Anatomical classification of and laparoscopic surgery for left-sided colorectal cancer with persistent descending mesocolon / 中华胃肠外科杂志

Objective: To investigate anatomical morphology and classification of persistent descending mesocolon (PDM) in patients with left-sided colorectal cancer, as well as the safety of laparoscopic radical surgery for these patients. Methods: This is a descriptive study of case series. Relevant clinical data of 995 patients with left colon and rectal cancer who had undergone radical surgery in Fujian Medical University Union Hospital from July 2021 to September 2022 were extracted from the colorectal surgery database of our institution and retrospectively analyzed. Twenty-four (2.4%) were identified as PDM and their imaging data and intra-operative videos were reviewed. We determined the distribution and morphology of the descending colon and mesocolon, and evaluated the feasibility and complications of laparoscopic surgery. We classified PDM according to its anatomical characteristics as follows: Type 0: PDM combined with malrotation of the midgut or persistent ascending mesocolon; Type 1: unfixed mesocolon at the junction between transverse and descending colon; Type 2: PDM with descending colon shifted medially (Type 2A) or to the right side (Type 2B) of the abdominal aorta at the level of the origin of the inferior mesentery artery (IMA); and Type 3: the mesocolon of the descending-sigmoid junction unfixed and the descending colon shifted medially and caudally to the origin of IMA. Results: The diagnosis of PDM was determined based on preoperative imaging findings in 9 of the 24 patients (37.5%) with left-sided colorectal cancer, while the remaining diagnoses were made during intraoperative assessment. Among 24 patients, 22 were male and 2 were female. The mean age was (63±9) years. We classified PDM as follows: Type 0 accounted for 4.2% (1/24); Type 1 for 8.3% (2/24); Types 2A and 2B for 37.5% (9/24) and 25.0% (6/24), respectively; and Type 3 accounted for 25.0% (6/24). All patients with PDM had adhesions of the mesocolon that required adhesiolysis. Additionally, 20 (83.3%) of them had adhesions between the mesentery of the ileum and colon. Twelve patients (50.0%) required mobilization of the splenic flexure. The inferior mesenteric artery branches had a common trunk in 14 patients (58.3%). Twenty-four patients underwent D3 surgery without conversion to laparotomy; the origin of the IMA being preserved in 22 (91.7%) of them. Proximal colon ischemia occurred intraoperatively in two patients (8.3%) who had undergone high ligation at the origin of the IMA. One of these patients had a juxta-anal low rectal cancer and underwent intersphincteric abdominoperineal resection because of poor preoperative anal function. Laparoscopic subtotal colectomy was considered necessary for the other patient. The duration of surgery was (260±100) minutes and the median estimated blood loss was 50 (20-200) mL. The median number of No. 253 lymph nodes harvested was 3 (0-20), and one patient (4.2%) had No.253 nodal metastases. The median postoperative hospital stay was 8 (4-23) days, and the incidence of complications 16.7% (4/24). There were no instances of postoperative colon ischemia or necrosis observed. One patient (4.2%) with stage IIA rectal cancer developed Grade B (Clavien-Dindo III) anastomotic leak and underwent elective ileostomy. The other complications were Grade I-II. Conclusions: PDM is frequently associated with mesenteric adhesions. Our proposed classification can assist surgeons in identifying the descending colon and mesocolon during adhesion lysis in laparoscopic surgery. It is crucial to protect the colorectal blood supply at the resection margin to minimize the need for unplanned extended colectomy, the Hartmann procedure, or permanent stomas.

Comparison of efficacy between laparoscopic versus open complete mesocolic excision for colon cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the differences in long-term outcomes between laparoscopic and open complete mesocolic excision(CME) for colon cancer.</p><p><b>METHODS</b>A total of 273 patients with colon cancer who underwent CME at the Fujian Medical University Union Hospital from September 2000 to December 2008 were divided into laparoscopic(LP, n=147) and open(OP, n=126) groups in a non-random manner. The oncologic and long-term outcomes were compared.</p><p><b>RESULTS</b>No significant differences were seen in the length of distal and proximal margin, and number of lymph nodes(all P>0.05). Median postoperative follow up was 50 months. Local regional recurrence rates (LP 6.1% vs. OP 7.9%) and distal metastasis rates(LP 23.8% vs. OP 16.7%) were similar between the two groups(all P>0.05). The 5-year overall survival rates (LP 69.4% vs. OP 74.0%, P=0.840) and 5-year disease-free survival rates(LP 68.5% vs. OP 70.9%, P=0.668) between the two groups were not statistically different.</p><p><b>CONCLUSIONS</b>Laparoscopic CME has the same oncologic clearance effects compared with open CME for colon cancer. It might become a new standardized surgery for colon cancer.</p>

Risk factors of postoperative chyle leak following complete mesocolic excision for colon cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the incidence, risk factors and preventative methods associated with chyle leak following complete mesocolic excision(CME) for colon cancer.</p><p><b>METHODS</b>Clinical data of 592 patients with colon cancer undergoing CME in the department of Colorectal Surgery in the Fujian Medical University Union Hospital from September 2000 to September 2011 were analyzed retrospectively.</p><p><b>RESULTS</b>Chyle leak occurred in 46 patients(7.7%). The incidence of postoperative chyle leak following right CME hemicolectomy was 13.3%(30/226), significantly higher than that after left CME hemicolectomy (4.4%). On univariate analysis, chyle leak following CME was associated with tumor size(P<0.05), tumor location(P<0.01), and lymph nodes harvested(P<0.01). Multivariate logistic regression revealed that tumor location and lymph nodes harvested were independent risk factors associated with chyle leak following CME(P<0.05).</p><p><b>CONCLUSIONS</b>Tumor location and lymph nodes harvested are independent risk factors for chyle leak following complete mesocolic excision for colon cancer. When the drainage output suddenly increases after oral intake resumption, the chyle test of ascitic fluid should be performed for early diagnosis and prompt management.</p>

Laparoscopic cylindrical abdominoperineal resection with transabdominal approach for lower rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and feasibility of laparoscopic cylindrical abdominoperineal resection.</p><p><b>METHODS</b>Six patients with rectal adenocarcinoma within 3 cm above the anal verge underwent laparoscopic cylindrical abdominoperineal resection. Transabdominal levator transaction was performed laparoscopically, with no position change during the perineal operation. Pelvic reconstruction was achieved using human acellular dermal matrix mesh in 3 patients.</p><p><b>RESULTS</b>All the procedures were successfully performed without any intraoperative complications, laparoscopy-associated complications, or conversion to the open approach. The mean operation time was 186.7 minutes and intraoperative blood loss was 101.7 ml. All the specimens had a cylindrical shape with levator muscles attached to the mesorectum and circumferential margins were all negative. No adverse incidence followed the pelvic reconstruction using human acellular dermal matrix mesh.</p><p><b>CONCLUSIONS</b>Laparoscopic transabdominal transection of the levator muscles without position change and pelvic floor reconstruction with human acellular dermal matrix mesh is feasible. This procedure simplifies cylindrical abdominoperineal resection which is aggressively invasive and technically complicated. The oncologic outcomes are acceptable and complications are less.</p>

Treatment of chyle leak following radical resection for colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the treatment of chyle leak following radical resection for colorectal cancer.</p><p><b>METHODS</b>The incidence of chyle leak was compared between the different surgical approaches (open vs. laparoscopic) as well as different tumor locations (right, left colon or rectum) in 1259 patients undergoing radical resection for colorectal cancer.</p><p><b>RESULTS</b>Overall incidence of chyle leak was 3.6% (46/1259) after surgery. Forty-five patients were successfully managed by conservative treatment and one patient required re-operation. No patients died. The incidence of chyle leak was not significantly different between the open (3.2%, 18/570) and laparoscopic (4.1%, 28/689) groups (P>0.05). However, right colectomy was associated with a significantly higher rate of chyle leak (9.6%, 16/167) as compared to left colectomy(2.6%, 7/268) and anterior resection (2.8%, 23/824) (P<0.05).</p><p><b>CONCLUSIONS</b>Conservative treatment is effective in early stage of chyle leak after radical resection for colorectal cancer. Right colectomy is associated with higher risk for chyle leak.</p>

Comparison of the incidence rates of anastomotic leak following lower anterior resection of rectal cancer between laparoscopic and open operation / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate and compare the incidence rates of postoperative anastomotic leak following laparoscopic (LP) versus open (OP) lower anterior resection for rectal cancer.</p><p><b>METHODS</b>Fifty-three cases of LP and 135 cases of OP lower anterior resection with rectal cancer site 5-8 cm away from anal edge were operated by the same surgeon team from Sep. 2000 to Dec. 2005. The differences of postoperative anastomotic leak of protective stomy and non-protective stomy between LP and OP groups were analysed.</p><p><b>RESULTS</b>In LP group, the incidence rates of the postoperative anastomotic leak of protective stomy and non-protective stomy were 4.6% (1/22) and 6.5% (2/31) respectively (P>0.05, chi(2)=0.088). In OP group, the incidence rates were 2.3% (1/43) and 8.7% (8/92) respectively (P>0.05, chi(2)=1.024). No significant difference existed between LP and OP groups with protective stomy (P=0.455), neither did LP and OP groups without protective stomy (P=0.288).</p><p><b>CONCLUSION</b>Laparoscopic low anterior resection of rectal cancer is a safe procedure. It doesn't increase the incidence rate of anastomotic leak as compared to traditional open surgery.</p>

Comparing the influencing factors of anastomotic bleeding in rectal carcinoma resection between laparoscopic and open radical approaches / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To observe the occurrence of anastomotic bleeding following laparoscopic and open radical resection for rectal carcinoma, and to explore its contributing factors.</p><p><b>METHODS</b>Two hundred and sixty-three cases of rectal carcinoma undergone radical resection were divided into 2 groups, laparoscopic surgery (LS) group (n=86) and open surgery (OS) group (n=177). According to the different locations of anastomotic stoma and with or without preventive colostomy, the two groups were divided into AR sub-group and LAR/UAR sub-group, colostomy sub-group and non-colostomy sub-group. After analyzing the incidence of anastomotic bleeding in each sub-group, a logistic regression model was established to determine the relationships between anastomotic bleeding and three contributing factors including surgical approaches (LS or OS), location of stoma (AR or LAR/UAR) and preventive colostomy.</p><p><b>RESULTS</b>Anastomotic bleeding occurred on 16 out of 263 patients with radical resection of rectal cancer (6.1%). The rates of anastomotic bleeding in LS group and OS group were 9.3% and 4.5%, in colostomy and non-colostomy were 8.1% and 5.5%, and in AR group and LAR/UAR group were 3.3% and 12.1% respectively, there were no significant differences between them (P>0.05). Comparing the two different surgical approaches (LS vs OS), the coefficient of regression, odd ratio and standard coefficient of regression for LS were 1.319, 3.741 and 0.342 respectively. In comparison of the locations of anastomosis (AR vs LAR/UAR), the three index for LAR/UAR were 2.460, 11.704, and 0.632 respectively. Comparing colostomy with non-colostomy, the three index for colostomy were -1.394, 0.248, and -0.327 respectively.</p><p><b>CONCLUSIONS</b>Anastomotic bleeding after radical rectectomy is related to the choice of surgical approach, location of anastomosis and with or without preventive colostomy. Both LS and LAR/UAR are risk factors, and preventive colostomy is a protective factor. Regarding to the significance of three factors, location of anastomosis takes the first place, following by surgical method and with or without preventive colostomy.</p>

Comparison of surgical complication rate between laparoscopic and open radical resection for colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the surgical complication rate between laparoscopic and open radical resection for colorectal cancer.</p><p><b>METHODS</b>From September 2000 to December 2005, 491 cases with colorectal cancer were divided into two groups prospectively and nonrandomly,and received radical laparoscopic operation (LP, n=214) and open operation (OP, n=277). The intra- and post-operative complication rate were compared between the two groups.</p><p><b>RESULTS</b>In laparoscopic groups, 14 cases (6.54%,14/214) were converted to open surgery,because of intra-operative complications in 7 cases,obesity or large tumors in 5 cases,narrow- pelvis in one case and retroperitoneal tumor in one case. The intra-operative complication rate was 4.8% (10/207) in LP group and 3.6% (10/277) in OP group (P > 0.05, chi2=0.446). There were no differences in post- operative intestinal obstruction, stoma leak, stoma bleeding, chyle leak, pulmonary infection except incision infection(5.5% vs 14.1%, P< 0.05) between LP and OP groups. The overall postoperative complication rate was 23.5% (47/200) in LP group and 36.8% (102/277) in OP group (P< 0.01, chi2=9.598).</p><p><b>CONCLUSIONS</b>There is no difference in intra-operative complication rate between LP and OP groups,but the post-operative complication rate is significantly lower in LP group than that in OP group.</p>

Feasibility of lymphadenectomy with skeletonization in extended right hemicolectomy by hand-assisted laparoscopic surgery / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility of lymphadenectomy with skeletonization in extended right hemicolectomy by hand-assisted laparoscopic surgery (HALS).</p><p><b>METHODS</b>From November 2001 to September 2004, 30 cases with right hemicolonic cancer were divided into two groups, and received laparoscopic or open extended right hemicolectomy plus lymphadenectomy with skeletonization. Clinical data of two groups were compared.</p><p><b>RESULTS</b>The mean operative time were (214.0 +/- 16.5) min and (245.0 +/- 24.6) min (t=2.248, P< 0.05), the mean volumes of intraoperative bleeding (78.4 +/- 24.3) ml and (203.3 +/- 48.5) ml (t=4.927, P< 0.05), the mean time of anal aerofluxus (53.4 +/- 6.7) h and (67.3 +/- 9.7) h (t=2.530, P< 0.05), the mean postoperative hospital stay (11.5 +/- 1.11) d and (17.9 +/- 3.98) d (t=3.413, P< 0.05) respectively in laparoscopic and open operation groups. The mean numbers of N1, N2 and N3 lymph nodes cleared in laparoscopic group were (15.3 +/- 2.6), (5.6 +/- 1.6) and (4.3 +/- 2.2) respectively,while (16.2 +/- 3.3), (5.9 +/- 2.2) and (6.1 +/- 1.5) respectively in open operation group (all P > 0.05). The complication rates were 20.0% (3/15) and 33.3% (5/15) respectively in laparoscopic and open operation groups (chi(2)=0.0227, P > 0.05).</p><p><b>CONCLUSION</b>Extended right hemicolectomy plus lymphadenectomy with skeletonization can be perfectly performed by HALS.</p>