Vascular-oriented D3 lymph node dissection with left colic artery preservation for distal sigmoid colon cancer: a variety of techniques.

BACKGROUND: One of the approaches to distal sigmoid colon cancer surgical treatment is segmental colonic resection with vascular preservation of left colic artery (LCA). D3 lymph node dissection may technically vary according to different vascular anatomy. This study aims to show the approaches to D3 lymph node dissection with LCA preservation for distal sigmoid colon cancer according to different patterns of inferior mesenteric artery (IMA) branching. METHODS: CT angiography with 3D reconstruction was routinely performed to identify the IMA branching pattern. Laparoscopic distal sigmoid colon resection with D3 lymph node dissection and left colic artery preservation in standardized fashion was performed in all cases. Data, including clinical, intraoperative, and short-term surgical outcomes, is presented as median numbers (Me) and interquartile range (IQR). RESULTS: Twenty-six patients with distal sigmoid colon cancer were treated with laparoscopic distal sigmoid colon resection. The approach to D3 lymph node dissection varied according to different anatomical variations. There was one conversion (3.8%) and one anastomotic leakage (3.8%) in patients with high BMI. At the same time, there was a high apical lymph node count (Me 3 (IQR 2-5), min-max 0-10) due to the skeletonization of the IMA. CONCLUSIONS: The technical aspects of D3 lymph node dissection with left colic artery preservation may vary in different types of LCA and sigmoid artery branching patterns regardless of the standardized anatomical landmarks. The anatomical features should be considered when performing vascular-sparing lymph node dissection.

Persistent descending mesocolon as a vital risk factor for anastomotic failure and prolonged operative time for sigmoid colon and rectal cancers.

BACKGROUND: The diagnostic criteria and effect of persistent descending mesocolon (PDM) on sigmoid and rectal cancers (SRCs) remain controversial. This study aims to clarify PDM patients' radiological features and short-term surgical results. METHOD: From January 2020 to December 2021, radiological imaging data from 845 consecutive patients were retrospectively analyzed using multiplanar reconstruction (MRP) and maximum intensity projection (MIP). PDM is defined as the condition wherein the right margin of the descending colon is located medially to the left renal hilum. Propensity score matching (PSM) was used to minimize database bias. The anatomical features and surgical results of PDM patients were compared with those of non-PDM patients. RESULTS: Thirty-two patients with PDM and 813 patients with non-PDM were enrolled into the study who underwent laparoscopic resection. After 1:4 matching, patients were stratified into PDM (n = 27) and non-PDM (n = 105) groups. The lengths from the inferior mesenteric artery (IMA) to the inferior mesenteric vein (1.6 cm vs. 2.5 cm, p = 0.001), IMA to marginal artery arch (2.7 cm vs. 8.4 cm, p = 0.001), and IMA to the colon (3.3 cm vs. 10.2 cm, p = 0.001) were significantly shorter in the PDM group than those in the non-PDM group. The conversion to open surgery (11.1% vs. 0.9%, p = 0.008), operative time (210 min vs. 163 min, p = 0.001), intraoperative blood loss (50 ml vs. 30 ml, p = 0.002), marginal arch injury (14.8% vs. 0.9%, p = 0.006), splenic flexure free (22.2% vs. 3.8%, p = 0.005), Hartmann procedure (18.5% vs. 0.0%, p < 0.001) and anastomosis failure (18.5% vs. 0.9%, p = 0.001) were significantly higher in the PDM group. Moreover, PDM was an independent risk factor for prolonged operative time (OR = 3.205, p = 0.004) and anastomotic failure (OR = 7.601, p = 0.003). CONCLUSION: PDM was an independent risk factor for prolonged operative time and anastomotic failure in SRCs surgery. Preoperative radiological evaluation using MRP and MIP can help surgeons better handle this rare congenital variant.

Real-time vascular anatomical image navigation for laparoscopic surgery: experimental study.

BACKGROUND: Recognition of the inferior mesenteric artery (IMA) during colorectal cancer surgery is crucial to avoid intraoperative hemorrhage and define the appropriate lymph node dissection line. This retrospective feasibility study aimed to develop an IMA anatomical recognition model for laparoscopic colorectal resection using deep learning, and to evaluate its recognition accuracy and real-time performance. METHODS: A complete multi-institutional surgical video database, LapSig300 was used for this study. Intraoperative videos of 60 patients who underwent laparoscopic sigmoid colon resection or high anterior resection were randomly extracted from the database and included. Deep learning-based semantic segmentation accuracy and real-time performance of the developed IMA recognition model were evaluated using Dice similarity coefficient (DSC) and frames per second (FPS), respectively. RESULTS: In a fivefold cross-validation conducted using 1200 annotated images for the IMA semantic segmentation task, the mean DSC value was 0.798 (± 0.0161 SD) and the maximum DSC was 0.816. The proposed deep learning model operated at a speed of over 12 FPS. CONCLUSION: To the best of our knowledge, this is the first study to evaluate the feasibility of real-time vascular anatomical navigation during laparoscopic colorectal surgery using a deep learning-based semantic segmentation approach. This experimental study was conducted to confirm the feasibility of our model; therefore, its safety and usefulness were not verified in clinical practice. However, the proposed deep learning model demonstrated a relatively high accuracy in recognizing IMA in intraoperative images. The proposed approach has potential application in image navigation systems for unfixed soft tissues and organs during various laparoscopic surgeries.

[A Resected Case of the Sigmoid Colon Cancer after the Endovascular Aneurysm Repair in Which Intraoperative Indocyanine Green Fluorescence Method Was Useful for Evaluating the Blood Flow in the Colon].

A man in his 70s underwent an endovascular aneurysm repair(EVAR)for abdominal aortic aneurysm. Blood test revealed an anemia and an increased tumor marker. Enhanced computed tomography revealed the wall thickening in the sigmoid colon and the Type Ⅱ endoleak after EVAR. Colonoscopy showed the wall thickening in the sigmoid colon, and biopsy indicated a diagnosis of adenocarcinoma. We performed open sigmoid colectomy with D3 lymph node dissection and ileostomy. We performed intraoperative indocyanine green (ICG) fluorescence method for evaluating the blood flow in the colon before the high ligation of the inferior mesenteric artery and the creation of the anastomosis, and perfusion of the colon was visualized. He was discharged postoperative day 14, and was performed closure of ileostomy 5 months later. Intraoperative ICG fluorescence method was safety and useful for evaluating the blood flow in the colon.

[Reasonable Surgery for Sigmoid Colon Cancer with Asymptomatic Celiac Artery Stenosis and Superior Mesenteric Artery Stenosis-A Case Report].

A 79-year-old woman was diagnosed with cT2N0M0, cStage Ⅰ sigmoid colon cancer. Preoperative staging computed tomography(CT)incidentally revealed severe stenosis of the celiac and superior mesenteric arteries. A collateral blood channel communicating between the inferior mesenteric artery and the celiac artery region was well developed. Therefore, a sigmoidectomy with D1 lymph node dissection was performed to preserve this collateral blood channel as a surgery for sigmoid colon cancer. There are few reports on surgical procedures for patients with simultaneous stenosis of multiple major abdominal arteries. In addition, there are no consensus about the optimal surgical procedure and extent of lymph node dissection for colorectal cancer with well-developed collateral vessels that should be preserved. Preoperative three-dimensional CT angiography(3D-CTA)and intraoperative blood-flow assessment using Indocyanine Green help risk management of multi- organ ischemia due to misidentification and injury of collateral arteries. It is important to keep oncological validity as well as risk management. We report a case of sigmoid colon cancer with asymptomatic stenosis of the celiac and superior mesenteric arteries.

Intestinal ultrasound for monitoring therapeutic response in patients with ulcerative colitis: results from the TRUST&UC study.

OBJECTIVE: Prospective evaluation of intestinal ultrasound (IUS) for disease monitoring of patients with ulcerative colitis (UC) in routine medical practice. DESIGN: TRansabdominal Ultrasonography of the bowel in Subjects with IBD To monitor disease activity with UC (TRUST&UC) was a prospective, observational study at 42 German inflammatory bowel disease-specialised centres representing different care levels. Patients with a diagnosis of a proctosigmoiditis, left-sided colitis or pancolitis currently in clinical relapse (defined as Short Clinical Colitis Activity Index ≥5) were enrolled consecutively. Disease activity and vascularisation within the affected bowel wall areas were assessed by duplex/Colour Doppler ultrasonography. RESULTS: At baseline, 88.5% (n=224) of the patients had an increased bowel wall thickness (BWT) in the descending or sigmoid colon. Even within the first 2 weeks of the study, the percentage of patients with an increased BWT in the sigmoid or descending colon decreased significantly (sigmoid colon 89.3%-38.6%; descending colon 83.0%-42.9%; p<0.001 each) and remained low at week 6 and 12 (sigmoid colon 35.4% and 32.0%; descending colon 43.4% and 37.6%; p<0.001 each). Normalisation of BWT and clinical response after 12 weeks of treatment showed a high correlation (90.5% of patients with normalised BWT had symptomatic response vs 9.5% without symptomatic response; p<0.001). CONCLUSIONS: IUS may be preferred in general practice in a point-of-care setting for monitoring the disease course and for assessing short-term treatment response. Our findings give rise to the assumption that monitoring BWT alone has the potential to predict the therapeutic response, which has to be verified in future studies.

The sigmoidea ima artery: A player in colonic ischemia?

INTRODUCTION: The sigmoidea ima artery is defined as the lowest sigmoid artery, which forms the distal end of the marginal artery by linking with the superior rectal artery. It supplies the rectosigmoid junction, which is a critical area for ischemia. The aim of the present study was to delineate the area supplied by the inferior mesenteric artery with special consideration of the sigmoidea ima artery. MATERIALS AND METHODS: The inferior mesenteric artery was dissected from its origin to the bifurcation of the superior rectal artery in 30 cadavers (15 male, 15 female). Vessel length and distance to the promontory were measured for each branch. RESULTS: There were two manifestations of the sigmoidea ima artery, irrespective of the branching pattern of the inferior mesenteric artery. It originated below the promontory in 25 cases (83.3%) and above it in three (10%). It did not derive from the superior rectal artery in two cases (6.7%). In these 16.7%, the marginal artery was absent near the rectosigmoid junction. CONCLUSIONS: We suggest the terms "arteria sigmoidea ima pelvina" and "arteria sigmoidea ima abdominalis" for the two variants. The terms "arteria marginalis pelvina" and "arteria marginalis abdominalis" could be applied in clinical practice. An abdominal marginal artery could be considered a risk factor for colonic ischemia in colorectal resections and abdominal aortic aneurysm repair. Both variants should be considered when pre- and intra-operative perfusion measurements are interpreted.

Sigmoid volvulus: identifying patients requiring emergency surgery with the dark torsion knot sign.

OBJECTIVES: To determine which clinical or CT imaging factors can help accurately identify complicated sigmoid volvulus (SV), defined as irreversible bowel ischaemia or necrosis requiring emergent surgery in patients with SV. METHODS: We performed a retrospective study of 51 patients admitted consecutively to the emergency department for SV. All patients attempted endoscopic detorsion as the first treatment. Clinical and contrast-enhanced CT factors were analysed. A newly described dark torsion knot sign (sudden loss of mucosal enhancement in the volvulus torsion knot) was included as a CT factor. Patients were diagnosed with complicated versus simple SV based on either surgery or follow-up endoscopic findings. Univariate and multivariate analyses were used to identify predictors of complicated SV. RESULTS: Of 51 study patients, 9 patients (17.6%) had complicated SV. Univariate analysis revealed that three clinical factors (sepsis, elevated C-reactive protein, and elevated lactic acid levels) and four CT factors (reduced bowel wall enhancement, increased bowel wall thickness, dark torsion knot sign, and diffuse omental infiltration) were significantly associated with complicated SV. Multivariate analysis identified only dark torsion knot sign (odds ratio = 104.40; p = 0.002) and sepsis (odds ratio = 16.85; p = 0.043) as independent predictive factors of complicated SV. CONCLUSION: A newly defined CT imaging factor of dark torsion knot sign and a clinical factor of sepsis can predict complicated SV necessitating emergent surgery instead of colonoscopic detorsion as a primary treatment of choice. KEY POINTS: • A newly defined CT imaging factor of dark torsion knot sign and a clinical factor of sepsis can be helpful for predicting complicated SV necessitating emergent surgery instead of endoscopic detorsion.

Cold Renal Perfusion During Simulation of Juxtarenal Aortic Aneurysm Repair Reduces Systemic Oxidative Stress and Sigmoid Damage in Rats.

OBJECTIVES: Juxtarenal aortic surgery induces renal ischaemia reperfusion, which contributes to systemic inflammatory tissue injury and remote organ damage. Renal cooling during suprarenal cross clamping has been shown to reduce renal damage. It is hypothesised that renal cooling during suprarenal cross clamping also has systemic effects and could decrease damage to other organs, like the sigmoid colon. METHODS: Open juxtarenal aortic aneurysm repair was simulated in 28 male Wistar rats with suprarenal cross clamping for 45 min, followed by 20 min of infrarenal aortic clamping. Four groups were created: sham, no, warm (37 °C saline), and cold (4 °C saline) renal perfusion during suprarenal cross clamping. Primary outcomes were renal damage and sigmoid damage. To assess renal damage, procedure completion serum creatinine rises were measured. Peri-operative microcirculatory flow ratios were determined in the sigmoid using laser Doppler flux. Semi-quantitative immunofluorescence microscopy was used to measure alterations in systemic inflammation parameters, including reactive oxygen species (ROS) production in circulating leukocytes and leukocyte infiltration in the sigmoid. Sigmoid damage was assessed using digestive enzyme (intestinal fatty acid binding protein - I-FABP) leakage, a marker of intestinal integrity. RESULTS: Suprarenal cross clamping caused deterioration of all systemic parameters. Only cold renal perfusion protected against serum creatinine rise: 0.45 mg/dL without renal perfusion, 0.33 mg/dL, and 0.14 mg/dL (p = .009) with warm and cold perfusion, respectively. Microcirculation in the sigmoid was attenuated with warm (p = .002) and cold renal perfusion (p = .002). A smaller increase of ROS production (p = .034) was seen only after cold perfusion, while leukocyte infiltration in the sigmoid colon decreased after warm (p = .006) and cold perfusion (p = .018). Finally, digestive enzyme leakage increased more without (1.5AU) than with warm (1.3AU; p = .007) and cold renal perfusion (1.2AU; p = .002). CONCLUSIONS: Renal ischaemia/reperfusion injury after suprarenal cross clamping decreased microcirculatory flow, increased systemic ROS production, leukocyte infiltration, and I-FABP leakage in the sigmoid colon. Cold renal perfusion was superior to warm perfusion and reduced renal damage and had beneficial systemic effects, reducing sigmoid damage in this experimental study.

Imbalanced mucosal microcirculation in the remission stage of ulcerative colitis using probe-based confocal laser endomicroscopy.

BACKGROUND: Microcirculatory disturbance is an important factor in the pathogenesis of Inflammatory Bowel Disease (IBD) but there have been few studies in this field. Confocal Laser Endomicroscopy (CLE) has been used over the last 10 years and has made it possible to explore the changes in microcirculation of the colonic mucosa. METHODS: We retrospectively selected patients who underwent probe-based Confocal Laser Endomicroscopy (pCLE) between 2014 and 2016. There were 7 patients with ulcerative colitis (UC) in clinical remission and 7 healthy subjects included in this study; all the UC patients' medical data were reviewed. For each patient, three segments of the colon were examined using pCLE including the ascending, transverse/descending and sigmoid colon. In each segment, the representative pCLE images of the three sites were selected for analysis. Four indicators, including Mean Vessel Diameter (MVD), Diameter Standard Deviation (DSD), Functional Capillary Density-long (FCDL) and Functional Capillary Density-area (FCDA), were measured with a specially designed detection software algorithm. The four indicators were compared between UC patients and healthy subjects. According to the different blood flow patterns, three types of distribution were established: the Around (A), Cobweb (C) and Deficiency (D) type. The relationships between the recurrence and blood flow patterns of UC patients were analyzed. RESULTS: MVD, DSD, FCDL and FCDA were 10.62 ± 0.56 µm, 2.23 ± 0.26, 0.030 ± 0.019 µm and 0.289 ± 0.030 for the healthy subjects and 11.06 ± 1.10 µm, 2.68 ± 0.29, 0.026 ± 0.005 µm and 0.272 ± 0.034 for the UC patients, respectively. Compared with healthy subjects, DSD was significantly increased and FCDA was significantly decreased (P < 0.01 for both). There was no difference in MVD and FCDL between UC patients and healthy subjects. The type A and type C blood flows were observed in healthy subjects (66.67 and 33.33%, respectively) while type C appears more in UC patients (71.3%) and type D blood flow could only be found in UC patients (14.29%) P < 0.01. UC patients who showed Type D blood flow had a shorter recurrence interval. CONCLUSIONS: Some local mucosal capillary density in UC patients was decreased, particularly in the inflammation-affected segment. The three mucosal blood flow patterns can be used as an indicator of mucosal healing.

Laparoscopic surgery for colorectal cancer with persistent descending mesocolon.

BACKGROUND: Persistent descending mesocolon (PDM) is caused by the absence of fusion of the descending colon to the retroperitoneum. We herein report two colorectal cancer cases with PDM that were treated with laparoscopic surgery. CASE PRESENTATION: Case 1: a 50-year-old man with sigmoid colon cancer and synchronous liver metastasis. After neoadjuvant chemotherapy, he underwent laparoscopic sigmoidectomy with lymph node dissection cutting the root of the inferior mesenteric artery (IMA) and synchronous liver resection. He experienced postoperative stenosis of the reconstructed colon possibly due to an impaired arterial blood flow in the reconstructed colon. Case 2: a 77-year-old man with rectal cancer. Laparoscopic low anterior resection preserving the left colic artery (LCA) was performed. Intraoperative infrared ray (IR) imaging using indocyanine green (ICG) showed good blood flow of the reconstructed colon. He had no postoperative complications. In cases of PDM, the mesentery of the descending and sigmoid colon containing the LCA is often shortened, and the marginal artery of the reconstructed colon is located close to the root of the LCA. Lymph node dissection accompanied by cutting the LCA carries a risk of marginal artery injury. Therefore, we recommend lymph node dissection preserving the LCA in colorectal cancer patients with PDM in order to maintain the blood flow of the reconstructed colon. If the IMA and LCA absolutely need to be cut for complete lymph node dissection, the marginal artery should be clearly identified and preserved. In addition, intraoperative IR imaging is extremely useful for evaluating colonic perfusion and reducing the risk of anastomotic complications. CONCLUSION: In colorectal cancer surgery in patients with PDM, surgeons should be aware of these tips for maintaining the blood flow of the reconstructed colon and thereby avoid postoperative complications caused by an impaired blood flow.

The impact of indocyanine-green fluorescence angiogram on colorectal resection.

BACKGROUND: Perfusion plays an important role in anastomotic healing. Indocyanine-green fluorescence angiogram allows objective bowel perfusion assessment. This study aimed to investigate the impact of perfusion assessment on intraoperative decision during left-sided colorectal resections. METHOD: This was a prospective, single-centre, observational study recruiting patients with left-sided colorectal resections. Perfusion of bowel segment was assessed with ICG fluorescence angiogram prior to resection and anastomosis intra-operatively. The planned transection site and the actual transection site after perfusion assessment were compared. The decision for diversion stoma was also evaluated. RESULTS: 110 patients with cancer of the sigmoid colon (29.1%) and rectum (70.9%) were recruited. Total mesorectal excision was performed in 51.8% of patients. The transection site was revised in 34.5% of cases: 30.9% more proximally and 3.6% more distally. The median distance between the intended and actual transection sites was 2 cm (range 1-17 cm). A proximal revision in the transection site was more likely seen in rectal cancers (p = 0.036, OR 3.58, 95% CI 1.09-11.78) and relatively under-perfused left colon (p = 0.036, OR 1.01, 95% CI 1.01-1.02). Three (2.7%) patients were spared from a diversion stoma. The overall anastomotic leakage rate was 5.5%. CONCLUSION: ICG fluorescence angiogram altered operative decisions in a significant proportion of cases. The impact on transection site was more pronounced in patients with rectal cancers and those with relatively under-perfused colon.

High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: a meta-analysis.

BACKGROUND: The ideal level of ligation of the inferior mesenteric artery (IMA) during curative resection of sigmoid colon and rectal cancer is still controversial. The aim of this meta-analysis was to examine the impact of high ligation and low ligation of the IMA on anastomotic leakage, overall morbidity, postoperative mortality, and oncological outcomes in patients undergoing surgery for sigmoid colon and rectal cancer. METHODS: PubMed, EMBASE, Web of Science, and BioMed Central databases were searched to identify relevant articles published from May 1953 to March 2018. A total of 18 articles (14 non-randomized studies and 4 randomized clinical trials) were identified. Review Manager 5.3 software was used for analysis of data. The pooled odds ratio (OR) and weighted mean difference (WMD), with 95% CI, were calculated using either the fixed effects model or random effects model. RESULTS: Of the 5917 patients included in this meta-analysis, 3652 patients underwent low ligation of the IMA and 2265 patients underwent high ligation of the IMA. Anastomotic leakage rate was 9.8% in high ligation patients vs. 7.0% in low ligation patients; the risk of anastomotic leakage was significantly higher in high ligation patients (OR = 1.33; 95% CI 1.10-1.62; P = 0.004). What is more, overall morbidity was also significantly higher in high ligation patients (OR = 1.39; 95% CI, 1.05-1.68; P = 0.05). Postoperative mortality, number of harvested lymph nodes, overall recurrence rate, and 5-year survival rate did not differ significantly between the two groups. CONCLUSION: Low ligation of the IMA during curative resection of sigmoid colon and rectal cancer appears to be associated with lower risk of anastomotic leakage and overall morbidity. However, there was no significant advantage of low ligation over high ligation of IMA in terms of postoperative mortality, the number of harvested lymph nodes, overall recurrence rate, or 5-year survival rate.

Can sidestream dark field (SDF) imaging identify subtle microvascular changes of the bowel during colorectal surgery?

BACKGROUND: Recognition of a non-viable bowel during colorectal surgery is a challenging task for surgeons. Identifying the turning point in serosal microcirculatory deterioration leading up to a non-viable bowel is crucial. The aim of the present study was to determine whether sidestream darkfield (SDF) imaging can detect subtle changes in serosal microcirculation of the sigmoid after vascular transection during colorectal surgery. METHODS: A prospective observational clinical study was performed at a single medical centre. All eligible participants underwent laparoscopic sigmoid resection and measurements were taken during the extra-abdominal phase. Microcirculation was measured at the transected bowel and 20 cm proximal to this point. Microcirculatory parameters such as Microvascular Flow Index (MFI), proportion of perfused vessels (PPV), perfused vessel density (PVD), total vessel density (TVD) and the Heterogeneity Index were determined. Data are presented as median (interquartile range) or mean ± standard deviation. RESULTS: A total of 60 SDF images were acquired for 10 patients. Perfusion parameters and perfused vessel density were significantly lower at the transected bowel compared with the non-transected measurements [MFI 2.29 (1.96-2.63) vs 2.96 (2.73-3.00), p = 0.007; PPV 74% (55-83) vs 94% (86-97), p = 0.007; and PVD 7.61 ± 2.99 mm/mm2 versus 10.67 ± 1.48 mm/mm2, p = 0.009]. Total vessel density was similar between the measurement locations. CONCLUSIONS: SDF imaging can identify changes of the bowel serosal microcirculation. Significantly lower serosal microcirculatory parameters of the vascular transected bowel was seen compared with the non-transected bowel. The ability of SDF imaging to detect subtle differences holds promise for future research on microvascular cut-off values leading to a non-viable bowel.

[Prevention of colorectal anastomotic leakage by using of intraoperative fluorescent angiography: prospective trial data]. / Primenenie intraoperatsionnoi fliuorestsentnoi angiografii v kachestve metoda profilaktiki nesostoiatel'nosti kolorektal'nogo anastomoza: rezul'taty prospektivnogo issledovaniia.

AIM: To evaluate the effect of intraoperative fluorescent angiography on the incidence of colorectal anastomosis failure. MATERIAL AND METHODS: Prospective, non-comparative study included 52 patients with rectal or sigmoid cancer who underwent surgery with stapled colorectal anastomosis. Intraoperative fluorescent angiography with indocyanine green was performed to determine colon perfusion. All patients underwent proctography with water-soluble contrast agent in 6-8 days after surgery in order to determine anastomotic leakage. RESULTS: Fluorescent angiography was followed by changed volume of proximal colectomy in 14 (27%) patients due to inadequate blood supply of intestinal wall at previous surgical level. Additionally, 1-5 cm of intestinal wall were excised. Postoperative anastomotic leakage occurred in 3 (5.8%) patients. CONCLUSION: Fluorescent angiography with indocyanine green is accompanied by reduced incidence of anastomotic failure in colorectal suregry.

Three-dimensional reconstruction of the vascular arrangement including the inferior mesenteric artery and left colic artery in laparoscope-assisted colorectal surgery.

BACKGROUND: We performed three-dimensional (3D) reconstruction to investigate the vascular anatomy, including the inferior mesenteric artery (IMA), left colic artery (LCA), and inferior mesenteric vein (IMV), for laparoscope-assisted left-side colorectal surgery. Furthermore, we also examined the distances from the root of the IMA to the bifurcation of the LCA and to the IMV using 3D imaging. METHODS: We retrospectively analyzed 46 patients who underwent laparoscope-assisted left-side colorectal surgery via 3D surgical reconstruction at Tsukuba Medical Center Hospital. The branching patterns among the IMA, LCA, and sigmoidal colic artery (SCA) in colon cancer could be classified into three groups (types A, B, and C): type A, in which both arteries (LCA and SCA) branch off from the same point of the IMA; type B, in which the common trunk of the LCA and SCA branches off from the IMA; and type C, in which the LCA and SCA branch off separately from the IMA. The shortest length from the root of the IMA to bifurcation of the LCA and SCA branches (D mm) or to the IMV (d mm) was measured by 3D imaging. RESULTS: The mean D mm and d mm for all cases were 39.4 ± 11.2 and 27.9 ± 9.21 mm, respectively. The D mm from the IMA root to the LCA or SCA branch in types A, B, and C was 37.8 ± 9.21, 40.5 ± 12.7, and 38.6 ± 10.2 mm, respectively. Similarly, the d mm from the IMA root to the IMV in types A, B, and C was 30.2 ± 11.3, 29.9 ± 7.27, and 25.2 ± 10.3 mm, respectively. CONCLUSION: The present 3D reconstruction technique was useful for determining the 3D vascular anatomical pattern including the relative positions of the IMA, SCA, and IMV during laparoscope-assisted left-side colorectal surgery.

[Fluorescence angiography in the detection of anastomotic perfusion during rectal and sigmoid resection - preliminary report]. / Fluorescencní angiografie v detekci kvality perfuze anastomózy u resekce sigmoidea a rekta - zhodnocení prubezných výsledku.

INTRODUCTION: The aim of the study was to evaluate the results of fluorescence angiography for assessing anastomotic perfusion after resection of the sigmoid colon and rectum since its introduction into clinical practice at the authors´ workplace and to evaluate the incidence of necessary resection line repositioning based on the quality of perfusion, and also to record any complications in anastomotic healing. METHOD: Retrospective unicentric analysis of prospectively collected data from patients with resection of the sigmoid colon and rectum with primary anastomosis. The patient set included 50 patients, 27 males and 23 females; the median age was 64.5 years (33-80). Forty-four patients were indicated for resection for cancer of the sigmoid colon or rectum, while 6 patients had a benign disease. Twenty-nine patients underwent total mesorectal excision with coloanal mechanical or hand-sewn anastomosis and 21 underwent resection of the sigmoid colon or upper rectum with mechanical anastomosis. Prior to the construction of the anastomosis, assessment of perfusion of the anastomotic segments by near infrared (NIR) indocyanine green (ICG) fluorescence angiography was performed in all patients. The quality of perfusion of the mesocolon and bowel wall and its impact on moving the resection line and complications of anastomotic healing 30 days postoperatively were all evaluated. RESULTS: Assessment of perfusion using fluorescence angiography was technically successfully performed in all 50 patients. In 5 cases (10%) the resection line had to be moved for signs of poor perfusion of the bowel wall. Postoperatively, healing of the anastomosis was complicated in four patients (8%). Dehiscence was recorded in 3 patients (10.3%) with total mesorectal excision and in 1 patient (4.8%) after resection of the sigmoid colon and upper rectum. CONCLUSION: The presented results indicate that fluorescence angiography may lead to a decrease in the incidence of anastomotic dehiscence after colorectal resections by mapping in detail the perfusion of the anastomosed segments.Key words: fluorescence angiography - indocyanine green - anastomotic leak - colorectal resection.

Anatomy of the inferior mesenteric artery evaluated using 3-dimensional CT angiography.

BACKGROUND: The branching of the inferior mesenteric artery and vein varies among individuals. Three-dimensional CT angiography is a less invasive modality than traditional angiographic examination to assess the artery and vein. OBJECTIVE: We aimed to demonstrate the clinical applicability of CT angiography by evaluating bifurcations of the inferior mesenteric artery and the positional relationship between the inferior mesenteric artery and vein. DESIGN: This was a prospective observational study of patients undergoing preoperative CT angiography. SETTINGS: This study was conducted at a single tertiary care institution in Japan. PATIENTS: A total of 471 consecutive patients who underwent preoperative CT angiography from April 2012 to December 2013 were prospectively enrolled. MAIN OUTCOME MEASURES: The branching pattern of the inferior mesenteric artery, the positional relationship between the inferior mesenteric artery and vein, and the associations between inferior mesenteric artery length and clinical features were evaluated. RESULTS: The length of the inferior mesenteric artery varied widely, from 10.1 to 82.2 mm. In 41.2% patients, the left colic artery arose independently from the sigmoid artery, and in 44.7% of the patients, the left colic artery and sigmoid artery had a common trunk, whereas the left colic artery did not exist in 5.1%. The left colic artery was located lateral to the inferior mesenteric vein at the level of the origin of the inferior mesenteric artery in 73.0% of the patients. The incidence of a short inferior mesenteric artery was significantly increased in men with high BMIs (75.0%). LIMITATIONS: Three-dimensional reconstruction was performed by the use of a single software, and angiographic examination was not performed. Therefore, accuracy and reliability of the 3-dimensional reconstruction could not be established for each modality. CONCLUSIONS: Using 3-dimensional CT angiography, preoperative understanding of the anatomic vascular variations can be easily obtained, which would help surgeons to safely perform laparoscopic surgery in the left-side colon and rectum.