The colon does not reach! A technical note with tricks to avoid colorectal anastomoses under tension.

AIM: We describe two options for colorectal anastomosis suitable in cases when the colon would reach the pelvis under tension. METHOD: Deloyers procedure and the retro-ileal colorectal anastomosis are presented, focusing on practical tips and tricks to perform them. Insights on patients who underwent the procedures are provided to demonstrate the advantages and feasibility of the techniques. RESULTS: Each step of both techniques is detailed. Ten patients underwent Deloyers procedure and nine underwent retro-ileal anastomosis at our unit. A minimally invasive approach was attempted in 13 patients, of whom five required conversion to open surgery due to the technical complexity of the abdominal procedure. Colorectal anastomosis was successfully performed in all patients. There were no major intra-operative complications, although five patients had postoperative complications requiring further treatment. CONCLUSIONS: Both techniques are effective in patients at risk of receiving a colorectal anastomosis under tension, and a minimally invasive approach can be used. However, owing to the complexity of surgery in this group of patients, the perioperative morbidity is not negligible. Careful postoperative management is advisable, and patients should be informed of the risks. In expert hands, the outcomes are acceptable, avoiding an ileorectal anastomosis and its constraints.

Long splenic flexure carcinoma requiring laparoscopic extended left hemicolectomy with CME and transverse-rectal anastomosis: technique for a modified partial Deloyers in 5 steps to achieve enough reach and preserving middle colic vessels.

INTRODUCTION: This How-I-Do-It article presents a modified Deloyers procedure by mean of the case of a 67-year-old female with adenocarcinoma extending for a long segment and involving the splenic flexure and proximal descending colon who underwent a laparoscopic left extended hemicolectomy (LELC) with derotation of the right colon and primary colorectal anastomosis. BACKGROUND: While laparoscopic extended right colectomy is a well-established procedure, LELC is rarely used (mainly for distal transverse or proximal descending colon carcinomas extending to the area of the splenic flexure). LELC presents several technical challenges which are demonstrated in this How-I-Do-It article. TECHNIQUE AND METHODS: Firstly, the steps needed to mobilize the left colon and procure a safe approach to the splenic flexure are described, especially when a tumor is closely related to it. This is achieved by mobilization and resection of the descending colon, while maintaining a complete mesocolic excision to the level of the duodenojejunal ligament for the inferior mesenteric vein and flush to the aorta for the inferior mesenteric artery. Subsequently, we depict the adjuvant steps required to enable a primary anastomosis by trying to mobilize the transverse colon and release as much of the mesocolic attachments at the splenic flexure area. Finally, we present the rare instance when a laparoscopic derotation of the ascending colon is required to provide a tension-free anastomosis. The resection is completed by delivery of the fully derotated ascending colon and hepatic flexure through a suprapubic mini-Pfannenstiel incision. The primary colorectal anastomosis is subsequently fashioned in a tension-free way and provides for a quick postoperative recovery of the patient. RESULTS: This modified Deloyers procedure preserves the middle colic since the fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump. Also, by eliminating the need for a mesenteric window and the transposition of the caecum, we allow the small bowel to rest over the anastomosis and the mobilized transverse colon and reduce the possibility of an internal herniation of the small bowel into the mesentery. CONCLUSIONS: Laparoscopic derotation of the right colon and a partial, modified Deloyers procedure preserving the middle colic vessels are feasible techniques in experienced hands to provide primary anastomosis after LELC with improved functional outcome. Nevertheless, it is important to consider anatomical aspects of the left hemicolectomy along with oncological considerations, to provide both a safe oncological resection along with good postoperative bowel function.

Colorectal anastomosis after laparoscopic extended left colectomy: techniques and outcome.

AIM: After extended left colectomy, traditional colorectal anastomosis is often not feasible because of insufficient length of the remaining colon to perform a tension-free anastomosis. Total colectomy with ileorectal anastomosis could be an alternative but this can lead to unsatisfactory quality of life. Trans-mesenteric colorectal anastomosis or inverted right colonic transposition (the so-called Deloyers procedure) are two possible solutions for creating a tension-free colorectal anastomosis after extended left colectomy. Few studies have reported their results of these two techniques and mostly via laparotomy. The aim of this study was to describe the trans-mesenteric colorectal anastomosis and the inverted right colonic transposition procedure via a laparoscopic approach and report the outcome in a series of 13 consecutive patients. METHOD: This was retrospective chart review of laparoscopic colorectal surgery with trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure from January 2015 up to 2019. An accompanying video demonstrates these two techniques. RESULTS: Thirteen consecutive patients underwent either a laparoscopic trans-mesenteric colorectal anastomosis (n = 9) or an inverted right colonic transposition procedure (n = 4). One patient had intra-operative presacral bleeding that was stopped successfully without conversion. Two patients had a postoperative intra-abdominal abscess, but no anastomotic complications were recorded. The median number of bowel movements per day after 6 months was 2 (range 2-5). CONCLUSIONS: Trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure is feasible laparoscopically. The now well-established classical advantages of the laparoscopic approach are associated with good functional outcome after these procedures.

Laparoscopic Deloyers procedure for tension-free anastomosis after extended left colectomy: technique and results.

BACKGROUND: The Deloyers procedure, which includes inversion of the right colon around the axis of the ileocolic vessels, can be used to achieve a well vascularized, tension-free colorectal anastomosis after extended left colectomy. The aim of this study is to report our technique and outcome in a series of ten consecutive patients who underwent right colonic transposition by laparoscopic approach. METHODS: Charts were retrospectively reviewed to analyze postoperative outcome and bowel function. A video was recorded to demonstrate the procedure. RESULTS: Conversion was required in one (10%) patient due to extensive adhesions. No intraoperative complications were recorded. Anastomotic leakage occurred in one (10%) case and was managed with peritoneal lavage and ileostomy. Six months after surgery, all patients reported a median number of 2.5 (range 2-3) bowel movements per day with solid stool consistency. Neither anastomotic stricture nor bowel ischemia was found at 1-year endoscopic follow-up. CONCLUSION: Our experience shows that laparoscopic right colonic transposition is a safe and feasible procedure and provides good functional outcomes.

Modified right colon inversion technique as a salvage procedure for colorectal or coloanal anastomosis.

AIM: A tension-free well vascularized colorectal or coloanal anastomosis is not always possible following rectal or sigmoid resection. The study reports on the short-term and long-term outcome of a modified right colon inversion technique as a means of facilitating a low colorectal or coloanal anastomosis. METHOD: All patients who underwent right colonic inversion, a modified Deloyers' procedure, were identified retrospectively from the prospective database of the Colorectal Department of the Royal Marsden Hospital from October 2008 to December 2013. RESULTS: There were 14 (nine male) patients of median age 58.7 (45-75) years. The main indication was extensive diverticular disease (50%) and previous colonic surgery (21.4%). A defunctioning stoma was performed in 64.3% which was reversed in all within 3-6 months. Three (21.4%) patients developed postoperative complications (Clavien-Dindo 1-2) and none required reoperation. The median duration of follow-up was 11 months. One (7.2%) patient had one bowel movement per day, 10 (71.4%) patients had two bowel movements per day and three (21.4%) patients had three per day. CONCLUSION: The modified right colonic inversion technique is safe and achieves intestinal continuity with a tension-free well vascularized anastomosis. Good function and low morbidity show that the procedure is a credible alternative to ileorectal or ileoanal anastomosis.

Usefulness of Deloyers procedure with minimally invasive coloproctectomy in an elderly patient with synchronous colorectal cancer: A case report.

Subtotal colectomy is often performed on patients with synchronous colorectal cancer. However, compared with colorectal anastomosis, ileorectal anastomosis with subtotal colectomy is more likely to result in bowel dysfunction. The Deloyers procedure is useful in preserving bowel function in a patient with synchronous colorectal cancer. An 87-year-old man presented with bloody stool. Colonoscopy showed masses in the cecum, transverse colon, rectosigmoid, and rectum above the peritoneal reflection. Computed tomography scan revealed no evidence of regional lymph node swelling and distant metastasis. Therefore, robot-assisted low anterior resection, laparoscopic extended left hemicolectomy, laparoscopic cecal resection, and diverting ileostomy were performed. The patient was discharged from the hospital without complications. There was no recurrence, and the patient did not have complaints such as urgency, fecal incontinence, and excretory dysfunction. Hence, minimally invasive coloproctectomy using the Deloyers procedure can be safe and useful in preserving postoperative bowel function in elderly patients.

Deloyers procedure compared to ileorectal anastomosis as restoration techniques of bowel continuity after extended left colon resection.

BACKGROUND: Restoration of bowel continuity after left extended colectomy may be challenging because the remaining colon may not reach the rectal stump without tension to perform a safe anastomosis. Performing a total colectomy with ileorectal anastomosis (IRA) is an option, but the quality of life can be significantly impaired due to loose stools and an increase in bowel frequency. In contrast, the preservation of the right colon and ileocaecal valve in the Deloyers procedure (DP) might ensure a better stool consistency and bowel transit, and therefore a superior quality of life. MATERIALS AND METHODS: A transverse study comparing patients that underwent DP versus patients with an IRA was performed. Postoperative morbidity, mortality, functional outcomes, and quality of life were analysed between groups. Quality of life after the surgical procedure was assessed with the SF-36 V2® health survey. RESULTS: A total of 16 patients with DP and 32 with IRA were included. The groups had similar demographic characteristics concerning age, sex, body mass index, ASA classification, diagnosis and Charlson comorbidity index. The median follow-up was 55 months for DP and 99 months for IRA. Postoperative complications were similar in both groups. Patients in the DP group had fewer bowel movements (P = 0.01), tenesmus (P = 0.04) and use of loperamide (P = 0.03). DP patients achieved better scores in physical pain (P = 0.02) and general health (P < 0.01) than IRA patients. CONCLUSIONS: DP for intestinal continuity restoration after extended left colon resection is a safe and feasible alternative, possibly achieving better functional outcomes and quality-of-life compared to IRA.

Extended Left Colectomy with Coloanal Anastomosis by Indocyanine Green-guided Deloyers Procedure: A Case Report.

The Deloyers procedure is performed after extended left colectomy, enabling the reach of the proximal colon to the rectum for anastomosis while preserving sufficient blood supply. We report a case of the Deloyers procedure performed safely under indocyanine green (ICG) fluorescence guidance. A 50-year-old man with obesity (body mass index, 35.7 kg/m2) and a history of diabetes underwent an extended left hemicolectomy and ultralow anterior resection of the rectum as radical resection for transverse and sigmoid colon cancers and a lower rectal neuroendocrine tumor. Reconstruction was performed by the Deloyers procedure. A necessary length of the transverse colon with reduced blood flow was additionally resected under ICG fluorescence guidance, and a transanal hand-sewn coloanal anastomosis was performed. This is the first report in which the Deloyers procedure was performed successfully with the ICG fluorescence method. ICG fluorescence may be useful when combined with the Deloyers procedure.

Restoring Intestinal Continuity in a Hostile Abdomen: The Deloyers Procedure.

BACKGROUND: Deloyers procedure enables anastomosis of the ascending colon to the rectum following extended resections that prevent usual fashion anastomosis. During the procedure, the right colon is completely mobilized and counterclockwise rotated to allow tension free and well-vascularized anastomosis while preserving the ileocecal valve. The purpose of this manuscript is to report our experience with laparoscopic Deloyers procedure in a hostile abdomen due to adhesions from previous surgeries. METHODS: We report the outcomes and our technique of laparoscopic Deloyers procedure in three patients. All patients had a surgical complication necessitating the creation of end colostomy with a short colonic remnant. The bowel status prevented restoration of continuity by the common colorectal anastomosis and laparoscopic Deloyers was elected. RESULTS: The procedure was successful in all patients, with no intra-operative complication and average surgery duration of three hours. Patients had uneventful postoperative recovery with only one case of minor complication and an adequate functional outcome. CONCLUSION: Laparoscopic Deloyers is safe and allows the restoration of bowel continuity with preservation of ileocecal valve and good functional outcome even in hostile abdomen.

Laparoscopic 3D high-definition Deloyers procedure: when, how, why?

After extensive mobilization and resection of the left colon, colorectal anastomosis may result impossible due to the distance between the remaining colon and the rectal stump. The Deloyers procedure represents an interesting alternative to total colectomy with ileorectal anastomosis. In this manuscript, we describe when and how to perform this technique with a mini-invasive approach. We also report the case of a patient who underwent Deloyers procedure, due to early ischemia of the descending colon after left colectomy.