Vascular Ligation Research Articles

CME versus D3 Dissection for Colon Cancer.

Over the past 30 years, rectal cancer surgery has been standardized by total mesorectal excision. More recently, some have suggested that colon cancer surgery should be standardized by complete mesocolic excision (CME) with central vascular ligation (CVL), especially in Western countries. Surgeons undertaking CME with CVL report optimal outcomes. Sharp dissection within the embryological plane and high vascular ligation at the vessel origin are essential. In Japan, a similar concept, D3 dissection, has been adopted for decades. Although both surgical procedures are similar, distinct differences exist. Some surgeons are confused about the principles and practice of these two procedures. As well as overviewing the theory behind CME with CVL and D3 dissection, the technical details of both procedures are described.

Inclusion of L5–S1 in oblique lumbar interbody fusion–techniques and early complications–a single center experience

Background contextThe oblique prepsoas retroperitoneal approach to the lumbar spine for interbody fusion or oblique lumbar interbody fusion (OLIF) provides safe access to nearly all lumbar levels. A wide interval between the psoas and aorta allows for a safe and straightforward left-sided oblique approach to the discs above L5. Inclusion of L5–S1 in this approach, however, requires modifications in the technique to navigate the complex and variable vascular anatomy distal to the bifurcation of the great vessels. While different oblique approaches to L5–S1 have been described in the literature, to our knowledge, no previous study has provided guidance for the choice of technique. PurposeOur objectives were to evaluate our early experience with the safety of including L5–S1 in OLIF using 3 different approach techniques, as well as to compare early complications between OLIF with and without L5–S1 inclusion. Study designRetrospective cohort study. Patient sampleOf the 87 patients who underwent lumbar interbody fusion at 167 spinal levels via an OLIF approach, 19 included L5–S1 (group A) and 68 did not (group B). Outcome measuresDemographics, levels fused, indications, operative time (ORT), estimated blood loss (EBL), vascular ligation, intraoperative blood transfusion, length of stay (LOS), discharge to rehabilitation facility, and complications (intraoperative, early ≤90 days, and delayed >90 days) were retrospectively assessed and compared between the groups. MethodsA retrospective chart and imaging review of all consecutive patients who underwent OLIF at a single institution was performed. Indications for OLIF included symptomatic lumbar degenerative stenosis, deformity, and spondylolisthesis. The L5–S1 level, when included, was approached via one of the following 3 techniques: (1) a left-sided intrabifurcation approach; (2) left-sided prepsoas approach; and (3) right-sided prepsoas approach. Vascular anatomic variations at the lumbosacral junction were evaluated using the preoperative magnetic resonance imaging (MRI), and a “facet line” was proposed to assess this relationship. A minimum of 6 months of follow-up data were assessed for approach-related morbidities. ResultsDemographics and operative indications were similar between the groups. The mean follow-up was 10.8 (6–36) months. ORT was significantly longer in group A than in group B (322 vs. 256.3 min, respectively; p=.001); however, no difference in ORT between the two groups was found in the subanalyses for 2- and 3-level surgeries. Differences in EBL (260 vs. 207.91 cc, p=.251) and LOS (2.76 vs. 2.48 days, p=.491) did not reach statistical significance. Ligation of the iliolumbar vein, segmental veins, median sacral vessels, or any vascular structure, as needed for adequate exposure, was required in 13 (68.4%) patients from group A and 4 (5.9%) from group B (p<.00001). Two patients suffered minor vascular injuries (1 in each group); however, no major vascular injuries were seen. Complications were not significantly different between groups A and B, or between the three approaches to L5–S1, and trended lower in the latter part of the series as the learning curve progressed. ConclusionsInclusion of L5–S1 in OLIF is safe and feasible through three different approaches but likely involves greater operative complexity. In our early experience, inclusion of L5–S1 showed no increase in early complications. This is the first series that reports the use of 3 different oblique approaches to L5–S1. The proposed “facet line” in the preoperative MRI may guide the choice of approach.

Right hemicolectomy with D3 lymph node dissection for right-sided transverse colon cancer using the Senhance robotic system: a case report

BackgroundThe evolution of remote systems and artificial intelligence technology has led to increase in robotic surgeries. One system used in this case report is the Senhance robotic system. The most important premise for using robotic surgery in cancer therapeutics is to ensure oncological safety. Similar to conventional laparoscopic surgery, robotic surgery needs to be a reliable and secure surgical procedure, such as complete mesocolic excisions with central vascular ligations in Western countries or D3 lymph node dissections (dissection of the lymph nodes that locates from the origin to the terminal branch of the main feeding artery of cancer) in Japan.Case presentationA 76-year-old man underwent clinical examination for severe anemia. He was diagnosed with transverse colon cancer of tumor (T)3, node (N)1a, metastasis (M)0 cancer stage IIIA. A right hemicolectomy with D3 lymph node dissection using the Senhance surgical system was performed. The operative time was 313 min and the estimated blood loss was 5 ml. He was discharged from our hospital 12 days after the surgery without any complications. What is the remarkable of this report, not only mobilization of right colon but also D3 lymph node dissection and vascular ligation were performed intraperitoneally by using Senhance robotic system as conventional laparoscopic surgery. We tried using fourth robotic arm to accomplish lymphadenectomies and middle colic artery dissection. A right hemicolectomy with D3 dissection using the Da Vinci surgical system was reported. Another report of a right hemicolectomy performed with the Senhance robotic system was identified; however, in that study, lymph node dissections were not performed intraperitoneally.ConclusionsTherefore, to our knowledge, this is the first report using the Senhance robotic system for right hemicolectomy with D3 dissection. We hope that our case report will assist in the establishment of this robotic procedure in surgical practice.

In vitro holding security of four friction knots of monofilament or multifilament suture used as a first throw for vascular ligation.

To evaluate holding security of 4 friction knots created with various monofilament and multifilament sutures in a vascular ligation model. 280 friction knot constructs. 10 friction knots of 4 types (surgeon's throw, Miller knot, Ashley modification of the Miller knot, and strangle knot) created with 2-0 monofilament (polyglyconate, polydioxanone, poliglecaprone-25, and glycomer-631) and braided multifilament (silk, lactomer, and polyglactin-910) sutures were separately tied on a mock pedicle and pressure tested to the point of leakage. Linear regression analysis was performed to compare leakage pressures among suture materials (within friction knot type) and among knot types (within suture material). Mean leakage pressure of surgeon's throws was significantly lower than that of all other knots tested, regardless of the suture material used. All the other knots had mean leakage pressures considered supraphysiological. Significant differences in mean leakage pressure were detected between various friction knots tied with the same type of suture and various suture types used to create a given knot. Variability in leakage pressure among knots other than the surgeon's throw was greatest for poliglecaprone-25 and lowest for polydioxanone. Most differences in knot security, although statistically significant, may not have been clinically relevant. However, results of these in vitro tests suggested the surgeon's throw should be avoided as a first throw for pedicle ligation and that poliglecaprone-25 may be more prone to friction knot slippage than the other suture materials evaluated.

ICG-assisted D3 lymphadenectomy in right colectomy for cancer

Background: The presence of regional lymph node (LN) metastasis is a strong negative prognostic factor in colorectal cancer (CLRC). Recent advances in surgical management of CLRC, such as complete mesocolic excision (CME) with central vascular ligation (CVL), are focused on quality of surgical specimen, including an increase of LN count, in order to obtain a better survival than standard surgery. The aim of the study is to verify if intraoperative real-time visualization of the lymph flow, using indocyanine green fluorescence imaging (ICG-FI), improves lymphadenectomy during laparoscopic right hemicolectomy for cancer, performed according to CME/CVL criteria.

Complete mesocolic excision for right colon cancer—state of art: a systematic review of the literature

: Complete mesocolic excision (CME) is a new concept of right hemicolectomy for colon cancer (CC) set up to improve oncological outcomes and based on three main points: dissection in the embryological plane, central vascular ligation (CVL) and resection of a sufficient length of bowel. During this last decade, many doubts and questions have been arised about safety and efficacy of CME. We conducted a systematic review of the literature to investigate the safety, quality and survival outcomes of this procedure. Literature search resulted in 659 articles found and after the selection process 21 studies properly fulfilling inclusion and exclusion criteria were included. The total number of collected patients was 7,402 (mean age 65.42 years, 51.27% men). The weighted mean number of lymph nodes retrieved was 27.45 and the mean number of metastatic nodes was 1.34. Surgical complication and overall operative mortality rate were 5.5% and 0.5% respectively. Five-year overall survival (OS) and disease-free survival (DFS) rates were 84.3% and 82.8%. Available data from literature have several limitations mostly including non-homogeneous and incomplete reports together with no evidence from randomized control trial (RCT) studies. Therefore, to date, the quality of evidence is low and does not consistently support the superiority of CME over the standard right hemicolectomy, despite a reported trend to improved survival with comparable operative morbidity and mortality. More reliable data from large sample size RCTs are needed before CME can be recommended as the standard of care for right CC.

Successful hybrid surgery for ileal conduit stomal varices following oxaliplatin-based chemotherapy in a patient with advanced colorectal cancer

BackgroundEctopic variceal bleeding is a rare but life-threatening complication of portal hypertension (PH). Oxaliplatin-based chemotherapy for colorectal cancer (CRC) is associated with sinusoidal obstruction syndrome of the liver, which can lead to PH.Case presentationHere, we report a successful hybrid surgery that included intraoperative obliteration of ileal conduit stomal varices (ICSVs) for a 66-year-old woman with CRC and liver metastasis that had been treated multimodally during the previous 4 years, including 17 courses of oxaliplatin-based chemotherapy. She was admitted to our hospital for massive hemorrhage from an ileal conduct stoma. Image findings showed ICSVs as a part of portosystemic shunt, which were afferently supplied from the superior mesenteric vein (SMV) and drained by the numerous cutaneous veins connected to the left femoral vein. Obliteration of the stomal varices by interventional radiologic techniques alone was inappropriate because of difficulties of cannulating the efferent cutaneous veins. We, therefore, performed hybrid surgery for the ICSV, which included cannulation into the SMV branch and antegrade obliteration of the varices with a 5% solution of ethanolamine oleate with iopamidol under blocking the SMV flow, using a vascular clip and ligation. Hemorrhage in her ileal conduit stoma disappeared completely.ConclusionCustomized treatment of ectopic varices should be based on their precise vascular anatomy; hybrid surgery with intraoperative angiography is an alternative treatment for ectopic varices such as ICSV.

Higher cut-offs for the number of lymph nodes harvested do not predict better prognosis in patients with colon cancer

BackgroundCurrent threshold for minimum lymph node harvest may not be adequate for appropriate staging in colon cancer and newer surgical techniques may allow more lymph nodes to be harvested. The aim of this study was to examine the prognostic role of harvesting and examining lymph nodes higher in number than the recommended threshold (≥12), in patients with colon cancer. MethodsThis retrospective study included 179 patients that underwent open colon resection for adenocarcinoma of the colon. A D3 resection with high vascular ligation was made so that large number of lymph nodes was removed in most patients. Differences in overall survival between below and above three cutoff points (≥18, ≥24, ≥40) were estimated. ResultsDuring median 33 months of follow-up, 45 patients died and mean overall survival was 108.7 ± 5.6 months (95% CI, 97.7–119.7). The mean number of lymph nodes harvested and examined was 44.0 ± 25.7 (median 38; range, 7–150). No significant effect was found for three different cut-off values (≥18, ≥24, or ≥40 nodes) on mean overall survival (p > 0.05 for all comparisons). The same was true for the whole study population as well as for N0 (N negative) and N1-2 (N positive) patient subgroups, when they are analyzed separately. ConclusionsOur findings do not support the survival benefit of substantially higher number of lymph nodes harvested in colon cancer.

Concept of Complete Mesocolic Excision and the Role of Computed Tomography Imaging

Abstract Complete mesocolic excision (CME) with central vascular ligation (CVL) has gained traction in recent years as an effective advanced surgical technique for surgical treatment of colon cancer. In this review, the concept of CME is described, along with relevant variant vascular anatomy and local staging implications for radiologists. Future directions in research are also explored, with a focus on correlation between radiology and pathology.

Laparoscopic complete mesocolic excision with true central vascular ligation for right-sided colon cancer

BackgroundComplete mesocolic excision (CME) is known to be effective for colon cancer. However, in right-sided colon cancer, central vascular ligation (CVL) is not easy to perform. In particular, in patients in whom the superior mesenteric vein (SMV) runs on the ventral side of the superior mesenteric artery (SMA) (Type V/A), laparoscopic ligation of the artery at its root is extremely difficult compared with this procedure in patients in whom the SMA runs on the ventral side of the SMV (Type A/V).MethodsWe started performing laparoscopic CME with true CVL for right-sided colon cancer using the SMA as a landmark in 2015, and by 2019, we had completed it for 60 patients. To start, the mesocolon is opened well to the caudal side of the ileocolic vessels. The mesentery is then fully detached from the retroperitoneal tissue, after which the ileocolic vessels are ligated at their roots. D3 lymph node dissection of the lymph nodes around the SMA and SMV on the resection side is also performed using the SMA as a landmark, and depending on the location of the tumor, the roots of the right and middle colic vessels are ligated and divided. This study was conducted with the approval of the Tokyo Medical University Ethics Committee. All patients provided informed consent.ResultsThe tumor was located in the cecum in 21 cases, the ascending colon in 33, and the transverse colon in 6. The mean operating time was 229 min and the mean volume of hemorrhage was 67 ml. There was one Clavien-Dindo Grade 3 or worse postoperative complication (ileus). There were no surgery-related or in-hospital deaths.ConclusionThis procedure can be performed comparatively safely. However, since it requires some skill, we consider that it should only be performed in suitable cases by teams with sufficient experience.

Robotic complete mesocolic excision and central vascular ligation for right-sided colon cancer: short-term outcomes from a case series.

Despite conflicting data regarding oncological outcomes, studies demonstrate that complete mesocolic excision (CME) and central vascular ligation (CVL) for right-sided colon cancer removes significantly more tissue and yields higher lymph node counts when compared to conventional resection. This study aims to report the safety profile of CME and CVL in patients undergoing robotic surgery for right-sided colon cancer during the introduction of this technique across two institutions. Patients who underwent an elective robotic right colectomy with CME and CVL for right-sided colon cancer in a public quaternary and a private tertiary healthcare centre between November 2018 and April 2020 were included. Demographic, clinical, perioperative and histopathological variables were recorded and analysed. Twenty patients (13 females) with a median age of 69 (23-83) years and median body mass index of 27 (19-46) were included. All of them had a pre-operative diagnosis of right-sided colon adenocarcinoma. Median operative time and blood loss were 140 (130-300) min and 30 (20-100) mL, respectively. There were no conversions or intra-operative complications. There were two post-operative complications recorded (one ileus and one intra-abdominal collection treated with intravenous antibiotics) and no re-interventions. Median length of stay was 4 (2-8) days. All patients had an R0 resection, and the median lymph node yield was 36 (22-80) lymph nodes. This series demonstrates a safe introduction of robotic CME and CVL in patients with right-sided colon cancer. The lymph node harvest obtained with CME and CVL in this setting was high.

Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer.

The treatment of colon cancer has had numerous recent advances, in terms of surgical approach, adjuvant therapies, and more. In this review, the authors examine randomized clinical trials comparing open surgery to laparoscopic surgery (including total mesocolic excision), and also examine the role of robotic surgery. Novel surgical techniques including the no-touch technique, side-to-side anastomosis, suture technique, complete mesocolic excision (CME) with central vascular ligation (CVL), and natural orifice transluminal endoscopic surgery (NOTES) are outlined. The role of placing endoscopic self-expandable metal stents (SEMS) for colonic obstruction is compared and contrasted with the surgical approach, and the effect that the anti-VEGF inhibitor bevacizumab may have on this side effect profile is further explored. The role of the resection of the primary tumor in the setting of metastatic disease is examined with respect to survival benefit. Pathways of perioperative care which can accelerate post-surgical recovery, including enhanced recovery after surgery (ERAS) are examined. The role of adjuvant chemotherapy in patients with high-risk stage II and patients with stage III disease is examined, along with the role on circulating tumor DNA (ctDNA) as well as with the biologic targeted agents cetuximab and bevacizumab. Lastly, the authors detail the postoperative surveillance schedules after surgical resection with respect to survival outcomes.

Robotic Complete Mesocolic Excision with Central Vascular Ligation for Right Colon Cancer: Surgical Technique and Short-term Outcomes

BackgroundMinimally invasive colorectal surgery has demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic assistance is an evolution of minimally invasive technique.PurposeThe study aims to present technical details and short-term oncological outcomes of robotic-assisted complete mesocolic excision (CME) with central vascular ligation (CVL) for right colon cancer.MethodologyFifty-two consecutive patients affected by right colon cancer were operated between May 2016 and February 2020 with da Vinci Xi platform. Data regarding surgical and short-term oncological outcomes were systematically collected in a colorectal specific database for statistical analysis.ResultsThirty-seven (71.15%) and 15 (28.85%) patients underwent right and extended right hemicoletomy with an extracorporeal anastomosis. Median age was 55 years. Mean operative time was 182 ± 36 min. Mean blood loss was 110 ± 90 ml. Conversion rate was 3.84% (two cases). 78.84% (41 cases) were pT3 and mean number of harvested lymph nodes was 28 ± 4. 1/52 (1.92%) had a documented anastomotic leak requiring exploratory laparotomy and diversion proximal ileostomy. Surgery-related grade IIIa–IIIb Calvien Dindo morbidity were noted in 9.61% and 1.92%, respectively.ConclusionRobotic assistance allows performance of oncological adequate dissection of the right colon with radical lymphadenectomy as in open surgery, confirming the safety and oncological adequacy of this technique, with acceptable results and short-term outcomes.

Comparative Study between Total Mesocolic Exesion Versus Conventional Right Hemicolectomy in management of Tumors of the Right Colon

The essential treatment for colon malignant growth is medical procedure. The piece of the huge inside with malignancy is evacuated, alongside encompassing lymph hubs. Malignancy found in the climbing colon and hepatic flexure, the correct side is evacuated by right hemicolectomy or expanded right hemicolectomy. The idea of complete mesorectal extraction (TME) as proposed by Heald et al. in the mid 80's brought about altogether better oncological results in rectal malignant growth medical procedure. TME likewise raised the issue of better results in colon malignant growth medical procedure, which, up to that point, was not normalized and the reports in the writing showed a lot of heterogeneity and high repeat rates. In 2009 and in corresponding to the TME idea, came the primary report and portrayal of the total mesocolic extraction (CME) with focal vascular ligation (CVL), with very noteworthy oncological results and a general 5-year endurance coming to up to 70% for stage III colon malignant growth patients. They additionally demonstrated that it is a sheltered and plausible strategy which bears at any rate a similar dreariness and mortality as the purported standard technique.CME with CVL comprises of two primary segments. Right off the bat, it focuses on the safeguarding of flawless fasciae of the mesocolon between which pertinent lymph hubs are contained. Also, the vessels that gracefully the tumor colon site must be ligated at their starting point, to be specific at the degree of the unrivaled mesenteric vein for right sided injuries, thusly the nerves of the celiac plexus, which run along the predominant mesenteric supply route, and the hypogastric plexus, which runs on the aorta, individually, are secured, and the evacuation of the total mesocolon and the greatest lymph hub yield is accomplished.

Prospective study of oncologic outcomes after laparoscopic modified complete mesocolic excision for non-metastatic right colon cancer (PIONEER study): study protocol of a multicentre single-arm trial

BackgroundThe introduction of complete mesocolic excision (CME) with central vascular ligation (CVL) for right-sided colon cancer has improved the oncologic outcomes. Recently, we have introduced a modified CME (mCME) procedure that keeps the same principles as the originally described CME but with a more tailored approach. Some retrospective studies have reported the favourable oncologic outcomes of laparoscopic mCME for right-sided colon cancer; however, no prospective multicentre study has yet been conducted.MethodsThis study is a multi-institutional, prospective, single-arm study evaluating the oncologic outcomes of laparoscopic mCME for adenocarcinoma arising from the right side of the colon. A total of 250 patients will be recruited from five tertiary referral centres in South Korea. The primary outcome of this study is 3-year disease-free survival. Secondary outcome measures include 3-year overall survival, incidence of surgical complications, completeness of mCME, and distribution of metastatic lymph nodes. The quality of laparoscopic mCME will be assessed on the basis of photographs of the surgical specimen and the operation field after the completion of lymph node dissection.DiscussionThis is a prospective multicentre study to evaluate the oncologic outcomes of laparoscopic mCME for right-sided colon cancer. To the best of our knowledge, this will be the first study to prospectively and objectively assess the quality of laparoscopic mCME. The results will provide more evidence about oncologic outcomes with respect to the quality of laparoscopic mCME in right-sided colon cancer.Trial registrationClinicalTrials.gov ID: NCT03992599 (June 20, 2019). The posted information will be updated as needed to reflect protocol amendments and study progress.

Laparoscopic extended right hemicolectomy with complete mesocolic excision and central vascular ligation for mid-transverse colon cancer.

Laparoscopic extended right hemicolectomy with complete mesocolic excision and central vascular ligation for mid-transverse colon cancer.

Laparoscopic left hemicolectomy with regional lymph node navigation and intracorporeal anastomosis for splenic flexure colon cancer.

Laparoscopic approaches have become a standard strategy for colon cancer patients who undergo surgical treatment. Complete mesocolic excision (CME) with central vascular ligation (CVL) is the fundamental principle of radical resection of colon cancers. Splenic flexure colon cancer (SFCC) is rare, accounting for less than 4% of all colorectal cancer cases. Moreover, a laparoscopic approach for SFCC following the CME/CVL concept can be challenging because the blood supply of the splenic flexure is derived from either the middle colic artery (MCA) branching from the superior mesenteric artery, the left colic artery (LCA) branching from the inferior mesenteric artery. In addition, approximately one third of SFCC patients have an accessory MCA that can originate from the celiac trunk. Herein, we describe the technical procedure of a laparoscopic left hemicolectomy for SFCC using indocyanine green (ICG) for necessary and sufficient lymphadenectomy followed by intracorporeal anastomosis. Two injections of ICG (0.5mg/0.2ml × 2) into the subserosa of the proximal and distal sides of the tumor preceded the surgical procedure after pneumoperitoneum. Near infrared images obtained throughout the laparoscopic procedure helped visualize lymphatic drainage vessels and inform decision making for determining vessels requiring ligation according to the CVL concept: MCA, LCA or accessory MCA. Complete intracorporeal anastomosis following necessary and sufficient lymphadenectomy with ICG can minimize the dissecting area of the laparoscopic left hemicolectomy for SFCC patients. Intravenous ICG injection (2.5mg) after anastomosis helps confirm blood perfusion at the anastomosis site. Four patients with SFCC underwent a laparoscopic colectomy under ICG navigation in 2019 at our institute. The median operative time was 237min, the median estimated blood loss was 0ml, and the median number of dissected lymph nodes was 13. No patients experienced postoperative complications. In conclusion, laparoscopic left hemicolectomy with ICG navigation and intracorporeal anastomosis for SFCC patients may be a feasible option for the radical resection of colon cancer.

Effects of electroacupuncture on skeletal muscle and blood glucose in rats with diabetic amyotrophy

To explore the effects of electroacupuncture (EA) on skeletal muscle and blood glucose in rats with diabetic amyotrophy. Among 40 SD rats, 10 rats were randomly selected into the control group and received no treatment. The remaining 30 rats were treated with intraperitoneal injection of streptozotocin (STZ, 60 mg/kg) to establish diabetes mellitus (DM) model, and then the rats were treated with vascular ligation at right posterior limb to establish amyotrophy model. The rats with diabetic amyotrophy were randomly divided into a model group and an EA group, 10 rats in each group (10 rats were excluded due to unsuccessful model establishment and death). The rats in the EA group was treated with EA at right-side "Yishu (EX-B 3)" "Shenshu (BL 23)" "Zusanli (ST 36)" and "Sanyinjiao (SP 6)", disperse-dense wave, 2 Hz/ 15 Hz, 20 minutes each time, once a day for 3 weeks. Before and after EA treatment, the blood sample was collected from inner canthus and the "glucose oxidase-peroxidase" method was used to detect fasting blood glucose level; ELISA method was used to detect insulin content. At the end of the treatment, HE staining method was used to observe the morphology of ischemic skeletal muscle in the right hindlimb; the real-time PCR method was used to detect the mRNA expression of muscle atrophy F-box (MAFbx), muscle ring finger-1 (MuRF1) and forkhead box O3a (FOXO3a) in the ischemic skeletal muscle tissue of right hindlimb. Before the treatment, the body mass in the model group and EA group was lower than that in the control group (P<0.01); after the treatment, the body mass in the control group was increased, while the body mass in the model group and EA group was decreased (P<0.01). Compared with the control group, the fasting blood glucose was significantly increased and insulin content was significantly decreased in the model group (P<0.01); compared with the model group, the fasting blood glucose was significantly decreased and the insulin content was significantly increased in the EA group after treatment (P<0.01). The muscle fibers of the model group were obviously broken, the number of the nuclei decreased, and the nuclei shrinked or even dissolved; the morphology of the muscle tissue of the EA group after intervention was improved compared with the model group. Compared with the control group, the cross-sectional area of ischemic skeletal muscle cells in the right hindlimb in the model group was decreased (P<0.01); compared with the model group, the cross-sectional area of ischemic skeletal muscle cells in the right hindlimb was increased in EA group (P<0.05). Compared with the control group, the levels of MAFbx, MuRF1 and FOXO3a mRNA in the right hindlimb ischemic skeletal muscle in the model group were increased significantly (P<0.01, P<0.05); compared with the model group, the levels of MAFbx, MuRF1 and FOXO3a mRNA in the EA group were decreased significantly (P<0.05, P<0.01). EA may play a role in the treatment of diabetic amyotrophy by inducing FOXO3a to reduce the transcription of MAFbx and MuRF1.

How to do a complete mesocolic excision and central vascular ligation.

We describe an approach for complete mesocolic excision and central vessel ligation utilizing a robotic platform. We describe the steps in detail focusing on a superior mesenteric vein-first approach.

Minimally invasive complete mesocolic excision and central vascular ligation (CME/CVL) for right colon cancer.

Total mesorectal excision (TME) is the standard of care in rectal cancer surgery. Complete mesocolic excision and central vascular ligation (CME and CVL) are surgical concepts that are extrapolated from the principles of TME. Increasingly adopted by surgical units worldwide, laparoscopic CME/CVL for right sided colon cancer is a challenging procedure that requires meticulous dissection by the surgeon and detailed knowledge of the colonic vascular anatomy. This review article addresses the main issues pertaining to this surgical technique and also discusses steps on how to perform this operation safely.