Mesorectal fat area as a useful predictor of the difficulty of robotic-assisted laparoscopic total mesorectal excision for rectal cancer.

BACKGROUND: Various predictors of the difficulty of total mesorectal excision for rectal cancer have been described. Although a bulky mesorectum was considered to pose technical difficulties in total mesorectal excision, no studies have evaluated the influence of mesorectum morphology on the difficulty of total mesorectal excision. Mesorectal fat area at the level of the tip of the ischial spines on magnetic resonance imaging was described as a parameter characterizing mesorectum morphology. This study aimed to evaluate the influence of clinical and anatomical factors, including mesorectal fat area, on the difficulty of total mesorectal excision for rectal cancer. METHODS: This study enrolled 98 patients who underwent robotic-assisted laparoscopic low anterior resection with total mesorectal excision for primary rectal cancer, performed by a single expert surgeon, between 2010 and 2015. Magnetic resonance imaging-based pelvimetry data were collected. Linear regression was performed to determine clinical and anatomical factors significantly associated with operative time of the pelvic phase, which was defined as the time interval from the start of rectal mobilization to the division of the rectum. RESULTS: The median operative time of the pelvic phase was 68 min (range 33-178 min). On univariate analysis, the following variables were significantly associated with longer operative time of the pelvic phase: male sex, larger tumor size, larger visceral fat area, larger mesorectal fat area, shorter pelvic outlet length, longer sacral length, shorter interspinous distance, larger pelvic inlet angle, and smaller angle between the lines connecting the coccyx to S3 and to the inferior middle aspect of the pubic symphysis. On multiple linear regression analysis, only larger mesorectal fat area remained significantly associated with longer operative time of the pelvic phase (p = 0.009). CONCLUSIONS: Mesorectal fat area may serve as a useful predictor of the difficulty of total mesorectal excision for rectal cancer.

[A Case Report of Robotic Assisted Laparoscopic Low Anterior Resection in a Patient with Rectal Cancer and Polysplenia Syndrome].

Polysplenia syndrome is a rare congenital disease characterized by variable thoracic and abdominal anomalies. A man in his 70s was diagnosed with rectal cancer by close exploration for fecal occult blood. A barium enema revealed a type 1 rectal tumor andwith non-rotation of intestine. CT revealed multiple abnormalities: a polyspleen, preduodenal portal vein, congenital absence of the pancreatic tail, bilateral superior vena cava, andbilateral bilobedlung. Basedon these findings, the patient was diagnosedas having rectal cancer with polysplenia syndrome andtreatedwith robotic assistedlaparoscopic low anterior resection. At operation, the whole colon was located in the left side of the abdominal cavity. The whole colon adhered with each other. The ileocecum adheredto the front of the aorta andthe right iliac artery. In the pelvis, anatomical abnormality was not detectedandrectal mobilization andresection was performedas usual. The patient hadno signs of recurrence of the rectal cancer. This is the first case presentation of laparoscopic low anterior resection in a patient with rectal cancer and polysplenia syndrome.

A Case of Acute Colonic Pseudo-Obstruction and Anastomotic Leakage After Sigmoidectomy for Sigmoid Volvulus.

Acute colonic pseudo-obstruction (ACPO) is characterized by significant colonic distension without a mechanical obstruction. We present a case of an 83-year-old male who developed ACPO following laparoscopic surgery for sigmoid volvulus. This report details the patient's postoperative journey, highlighting the diagnostic and management challenges encountered. Despite various medical interventions, the patient's condition necessitated further surgical attention due to complications. This case underscores the importance of early diagnosis and aggressive management in ACPO to prevent life-threatening consequences and improve patient outcomes.

Sigmoid Colon Perforation in Diffuse Large B-Cell Lymphoma Due to Tacrolimus-Induced Immunodeficiency: A Case Report.

The sigmoid colon is an uncommon site for the origin of primary malignant lymphomas in the GI tract. Additionally, immunosuppressive agents, widely used in treating autoimmune diseases, have been associated with the induction of malignancies, including lymphoproliferative disorders. In this report, we present a rare case of GI perforation suggesting a link between immunosuppressive therapy, particularly tacrolimus treatment, and diffuse large B-cell lymphoma (DLBCL). A 75-year-old female patient presented with abdominal pain to our ER. She had a medical history of polymyositis and interstitial pneumonia, treated with the immunosuppressant tacrolimus. An abdominal CT scan revealed free gas in the abdominal cavity, leading to a diagnosis of GI perforation. The patient exhibited generalized peritonitis and underwent emergency surgery the same day. During surgery, a perforation in the sigmoid colon was identified, and a Hartmann procedure was performed. Postoperative pathology showed CD20+, CD30+, CD5-, CD10-, BCL6+, MUM1+, and MIB-1 LI of 50-60%. The diagnosis of DLBCL was confirmed, classified as EBV-positive diffuse large B-cell lymphoma, not otherwise specified (NOS), in the sigmoid colon, with positive EBER-ISH, LMP-1, and EBNA2 findings. Given her history of immunosuppressant use, she was categorized as having other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD), according to the WHO Classification of 2017. This case highlights the importance for clinicians to consider the risk of oncogenesis associated with the prolonged use of immunosuppressive agents.