a family history of colorectal cancer, changes in bowel habits, unexplained weight loss, and blood mixed with the stool instead of blood on the surface of the stool).

THE COLONIC MUCOSAL MICROBIOME IN IBD-ASSOCIATED ARTHRITIS IS MORE VARIABLE THAN IN IBD ALONE

Abstract BACKGROUND Inflammatory bowel disease (IBD)-associated arthritis affects over 25% of those with IBD and is associated with several risk factors including disease location. The intestinal microbiome varies throughout the intestinal tract and is thought to play a role in the development of IBD, although the precise mechanism remains unexplored. To better characterize its relationship with IBD-associated arthritis, we analyzed the intestinal microbiome from a subset of subjects in the LOCATION-IBD cohort. METHODS Microbiome analysis was performed on 16S rRNA V3V4 amplicon sequencing data generated from mucosal biopsies from the terminal ileum (TI), hepatic flexure (HF), and the distal descending colon (DDC) of participants in the LOCATION-IBD cohort. Alpha diversity was assessed using the Shannon index, while beta diversity between samples from the same participant were assessed using Jenson-Shannon Divergence (JSD). ZicoSeq was used to assess differential abundances in composition between those with vs without IBD-associated arthritis. RESULTS In this analysis, we included a subset of samples from participants in the LOCATION-IBD cohort with (n= 68 from 25 participants) and without (n = 86 from 29 participants) joint EIMs and with joint pain of unclear etiology (n= 14 from 5 participants). Overall, samples clustered predominantly based on participant, and similar genera were present across TI, HF, and DDC mucosal samples. Shannon diversity was similar across samples, regardless of the associated arthritis category, though diversity was lower in those with CD compared to those with UC (p-value = 0.0007, Tukey post-hoc p-value = 0.0004) and trended to be higher in sites of inflammation (p-value = 0.0645). JSDs between samples for an individual participant were higher for those with compared to those without IBD-associated arthritis (p-value = 0.038). In those with joint EIMs, Flavonifractor and Fusicatenibacter were significantly lower without accounting for sampling location, whereas other species including Lachnoclostridium (increased) and Fusobacterium (decreased) were noted in the proximal colon. CONCLUSIONS To our knowledge, this represents the first assessment of the mucosal microbiome across several intestinal sites in individuals with and without IBD-associated arthritis. Our finding that similar bacteria are found across the terminal ileum, proximal colon, and distal colon, but that less site-to-site concordance is seen in those with IBD-associated arthritis, aligns with previous findings that the involvement of specific colonic segments is associated with IBD-associated arthritis. Further, our finding that the abundances of specific bacteria are altered, frequently in a site-specific manner, identifies potential opportunities for future studies.

Oncologic safety of transverse colon cancer surgery without central vessel ligation.

108 Background: Transverse colon cancers (TCC) have mixed embryological and molecular characteristics of right and left colon cancers and they are difficult to classified to right or left colon cancer due to the ambiguity of their location. Therefore, there is a lack of research about TCC alone, and it tended to be excluded in previous large clinical trials. Also, the optimal surgical procedure for each TCC varies depending on the location and stage of the tumor and anatomic structure of the patient. Consequently, standardization of surgery for TCC has not been established, and the oncologic benefits of central vessel ligation (CVL) with complete mesocolic excision and D3 dissection are unclear yet. The aim of the study is to evaluate oncologic safety of TCC surgery without CVL of middle colic artery. Methods: It is a retrospective, observational study. The clinical, surgical, and pathological characteristics were investigated retrospectively and statistical analyses were performed using chi-square test, independent samples T-test, and Kaplan-Meier analysis. Mid TCC was defined as tumor arising in the middle third of transverse colon and determined by intraoperative exploration. Hepatic and splenic flexure colon cancer, which were defined as tumor is adjacent to liver or spleen, were excluded. Radical resection was conducted along the embryological surgical plane, following D2 or D3 dissection. Central vessel ligation was defined as ligation of root of middle colic artery. Results: The numbers of proximal, mid, and distal TCC were 48 (45.3%), 32 (30.2%), and 26 (24.5%), respectively. The numbers of right hemicolectomy, transverse colectomy and left hemicolectomy were 57 (53.8%), 28 (26.4%) and 21 (19.8%). The numbers of No CVL group and CVL group were 47 (44.3%) and 59 (55.7%). The numbers of stage I, II and III were 24 (22.6%), 45 (42.5%), 37 (34.9%), and 49 patients underwent adjuvant treatment. The most frequent organ of recurrence was peritoneum (N=6, 5.6%). There was no statistically significant difference of stage, mean number of retrieved lymph node (24.12 vs. 22.36 p=0.464), mean number of metastatic lymph node (1.53 vs. 0.74, p=0.163), mean proximal margin (19.2 cm vs. 16.7 cm, p=0.139), mean distal margin (9.6 cm vs. 9.9 cm, p=0.753), adjuvant chemotherapy, and the rate of recurrence with lymph node metastasis. Also, there was no statistically significant difference of 6-year DFS survival and OS in stage II and III. Conclusions: When following oncologic plane and adequate lymph node dissection, resection without CVL for TCC is considered to have equal surgical and oncologic outcomes comparing to resection with CVL. Therefore, it is considered that CVL would not be always mandatory for TCC surgery, and a branch of middle colic artery could be preserved, if necessary.