Comparative Efficacy and Long-Term Oncological Safety of Extended Right Hemicolectomy Versus Left Colectomy for Splenic Flexure Adenocarcinoma: A Systematic Review and Meta-Analysis.

BACKGROUND: Splenic flexure adenocarcinoma poses unique challenges in surgical management due to its location and lymphatic drainage. This study compared the efficacy and oncological safety of extended right hemicolectomy (ERC) and left colectomy (LC) for treating this condition. METHODS: This study followed the PRISMA and AMSTAR 2 guidelines. Key outcomes included postoperative mortality, morbidity, severe complications, operative results, pathological findings (R0 resection, lymph nodes), and oncological results (overall survival and disease-free survival at 3 and 5 years). RESULTS: Twelve non-randomised studies were included involving 1710 patients (713 ERC group, 997 LC group). The analysis showed that ERC was associated with more lymph nodes and a lower conversion rate. However, there were no significant differences between ERC and LC in terms of mortality, morbidity, severe complications, anastomotic leak, wound infection, ileus, reoperation, R0 resection, hospital stay, and overall and disease-free survival rates. CONCLUSIONS: ERC and LC are comparable in terms of postoperative and long-term oncological outcomes for splenic flexure adenocarcinoma, with ERC potentially producing a higher lymph node harvest rate and a lower conversion rate. ERC could be suggested for a better stage of the disease and when the surgical team considers the laparoscopic approach.

Two Types of Variational Arteries' Courses From the Superior Mesenteric Artery to Supply the Splenic Flexure: Gross Anatomical Study.

BACKGROUND: Complete mesocolic excision with central vascular ligation is a standard method for managing colon cancer. However, there is no consensus on its procedure, especially for cancer in the splenic flexure of the transverse colon. This is because various types of variational arteries are distributed to the region, and their running course below and near the pancreas leads to difficulty in ligating the artery. OBJECTIVE: To clarify the arterial distribution to the splenic flexure of the transverse colon using cadavers. DESIGN: The arteries in the transverse mesocolon distributed to the colon were dissected in cadavers, and their route was quantitatively visualized using drawing software. SETTINGS: This study was conducted at the Department of Anatomy, Tokyo Medical University. PATIENTS: Sixty cadavers donated to Tokyo Medical University in 2017-2021 were used. MAIN OUTCOME MEASURES: The arterial courses to the splenic flexure of the transverse colon in the mesocolon and their patterns were evaluated. RESULTS: We found 34 variational arteries distributed to the splenic flexure of the transverse colon. Most originated from the superior mesenteric artery and the middle colic artery, with their typical course below the pancreas. We identified another arterial course, crossing the mesocolon away from the pancreas toward the splenic flexure of the transverse colon. Furthermore, the origin of these arteries was not behind the pancreas and can be found in the caudal region of the pancreas. LIMITATIONS: We cannot discuss how the arteries within the transverse mesocolon are observed by CT examination. CONCLUSIONS: This study showed 2 types of arterial courses (below the pancreas and within the mesocolon) toward the splenic flexure of the transverse colon for the first time. In the latter case, the complete mesocolic excision with central vascular ligation is likely performed more easily than in the former. See Video Abstract. DOS TIPOS DE RECORRIDO VARIACIONAL DE LA ARTERIA DESDE LA ARTERIA MESENTRICA SUPERIOR PARA IRRIGAR EL NGULO ESPLNICO ESTUDIO ANATMICO MACROSCPICO: ANTECEDENTES:La escisión mesocólica completa con ligadura vascular central es un método estándar para el cáncer de colon. Sin embargo, no hay consenso sobre su procedimiento, especialmente para el cáncer en el ángulo esplénico del colon transverso. Esto se debe a que varios tipos de arterias variacionales se distribuyen en la región, y su recorrido por debajo y cerca del páncreas dificulta la ligadura de la arteria.OBJETIVO:Este estudio tuvo como objetivo aclarar la distribución arterial al SF del colon transverso utilizando cadáveres.DISEÑO:Las arterias en el mesocolon transverso distribuidas al colon fueron disecadas en cadáveres, y su ruta fue visualizada cuantitativamente utilizando un software de dibujo.AJUSTES:Este estudio se realizó en el Departamento de Anatomía de la Universidad Médica de Tokio.PACIENTES:Se utilizaron sesenta cadáveres donados a la Universidad Médica de Tokio en 2017-2021.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los cursos arteriales al ángulo esplénico del colon transverso en el mesocolon y sus patrones.RESULTADOS:Encontramos 34 arterias variacionales distribuidas al ángulo esplénico del colon transverso. La mayoría se originaron en la arteria mesentérica superior y la arteria cólica media, con su trayecto típico por debajo del páncreas. Identificamos otro curso arterial, cruzando el mesocolon alejándose del páncreas hacia el ángulo esplénico del colon transverso. Además, el origen de estas arterias no estaba detrás del páncreas y se pueden encontrar en la región caudal del páncreas.LIMITACIONES:No podemos discutir cómo se observan las arterias dentro del mesocolon transverso mediante un examen de tomografía computarizada.CONCLUSIONES:Este estudio mostró por primera vez dos tipos de trayectos arteriales (por debajo del páncreas y dentro del mesocolon) hacia el ángulo esplénico del colon transverso. En el último caso, es probable que la escisión mesocólica completa con ligadura vascular central se realice más fácilmente que en el primero. (Traducción-Dr. Aurian Garcia Gonzalez ).

Cadaveric Study of Colon-Lengthening Maneuvers After Sigmoidectomy.

BACKGROUND: Creation of a tension-free colorectal anastomosis after left colon resection or low anterior resection is a key requirement for technical success. The relative contribution of each of a series of known lengthening maneuvers remains incompletely characterized. OBJECTIVE: The aim of this study was to compare technical procedures for lengthening of the left colon before rectal anastomosis. DESIGN: A series of lengthening maneuvers was performed on 15 fresh cadavers. Mean distance gained was measured for each successive maneuver, including 1) high inferior mesenteric artery ligation, 2) splenic flexure takedown, and 3) high inferior mesenteric vein ligation by the ligament of Treitz. SETTING: Cadaveric study. MAIN OUTCOME MEASURES: The premobilization and postmobilization position of the proximal colonic end was measured relative to the inferior edge of the sacral promontory. Measurements of the colonic length relative to the sacral promontory were taken after each mobilization maneuver. The inferior mesenteric artery, sigmoid colon, and rectum specimen lengths were measured. The distance from the inferior border of the sacral promontory to the pelvic floor was measured along the sacral curvature. RESULTS: Mean sigmoid colon resection length was 34.7 ± 11.1 cm. Before any lengthening, baseline reach was -1.3 ± 4.2 cm from the sacral promontory. Inferior mesenteric artery ligation yielded an additional 11.5 ± 4.7 cm. Subsequent splenic flexure takedown added an additional 12.8 ± 9.6 cm. Finally, inferior mesenteric vein ligation added an additional 11.33 ± 6.9 cm, bringing the total colonic length to 35.7 ± 14.7 cm. BMI and weight negatively correlated with length gained. LIMITATIONS: The study was limited by nature of being a cadaver study. CONCLUSIONS: Stepwise lengthening maneuvers allow significant additional reach to allow a tension-free left colon to rectal anastomosis. See Video Abstract . ESTUDIO CADAVRICO DE MANIOBRAS DE ALARGAMIENTO COLNICO TRAS UNA SIGMOIDECTOMA: ANTECEDENTES:La creación de una anastomosis colorrectal libre de tensión tras una resección de colon izquierdo o tras una resección anterior baja es un requisito clave para el éxito relacionado con la técnica quirúrgica. La relativa contribución de las diversas maniobras de alargamiento permanece caracterizada de manera incompleta.OBJETIVO:El propósito de este estudio fue la de comparar procedimientos técnicos de alargamiento del colon izquierdo previo a la anastomosis rectal.DISEÑO:Una serie de maniobras de alargamiento fueron realizados en 15 cadáveres frescos. La distancia promedio ganada fue medida para cada maniobra sucesiva, incluyendo (1) ligadura alta de la arteria mesentérica inferior, (2) descenso del ángulo esplénico, (3) ligadura alta de la vena mesentérica interior mediante el ligamento de Treitz.AJUSTES:Estudio cadavérico.PRINCIPALES MEDIDAS DE RESULTADO:La posición premobilizacion y postmobilizacion del extremo proximal del colon fue medido tomando en cuenta el borde inferior del promontorio sacro. Las mediciones de la longitud colónica en relación al sacro fueron tomadas luego de cada maniobra de movilización. Fueron tomadas así mismo las longitudes de la arteria mesentérica inferior, el colon sigmoides y recto. Las distancias desde el borde inferior del promontorio sacro al suelo pelvico fueron medidas a lo largo de la curvatura sacra.RESULTADOS:Average sigmoid colon resection length was 34.7 ± 11.1 cm. Prior to any lengthening, baseline reach was -1.3 ± 4.2 cm from the sacral promontory. Inferior mesenteric artery ligation yielded an additional 11.5 ± 4.7 cm. Subsequent splenic flexure takedown added an additional 12.8 ± 9.6 cm. Finally, inferior mesenteric vein ligation added an additional 11.33 ± 6.9 cm, bringing the total colonic length to 35.7 ± 14.7 cm. BMI and weight negatively correlated with length gained.LIMITACIONES:Este estudio tuvo como limitación la naturaleza de haber sido un estudio cadavérico.CONCLUSIONES:Maniobras de alargamiento permiten un alcance adicional significativo permitiendo de esta manera una anastomosis de colon izquierdo a recto libre de anastomosis. (Traducción-Dr Osvaldo Gauto ).

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

AIM: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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.

Splenic flexure mobilization in left-sided colonic and rectal resections: A meta-analysis and meta-regression of factors associated with anastomotic leak and complications.

AIM: Splenic flexure mobilization (SFM) is commonly performed during left-sided colon and rectal resections. The aim of the present systematic review was to assess the outcomes of SFM in left-sided colon and rectal resections and the risk factors for complications and anastomotic leak (AL). METHOD: This study was a PRISMA-compliant systematic review. PubMed, Scopus and Web of Science were searched for studies that assessed the outcomes of sigmoid and rectal resections with or without SFM. The primary outcomes were AL and total complications, and the secondary outcomes were individual complications, operating time, conversion to open surgery, length of hospital stay (LOS) and pathological and oncological outcomes. RESULTS: Nineteen studies including data on 81 116 patients (49.1% male) were reviewed. SFM was undertaken in 40.7% of patients. SFM was associated with a longer operating time (weighted mean difference 24.50, 95% CI 14.47-34.52, p < 0.0001) and higher odds of AL (OR 1.19, 95% CI 1.06-1.33, p = 0.002). Both groups had similar odds of total complications, splenic injury, anastomotic stricture, conversion to open surgery, (LOS), local recurrence, and overall survival. A secondary analysis of rectal cancer cases only showed similar outcomes for SFM and the control group. CONCLUSIONS: SFM was associated with a longer operating time and higher odds of AL, yet a similar likelihood of total complications, splenic injury, anastomotic stricture, conversion to open surgery, LOS, local recurrence, and overall survival. These conclusions must be cautiously interpreted considering the numerous study limitations. SFM may have only been selectively undertaken in cases in which anastomotic tension was suspected. Therefore, the suboptimal anastomoses may have been the reason for SFM rather than the SFM being causative of the anastomotic insufficiencies.

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

BACKGROUND: Surgical standardization for transverse colon cancers (TCC) has not been established, and the oncologic benefit of central vessel ligation (CVL) are still unclear. This study aimed to evaluate the oncologic safety of TCC surgery without CVL of the middle colic artery (MCA). METHODS: This is a single-center, retrospective, observational, comparative study. The clinical, surgical, and pathological characteristics of the patients who underwent radical surgery for non-metastatic TCC between January 2012 and December 2020 were investigated, and the characteristic and oncologic outcomes of No CVL and CVL groups were compared. RESULTS: The number of No CVL and CVL groups was 47 (44.3%) and 59 (55.7%), respectively. There was no statistically significant difference between the two groups in surgical complications, stage, mean number of retrieved lymph nodes (LN) (24.12 vs. 22.36 p = 0.464), mean number of metastatic LN (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, total recurrence rate (6.4 vs. 11.9%, p = 0.507), lymphatic recurrence rate (0.0% vs. 5.1%, p = 0.253), and local recurrence rate (2.1 vs. 1.7%, p = 0.984). Furthermore, there was no statistically significant difference of 5-year disease-free survival (DFS) and overall survival (OS) in stage II (DFS: 94.4 vs. 91.3%, p = 0.685, OS: 94.1 vs. 95.5%, p = 0.838) and stage III (DFS: 88.5 vs. 68.4%, p = 0.253, OS: 100.0% vs. 79.7, p = 0.328). CONCLUSION: TCC surgery without CVL of the MCA showed comparable surgical and oncologic outcomes compared to surgery with CVL. Therefore, preservation of a branch of the MCA may be considered a safe option, when combined with adequate lymph node dissection, if necessary. A large, prospective, and controlled study will be necessary to provide solid evidence of the oncologic safety of this procedure.

Innovative pancreas-guided technique for splenic flexure mobilization in laparoscopic left hemicolectomy.

OBJECTIVE: Splenic flexure mobilization (SFM) is a major challenge in laparoscopic left hemicolectomy. This study aims to assess the safety and effectiveness of the pancreas-guided SFM technique during laparoscopic left hemicolectomy. METHODS: From January 2018 to December 2023, 352 patients with left-sided colon cancer underwent laparoscopic left hemicolectomy. Based on the SFM method used, the patients were divided into the pancreas-guided group (167 cases) or the "Three Approaches Roundabout"/classic group (185 cases). Clinicopathologic characteristics and intraoperative and postoperative variables were compared between the two groups. RESULTS: The two groups had no significant differences in baseline indicators (P > 0.05). All surgeries were successful without needing to convert to laparotomy, and there were no combined organ resections involving the spleen or pancreas in either group. The mean duration of surgery was significantly lower in the pancreas-guided group than in the classic group (P < 0.01). The median volume of intraoperative blood loss in the pancreas-guided group was lower than that in the classic group (P < 0.01). Through video playback, it was found that the retro-pancreatic space had been entered during operation in 8 cases (4.3%) in the classic group, while there were no such occurrences in the pancreas-guided group. This difference was statistically significant (P < 0.05). The difference in the number of lymph nodes cleared, postoperative hospital stays, and incidence of complications were not statistically significant (all P > 0.05) between the groups. CONCLUSION: The pancreas-guided SFM technique is a safe and feasible option for laparoscopic left hemicolectomy. Our study's findings suggest that this approach facilitates accurate access to the correct anatomic plane, potentially improving surgical efficiency.

Optimal surgical approach for mid-transverse colon cancer: a systematic review and meta-analysis.

BACKGROUND AND AIM: The incidence of cancer colon has increased dramatically. In addition, the database lacks a review to analyze the outcomes of surgeries for mid-transverse colon cancer with several recent controversial studies. We aimed to compare the outcomes of extended hemicolectomy versus transverse colectomy for mid-transverse colon cancer. METHOD: PubMed, Scopes, Web of Science and Cochrane Library were searched for eligible studies from inception to 1 December 2022 and a systematic review and meta-analysis were done to detect. RESULTS: According to eligibility criteria, 8 studies (2237 patients) were included in our study. The pooled results of the included studies showed no difference in the 5-year OS, 3-year DFS and 5-year DFS between the two types of surgery (5-year OS, RR = 1.15, 95% CI 0.94-1.39, P = 0.17), (3-year OS, RR = 0.96, 95% CI 0.88-1.06, P = 0.42) and (5-year DFS, RR = 1.21, 95% CI 0.91-1.62, P = 0.20). In addition to that, the recurrence rate and the incidence of complications were similar in the two groups (Recurrence rate, RR = 1.08, 95% CI 0.62-1.89, P = 0.79) and (Complications, RR = 1.07, 95% CI 0.74-1.54, P = 0.72). However, the number of LN harvest and the time of the operation were more in case of extended hemicolectomy. CONCLUSION: Despite harvesting less LN, transverse colectomy has similar oncological outcomes to extended hemicolectomy for mid-transverse colon cancer. In addition to that, there was no significant difference in the incidence of complications between the two surgeries.

Unveiling the hidden: identification and management of overlooked blood vessels in laparoscopic left hemicolectomy for splenic flexure cancer.

BACKGROUND: During laparoscopic left hemicolectomy procedures, a previously overlooked consistently thick blood vessel within the gastrocolic ligament near the splenic hilum may contribute to post-operative bleeding complications. The purpose of this study was to investigate the identification and management of the previously overlooked blood vessel. METHODS: This is a retrospective descriptive study of patients undergoing laparoscopic left colectomy for splenic fexure cancer conducted at a national gastrointestinal surgery centre in China. Consecutive patients with splenic fexure cancer who underwent laparoscopic left colectomy using our"five-step process"(n = 34) between January 2021 and July 2023 were included. RESULTS: The vessels can be effectively exposed using the aforementioned "five-step process." It was observed that the overlooked vessels consistently present in all patients were identified as the omental branch of the left gastroepiploic artery and vein. CONCLUSION: We have identified the origin of previously overlooked blood vessels and recommended a safe method for their management. This may offer advantages to colorectal surgeons performing laparoscopic left colectomy for splenic flexure cancer.

Modified Rosi-Cahill technique after left extended colectomy for splenic flexure advanced tumors.

Advanced splenic flexure tumors are uncommon and have a higher risk of relapse. To ensure that the resection includes the entire area of lymphatic drainage with a complete mesocolic excision (CME), a left extended colectomy is needed. In peritoneal carcinomatosis, there is often extensive involvement of the sigma and splenic flexure of the colon. In many instances, total colectomies are chosen for these patients, even when a significant portion of the colon could be preserved. The potential impact on quality of life after splenic flexure colon resection is discussed, as well as the importance of anatomical knowledge and expertise in performing this type of surgery. Overall, this work presents a modified technique that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer. Creating a tension-free anastomosis after extended left-sided colorectal resection is challenging. There is a negative impact on quality of life when an ileorectal anastomosis is created. The colorectal anastomosis performed after modified Rosi-Cahill or Deloyers' technique allows reduced small bowel bacterial overgrowth, achieves better water and sodium absorption, and altogether permits improved stool consistency. There are potential advantages of the Rosi-Cahill technique over other popular options such as Deloyers' procedure as there is no torsion of the ileocolic vessels and no mesenteric windows. A video was recorded showing a potential pitfall during Deloyers' technique resulting in the creation of a mesenteric window. The proper rotation of the colon during the modified Rosi-Cahill procedure was also filmed. Overall, this work presents a modified technique for reconstruction after left extended colectomy that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer.

Surgical maneuvers for long-segment Hirschsprung pull-through in unique patients.

PURPOSE: Patients with Hirschsprung disease affecting the splenic flexure or more proximal segments present a surgical challenge. Mobilizing the transverse colon to the pelvis during a pull-through may obstruct the distal ileum, or the length may be insufficient to reach the lower pelvis. This retrospective study aimed to describe two surgical techniques that facilitate mobilization of the transverse colon and their outcome. METHODS: We included patients operated on between April 2017 and April 2024 and analyzed sex, comorbidities, type of pull- through, age at pull-through, history of previous surgeries, cause of the proximal transverse colon pull-through, technique used (Deloyers or Turnbull), complications , postoperative outcome and follow-up. The first technique used was the maneuver described by Turnbull. This operation creates a mesenteric defect and mobilizes the colon into this mesenteric window at the distal ileum level. The second technique was described by Deloyers and involves a 180-degree rotation of the right colon by dissecting the right colon attachment and the hepatocolic ligament. The cecum and the ileocecal valve are placed in the right upper quadrant, and the distal colon is mobilized into the pelvis. RESULTS: We included 13 patients, 12 boys and 1 girl. Eight patients had previous surgeries in another hospital: five had an initial transverse colostomy, and three had an ileostomy. The remaining five had the initial operation in our hospital: two had an ileostomy, two had a colostomy, and one had a primary pull-through. The median age at pull-through was 16 months (4-59 months). We used the Turnbull technique in four patients whose aganglionosis was limited to the middle transverse colon. The Deloyers technique was used in the remaining patients, with ganglion cells in the proximal transverse colon. We left a protective ileostomy in five patients. The median follow-up was 4.5 years (3 months to 10 years). The stoma takedown is pending in one patient. CONCLUSION: The Turnbull and Deloyers techniques were helpful in patients with aganglionosis affecting the transverse colon.

[A Case of the Huge GIST in the Transverse Colon Mesentery with Intra-Tumoral Hemorrhage and Jejunal Infiltration].

A 38-year-old woman was admitted to our hospital due to severe anemia. CT showed a 13×12 cm tumor with moderately enhanced wall thickening in the right upper abdomen. The huge tumor located adjacent to the jejunum and compressed the right transverse colon. Hemorrhagic necrosis and air were observed within the tumor, suspecting tumor penetration into the jejunum. The patient was diagnosed with abdominal GIST with jejunal infiltration. Laparotomy revealed a 13× 11 cm solid mass with intra-tumoral hemorrhage and invasion into the jejunum, located in the transverse mesocolon. Tumor resection combined with partial jejunectomy and transverse colectomy were performed. Immunohistochemical findings of the resected specimen was positive for c-kit and DOG-1, and the MIB-1 positive rate was 10%. Three weeks after the operation, re-anastomosis was performed due to transverse colon anastomotic stricture. She was discharged 45 days after first operation. Currently, 9 months after the operation, patient has been prescribed imatinib and is alive without recurrence.

[A Case of Left Upper Abdominal Evisceration for Transverse Colon Cancer with Multiple Organ Invasion].

The case is a 73-year-old woman. She visited primary care doctor for abdominal pain, vomiting, diarrhea, and melena that persisted for 2 weeks. She was referred to our department because she had an elevated inflammatory response and CT showed a mass in her left upper quadrant. Contrast-enhanced CT showed a tumorous lesion mainly in the splenic flexure of the transverse colon, involving the greater curvature of the stomach, the tail of the pancreas, and the hilus of the spleen, accompanied by abscess formation. We suspected highly advanced colon cancer with multiple organ involvement, but we opted for multiple visceral resection because it was associated with high-grade inflammatory findings due to abscess formation. After she was treated with antibiotics, she underwent laparotomy on the 6th day of illness. Intraoperative findings showed no clear nodular lesions suggesting dissemination in the abdominal cavity and intraoperative washing cytology was negative. Since the mobility of the mass that invaded the posterior wall of the greater curvature of the stomach, the tail of the pancreas, and the splenic hilum centered on the splenic flexure was confirmed, the entire left upper abdominal evisceration was resected by resecting the splenic flexure of the colon, the stomach, the tail of the pancreas, and the spleen. The postoperative course was uneventful, and she was discharged on postoperative day 9. Histopathological examination confirmed invasion of colon cancer into the pancreas, spleen, and retroperitoneum. In this report, we present a case of colon cancer with multi-organ invasion that underwent left upper abdominal evisceration.

[A Case of Transverse Colon Cancer with Gastrointestinal Amyloidosis Prevented from Anastomotic Leakage by Multidimensional Approach].

The patient was a 68-year-old woman who was on hemodialysis due to systemic amyloidosis and nephrotic syndrome. Biopsy revealed amyloid deposition in the stomach, duodenum, and colon. A transverse colon tumor was found on a follow- up CT after the aortic dissection surgery. We performed lower gastrointestinal endoscopy and contrast-enhanced CT and diagnosed transverse colon cancer with gastric wall infiltration(cStage Ⅲc). We considered that transverse colon resection was oncologically sufficient. However, due to concurrent gastrointestinal amyloidosis, which increased the risk of anastomotic leakage we performed laparoscopic extended right hemicolectomy to avoid colon-colon anastomosis with partial gastrectomy. Additionally intraoperative indocyanine green(ICG)fluorescence imaging showed that the fluorescence signal in the small intestinal wall was satisfactory, while it was weak in the colon wall. As a result, we suspected of impaired blood flow of colon wall due to an amyloidosis, so we additionally created a loop ileostomy. It is said that gastrointestinal amyloidosis raises the risk of anastomotic leakage. A case of transverse colon cancer complicated by gastrointestinal amyloidosis in which we successfully prevented anastomotic leakage through a multidimensional evaluation and approach is reported, along with a literature review.

[A Case of Intestinal Obstruction Due to an Internal Hernia in the Mesenteric Defect after Laparoscopic Resection of Transverse Colon].

72-year-old man who was diagnosed with transverse colon cancer cT3N1aM0, Stage Ⅲb, and underwent laparoscopic- assisted resection of the transverse colon. Postoperatively, the patient was discharged from the hospital after 24 days due to complications such as paralytic ileus and intra-abdominal abscess caused by prolonged intestinal congestion. On postoperative day 91, the patient developed abdominal pain and vomiting at home, and was rushed to our hospital on the same day. Abdominal CT showed that an internal hernia had formed in the mesenteric defect after resection of the transverse colon, which was suspected to have caused obstruction of the small intestine. After adequate preoperative decompression of the intestinal tract, a laparoscopic surgery was performed on the 9th day. The operative findings were that the jejunum(100- 160 cm from the Treitz ligament)had strayed into the mesenteric defect of the transverse colon, resulting in an internal hernia. After the internal hernia was repaired laparoscopically, the mesenteric defect was closed with a 3-0 V-Loc(non- absorbable). The patient had a good postoperative course and was discharged home 6 days after surgery.

Segmental or right hemi-colectomy? The optimal surgical procedure for transverse colon cancer: a propensity score-matched, multicenter, retrospective study.

PURPOSE: Extended colectomy is sometimes chosen for treatment of transverse colon cancer (TCC) because of concerns about short- and long-term outcomes. However, there is still a lack of evidence regarding the optimal surgical procedure. METHODS: We retrospectively collected and analyzed data of patients who underwent surgical treatment of pathological stage II/III TCC at four hospitals from January 2011 to June 2019. We excluded the patients with TCC located at distal transverse colon, and just evaluated and analyzed proximal and middle third TCC. Inverse probability treatment-weighted propensity score analyses was used to compare short- and long-term outcomes between patients who underwent segmental transverse colectomy (STC) and those who underwent right hemicolectomy (RHC). RESULTS: In total, 106 patients were enrolled in this study (STC group, n = 45; RHC group, n = 61). The patients' backgrounds were well balanced after matching. The incidence of major postoperative complications (Clavien-Dindo grade ≥ III) was not significantly different between the STC and RHC groups (4.5% vs. 5.6%, respectively; P = 0.53). The 3-year recurrence-free survival and overall survival rates were not significantly different between the STC and RHC groups (88.2% vs. 81.8%, P = 0.86 and 90.3% vs. 91.9%, P = 0.79, respectively). CONCLUSION: RHC has no significant benefits over STC with respect to either short- or long-term outcomes. STC with necessary lymphadenectomy could be an optimal procedure for proximal and middle TCC.

Comparison of survival outcomes between laparoscopic and open colectomy for transverse colon cancer: a systematic review and meta-analysis.

PURPOSE: This study aimed to compare laparoscopic with open resection for transverse colon cancer (TCC) regarding long-term survival outcomes. METHODS: Systematic literature search was performed on PubMed, Ovid, and Cochrane Library for studies comparing laparoscopic with open resection for TCC. The last search was performed on October 7, 2022. Oncological and survival outcomes were collected and analyzed. This meta-analysis was performed using Review Manager Software (v 5.3). RESULTS: This study included fifteen studies published between 2014 and 2022 with 2556 patients in total. When compared with the laparoscopic group, the open group had significantly more tumors locating on middle transverse colon (P = 0.006, OR = 0.67, 95%CI [0.50, 0.89], I2 = 12%) and more patients received transverse colectomy (P = 0.03, OR = 0.66, 95%CI [0.46, 0.96], I2 = 53%) as results. Comparable tumor stage (P = 0.13, OR = 0.81, 95%CI [0.62, 1.06], I2 = 55%) and number of lymph node harvested (P = 0.22, WMD = -0.81, 95%CI [-2.09, 0.47], I2 = 73%) were observed between the two groups. As for survival outcomes, no significant difference was observed between the two groups for 5-year disease-free survival (DFS; P = 0.61, OR = 0.93, 95%CI [0.72, 1.21], I2 = 0%), 5-year overall survival (OS; P = 0.83, OR = 0.97, 95%CI [0.71, 1.32], I2 = 0%), 3-year DFS (P = 0.97, OR = 0.96, 95%CI [0.69, 1.32], I2 = 0%), and 3-year OS (P = 0.67, OR = 0.92, 95%CI [0.63, 1.35], I2 = 0%). In the subgroup analysis according to tumor stage, the results did not change. CONCLUSION: Current evidence based on studies demonstrated that laparoscopic procedure could be safely performed for TCC, and it would not affect the long-term survival. Randomized clinical trials with a larger sample size are warranted in the future for further investigation.

Discontinuity of marginal artery at splenic flexure and rectosigmoid junction: A systematic review and meta-analysis.

AIM: The aim of this study was to provide comprehensive evidence-based assessment of the discontinuity of the marginal artery at the splenic flexure (SF) and the rectosigmoid junction (RSJ). METHOD: A systematic review was conducted of literature published to 26 December 2022 in the electronic databases PubMed, SCOPUS and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using the Metafor package in R. The primary outcomes were the pooled PPEs of the marginal artery at the SF and the RSJ. The secondary outcome was the size of vascular anastomoses. RESULTS: A total of 21 studies (n = 2,864 patients) were included. The marginal artery was present at the splenic flexure in 82% (95% CI: 62-95) of patients. Approximately 81% (95% CI: 63-94%) of patients had a large macroscopic anastomosis, while the remainder (19%) had small bridging ramifications forming the vessel. The marginal artery was present at the RSJ in 82% (95% CI: 70-91%) of patients. CONCLUSION: The marginal artery may be absent at the SF and the RSJ in up to 18% of individuals, which may confer a higher risk of ischaemic colitis. As a result of high interstudy heterogeneity noted in our analysis, further well-powered studies to clarify the prevalence of the marginal artery at the SF and the RSJ, as well as its relationship with other complementary colonic collaterals (intermediate and central mesenteric), are warranted.

Novel approach toward minimally invasive surgery for mid-transverse colon cancer: 'moving the left colon' technique.

AIM: During surgery for mid-transverse colon cancer (MTC), surgeons often face the dilemma of whether to mobilize the hepatic or splenic flexure. There is no established optimal minimally invasive surgical procedure for MTC. METHODS: We present our novel minimally invasive surgical technique, called the 'moving the left colon' technique for MTC, along with a video demonstration. The procedure involves four main steps: (i) mobilization of the splenic flexure using a medial-to-lateral approach, (ii) dissection of lymph nodes around the middle colic artery from the left side of the superior mesenteric artery approach, (iii) separation of the pancreas and transverse mesocolon and (iv) 'moving the left colon' and performing an intracorporeal anastomosis. By mobilizing the splenic flexure, anatomical landmarks are revealed, which enables safer dissection. Combining this technique with intracorporeal anastomosis allows for a safe and easy anastomosis. RESULTS: Between April 2021 and January 2023, a single-skilled colorectal surgeon performed laparoscopic transverse colectomies using our new approach on three consecutive patients with MTC. The patients had a median age of 75 years (range 46-89 years). The median operative time was 194 min (range 193-228 min) and blood loss was 8 mL (range 0-20 mL). None of the patients experienced any perioperative complications and the median postoperative hospital stay was 6 days. CONCLUSION: We introduced a novel approach for laparoscopic surgery for MTC. This technique can be performed safely and may help standardize minimally invasive surgery for MTC.

Development of a procedure-specific tool for skill assessment in left- and right-sided laparoscopic complete mesocolic excision.

AIM: To (1) develop an assessment tool for laparoscopic complete mesocolic excision (LCME) and (2) report evidence of its content validity. METHOD: Assessment statements were revealed through (1) semi-structured expert interviews and (2) consensus by the Delphi method, both involving an expert panel of five LCME surgeons. All experts were interviewed and then asked to rate LCME describing statements from 1 (strongly disagree) to 5 (strongly agree). Responses were returned anonymously to the panel until consensus was reached. Statements were directly included as content in the assessment tool if ≥60% of the experts responded "agree" or "strongly agree" (ratings 4 and 5), with the remaining responses being "neither agree nor disagree" (rating 3). Interclass correlation coefficient (ICC) was calculated for expert agreement evaluation. All included statements were subsequently reformulated as tool items and approved by the experts. RESULTS: Four Delphi rounds were performed to reach consensus. Disagreement was reported for statements describing instrument handling around pancreas; visualisation of landmarks before inferior mesenteric artery ligation; lymphadenectomy around the inferior mesenteric artery, and division of the terminal ileum and transverse colon. ICC in the last Delphi-round was 0.84. The final tool content included 73 statements, converted to 48 right- and 40 left-sided items for LCME assessment. CONCLUSION: A procedure-specific, video-based tool, named complete mesocolic excision competency assessment tool (CMECAT), has been developed for LCME skill assessment. In the future, we hope it can facilitate assessment of LCME surgeons, resulting in improved patient outcome after colon cancer surgery.