Resultados de la cirugía de urgencia en pacientes con cáncer de colon perforado / Results of emergency surgery in patients with perforated colon cancer

RESUMEN: Gran parte de los pacientes con cáncer de colon (CC), son diagnosticados y tratados de forma electiva. Sin embargo, aproximadamente un 20 % de ellos debutará como una emergencia (obstrucción o perforación). El objetivo de este estudio fue determinar morbilidad postoperatoria (MPO) y supervivencia global (SVG) en pacientes resecados por CC perforado (CCP). Serie de casos retrospectiva de pacientes con CCP, sometidos a colectomía y linfadenectomía, de forma consecutiva, en Clínica RedSalud Mayor y Hospital de Temuco, Chile, entre 2010 y 2019. Las variables resultados fueron SVG y MPO. Otras variables de interés fueron: tiempo quirúrgico, resecabilidad, número de linfonodos resecados, estancia hospitalaria, mortalidad operatoria, recurrencia y supervivencia libre de enfermedad (SLE). Los pacientes fueron seguidos de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión; y análisis de SV con curvas de Kaplan Meier. Se intervinieron 15 pacientes (60 % mujeres), con una mediana de edad de 62 años. La localización más frecuente fue sigmoides (6 casos; 40,0 %). La resecabilidad de la serie fue 100 %. La medianas del tiempo quirúrgico, número de linfonodos resecados y estancia hospitalaria; fueron 80 min, 20 y 5 días respectivamente. La MPO fue 26,7 % (4 casos). Con una mediana de seguimiento de 36 meses, se verificó una recurrencia de 40,0 %. Por otra parte, la SVG y SLE a 5 años fue 46,7 % y 33,3 % respectivamente. Los resultados obtenidos, en términos de MPO y SVG, fueron similares a series internacionales.

SUMMARY: Most patients with colon cancer (CC) are diagnosed and treated electively. However, a fifth of them will debut as an emergency (obstruction or perforation). The aim of this study was to determine postoperative morbidity (POM) and overall survival (OS) in patients resected by perforated CC (PCC). Retrospective case series of patients with PCC undergoing colectomy and lymphadenectomy, consecutively, at RedSalud Mayor Clinic and Temuco hospital, Chile, between 2010 and 2019. The outcome variable were POM and OS. Other variables of interest were surgical time, resectability, number of resected lymph nodes, hospital stay, mortality, recurrence, and disease-free survival (DFS). Patients were followed clinically. Descriptive statistics was used (measures of central tendency and dispersion), and OS analysis was applying Kaplan Meier curves.15 patients (60 % women) were intervened, with a median age of 62 years. The most frequent location was the sigmoid colon (6 cases, 40.0 %). Resectability of the series was 100 %. Median surgical time, number of lymph nodes resected, and hospital stay; they were 80 min, 20 and 5 days respectively. POM was 26.7 % (4 cases). With a median follow-up of 36 months, recurrence was 40.0 %. On the other hand, OS and DFS at 5 years were 46.7 % and 33.3 %, respectively. The observed results, in terms of POM and OS, were like international series.

A comparison between different management surgical approaches in the treatment of splenic flexure colon cancer

Background: There are many surgical approaches which described extent of resection of the colon for adequate surgicalmanagement of splenic flexure cancer, but up till now there is no established surgical procedure, this is because the presence of double lymphatic drainage of themesenteric vessels. Segmental resection of the colon for the management of splenic flexure cancer was a recently accepted surgical procedure. Objective: In the present study, we aimed to compare three surgical management techniques to clarify the best management approach of Egyptian patients with splenic flexure cancer regarding operative, clinical, and oncological outcomes: segmental resection, and extended left or right hemicolectomy,. Materials and Methods In the present study, we included 90 patients with splenic flexure cancer. Cases were divided into 3 groups. Each group included 30 patients in order to compare three surgical techniques: segmental resection, extended left hemicolectomy, and extended right hemicolectomy. Results: We have found no statistically significant differences between the three included groups regarding operative findings, postoperative complications, local recurrence, distant recurrence, disease progression, recurrence-free survival rate, progression-free survival rate, and overall survival rate. The operative time was longer, and the number of lymph nodes was higher in the extended right hemicolectomy group (p<0.001). Conclusion: We have shown that segmental resection of the splenic flexure is surgically and clinically suitable for the adequate management of operable cases of carcinoma of the splenic flexure. (AU)

Beneficios del preoperatorio con recuperación acelerada en pacientes operados de colon por cirugía electiva / Preoperative Benefits with Accelerated Recovery on Patients Operated on for Colon Cancer by Elective Surgery

Introducción: Con la introducción del programa de recuperación acelerada en el servicio de Cirugía General del Hospital Militar de Ejército "Dr. Mario Muñoz Monroy" han ocurrido cambios en la atención perioperatoria del paciente con cirugía electiva para el cáncer de colon. Es de vital importancia conocer sus beneficios en relación al procedimiento tradicional desde que se decide la intervención quirúrgica. Objetivo: Evaluar los beneficios de la recuperación acelerada en pacientes operados de colon por cirugía electiva. Métodos: Se realizó un estudio analítico de caso y control durante el período de enero de 2015 a diciembre de 2019. El grupo de casos cumplió con 12 acciones perioperatorias definidas por el programa de recuperación acelerada y el de control siguió el procedimiento tradicional. Se realizó análisis bivariable de Chi cuadrado y Odds Ratio con intervalo de confianza del 95 por ciento. Resultados: Con la implementación del programa de recuperación acelerada desde el preoperatorio, los pacientes llegaron a la cirugía con adecuada capacidad funcional y compensación de sus comorbilidades. Esta conducta favoreció la evolución posoperatoria, redujo las complicaciones en un 33 por ciento Odds Ratio de 0,05 y la estadía hospitalaria en 5,67 días con Odds Ratio de 2[10,4-5,1]. Conclusiones: Los pacientes con el procedimiento de recuperación acelerada en su preoperatorio recibieron beneficios en relación a reducir el estrés quirúrgico, mayores reservas fisiológicas y mejor recuperación posoperatoria. La estadía hospitalaria está asociada significativamente a la edad de los pacientes, las comorbilidades y número de estas(AU)

Introduction: With the introduction of the accelerated recovery program in the general surgery service of Dr. Mario Muñoz Monroy Military Hospital of the Army (Matanzas, Cuba), changes have occurred in the perioperative care of the patient with elective surgery for colon cancer. It is of vital importance to know its benefits with respect to the traditional procedure from the moment the surgical intervention is decided. Objective: To assess the benefits of accelerated recovery in patients undergoing elective colon surgery. Methods: An analytical case-control study was carried out during the period from January 2015 to December 2019. The case group completed 12 perioperative actions defined by the accelerated recovery program, while the control group followed the traditional procedure. A bivariate analysis of chi-square and odds ratio (OR) with 95 percent confidence interval was performed. Results: With the implementation of the accelerated recovery program from the preoperative period, patients arrived at surgery with adequate functional capacity and compensation of their comorbidities. This behavior favored postoperative evolution, reduced complications by 33 percent (OR: 0.05) and hospital stay by 5.67 days (OR: 2) [10.4-5.1]. Conclusions: With the accelerated recovery procedure in their preoperative period, patients received benefits associated with reduced surgical stress, greater physiological reserves and better postoperative recovery. Hospital stay is significantly associated with patient age, comorbidities and number of comorbidities(AU)

Application of three-dimensional visualization technique in laparoscopic D3 radical resection of right colon cancer / 南方医科大学学报

OBJECTIVE@#To explore the clinical value of three-dimensional (3D) visualization technique in laparoscopic D3 radical resection of right colon cancer.@*METHODS@#We retrospectively analyzed the clinical data of 73 patients with right colon cancer undergoing laparoscopic D3 radical operation in our hospital between May, 2019 and March, 2021. Among these patients, 41 underwent enhanced CT examination with 3D visualization reconstruction to guide the actual operation, and 32 underwent enhanced CT examination only before the operation (control group). In 3D visualization group, we examined the coincidence rate between the 3D visualization model and the findings in surgical exploration of the anatomy and variations of the main blood vessels, supplying vessels of the tumor, and the tumor location, and the coincidence rate between the actual surgical plan for D3 radical resection of right colon cancer and the plan formulated based on the 3D model. The operative time, estimated blood loss, unexpected injury of blood vessels, number of harvested lymph nodes, mean time of the first flatus, complications, postoperative hospital stay and postoperative drainage volume were compared between the two groups.@*RESULTS@#The operative time was significantly shorter in 3D visualization group than in the control group (P < 0.05). The volume of blood loss, proportion of unexpected injury of blood vessel, the number of harvested lymph nodes, time of the first flatus, proportion of complications, postoperative hospital stay and postoperative drainage volume did not differ significantly between the two groups (P > 0.05). In the 3D visualization group, the 3D visualization model clearly displayed the shape and direction of the colon, the location of the tumor, the anatomy and variation of the main blood vessels and the blood vessels supplying the cancer, and showed a coincidence rate of 100% with the findings by surgical exploration. The surgical plan for D3 radical resection of right colon cancer was formulated based on the 3D model also showed a coincidence rate of 100% with the actual surgical plan.@*CONCLUSION@#The 3D visualization reconstruction technique allows clear visualization the supplying arteries of the tumor and their variations to improve the efficiency, safety and accuracy of laparoscopic D3 radical resection of right colon cancer.

Medial border of D3 lymphadenectomy for right colon cancer / 中华胃肠外科杂志

The extent of D3 lymphadenectomy for right colon cancer, especially the medial border of central lymph node dissection remains controversial. D3 lymphadenectomy and complete mesocolon excision (CME) are two standard procedures for locally advanced right colon carcinoma. D3 lymphadenectomy determines the medial border according to the distribution of the lymph nodes. The mainstream medial border should be the left side of superior mesenteric vein (SMV) according to the definition of D3, but there are also some reports that regards the left side of superior mesenteric artery (SMA) as the medial border. In contrast, the CME procedure emphasizes the beginning of the colonic mesentery and the left side of SMA should be considered as the medial border. Combined with the anatomical basis, oncological efficacy and technical feasibility of D3 lymph node dissection, we think that it is safe and feasible to take the left side of SMA as the medial boundary of D3 lymph node dissection. This procedure not only takes into account the integrity of mesangial and regional lymph node dissection, but also dissects more distant lymph nodes at risk of metastasis. It has its anatomical basis and potential oncological advantages. However, at present, this technical concept is still in the exploratory stage in practice, and the related clinical evidence is not sufficient.

Splenic flexure cancer: surgical procedures and extent of lymphadenectomy / 中华胃肠外科杂志

Splenic flexure colon cancer occurs at a relatively lower rate than colon cancer of other sites. It is also associated with more advanced disease and higher rate of acute obstruction. The splenic flexure receives blood supply from both superior and inferior mesenteric arteries (SMA and IMA), and therefore has lymphatic drainage to both areas. The blood supply is also highly variable, causing difficulties in determining the main feeding vessels and the main direction of lymph drainage. Few studies with limited cases focused on this specific tumor site with respect to the patterns of lymph node spread, especially the main lymph node status and the value of its dissection. The lack of information limits the development of a consensus on the extent of surgical resection and lymphadenectomy. Adequate mobilization of the colon facilitates a sufficient length of bowel resection and the high ligation of feeding arteries from both SMA and IMA. Further evidence on the chnoice of procedures and the extent of lymph node dissection need multicenter collaboration, with the use of modern techniques, including CT 3D reconstruction of the colon and angiography, as well as intraoperative fluorescent real-time imaging of lymph nodes.

Risk factors of postoperative surgical site infection in colon cancer based on a single center database / 中华胃肠外科杂志

Objective: To explore the incidence and risk factors of postoperative surgical site infection (SSI) after colon cancer surgery. Methods: A retrospective case-control study was performed. Patients diagnosed with colon cancer who underwent radical surgery between January 2016 and May 2021 were included, and demographic characteristics, comorbidities, laboratory tests, surgical data and postoperative complications were extracted from the specialized prospective database at Department of General Surgery, Peking Union Medical College Hospital. Case exclusion criteria: (1) simultaneously multiple primary colon cancer; (2) segmental resection, subtotal colectomy, or total colectomy; (3) patients undergoing colostomy/ileostomy during the operation or in the state of colostomy/ileostomy before the operation; (4) patients receiving natural orifice specimen extraction surgery or transvaginal colon surgery; (5) patients with the history of colectomy; (6) emergency operation due to intestinal obstruction, perforation and acute bleeding; (7) intestinal diversion operation; (8) benign lesions confirmed by postoperative pathology; (9) patients not following the colorectal clinical pathway of our department for intestinal preparation and antibiotic application. Univariate analysis and multivariate analysis were used to determine the risk factors of SSI after colon cancer surgery. Results: A total of 1291 patients were enrolled in the study. 94.3% (1217/1291) of cases received laparoscopic surgery. The incidence of overall SSI was 5.3% (69/1291). According to tumor location, the incidence of SSI in the right colon, transverse colon, left colon and sigmoid colon was 8.6% (40/465), 5.2% (11/213), 7.1% (7/98) and 2.1% (11/515) respectively. According to resection range, the incidence of SSI after right hemicolectomy, transverse colectomy, left hemicolectomy and sigmoid colectomy was 8.2% (48/588), 4.5% (2/44), 4.8% (8 /167) and 2.2% (11/492) respectively. Univariate analysis showed that preoperative BUN≥7.14 mmol/L, tumor site, resection range, intestinal anastomotic approach, postoperative diarrhea, anastomotic leakage, postoperative pneumonia, and anastomotic technique were related to SSI (all P<0.05). Multivariate analysis revealed that anastomotic leakage (OR=22.074, 95%CI: 6.172-78.953, P<0.001), pneumonia (OR=4.100, 95%CI: 1.546-10.869, P=0.005), intracorporeal anastomosis (OR=5.288, 95%CI: 2.919-9.577,P<0.001) were independent risk factors of SSI. Subgroup analysis showed that in right hemicolectomy, the incidence of SSI in intracorporeal anastomosis was 19.8% (32/162), which was significantly higher than that in extracorporeal anastomosis (3.8%, 16/426, χ(2)=40.064, P<0.001). In transverse colectomy [5.0% (2/40) vs. 0, χ(2)=0.210, P=1.000], left hemicolectomy [5.4% (8/148) vs. 0, χ(2)=1.079, P=0.599] and sigmoid colectomy [2.1% (10/482) vs. 10.0% (1/10), χ(2)=2.815, P=0.204], no significant differences of SSI incidence were found between intracorporeal anastomosis and extracorporeal anastomosis (all P>0.05). Conclusions: The incidence of SSI increases with the resection range from sigmoid colectomy to right hemicolectomy. Intracorporeal anastomosis and postoperative anastomotic leakage are independent risk factors of SSI. Attentions should be paid to the possibility of postoperative pneumonia and actively effective treatment measures should be carried out.

The effects of robotic-assisted versus laparoscopic-assisted radical right hemicolectomy on short-term outcome and long-term prognosis based on propensity score matching / 中华外科杂志

Objective: To compare the short-term and long-term outcomes between robotic-assisted and laparoscopic-assisted radical right hemicolectomy in patients with adenocarcinoma of the right colon. Methods: Retrospective review of a prospectively collected database identified 288 right colon cancer patients who underwent either robotic-assisted (n=57) or laparoscopic-assisted right hemicolectomy (n=231) between October 2014 and October 2020 at Department of Gastrointestinal Surgery, the Affiliated Hospital of Qingdao University. There were 161 males and 127 females, aging (60.3±12.8) years (range: 17 to 86 years). After propensity score matching as 1∶4 between robotic-assisted and laparoscopic-assisted right hemicolectomy, there were 56 cases in robotic group and 176 cases in laparoscipic group. Perioperative outcomes and overall survival were compared between the two groups using t test, Wilcoxon rank sum test, χ2 test, Fisher exact test, Kaplan-Meier method and Log-rank test, respectively. Results: The total operative time was similar between the robotic and laparoscopic group ((206.9±60.7) minutes vs. (219.9±56.3) minutes, t=-1.477, P=0.141). Intraoperative bleeding was less in the robotic group (50 (20) ml vs. 50 (50) ml, Z=-4.591, P<0.01), while the number of lymph nodes retrieved was significantly higher (36.0±10.0 vs. 29.0±10.1, t=4.491, P<0.01). Patients in robotic group experienced significantly shorter hospital stay, shorter time to first flatus, and defecation (t: -2.888, -2.946, -2.328, all P<0.05). Moreover, the overall peri-operative complication rate was similar between robotic and laparoscopic group (17.9% vs. 22.7%, χ²=0.596,P=0.465). The 3-year overall survival were 92.9% and 87.9% respectively and the 3-year disease-free survival rates were 83.1% and 82.6% with no statistical significance between the robotic and laparoscopic group (P>0.05). Conclusions: Compared to laparoscopic-assisted right hemicolectomy, robot-assisted right hemicolectomy could improve some short-term clinical outcomes. The two procedures are both achieving comparable survival.

Safety and feasibility of overlapped delta-shaped anastomosis technique for digestive tract reconstruction during complete laparoscopic right hemicolectomy / 中华肿瘤杂志

Objective: To explore the clinical safety and feasibility of overlapped delta-shaped anastomosis (ODA) in totally laparoscopic right hemicolectomy (TLRHC). Methods: From May 2017 to October 2019, of the 219 patients who underwent TLRHC at the Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 104 cases underwent ODA (ODA group) and 115 cases underwent conventional extracorporeal anastomosis (control group) were compared the surgical outcomes, postoperative recovery, pathological outcomes and perioperative complications. Results: The length of the skin incision in the ODA group was significantly shorter than that in the control group [(5.6±0.9) cm vs. (7.1±1.7) cm, P<0.05], and the time to first flatus and first defecation after surgery in the ODA group was significantly earlier than that in the control group [(1.7±0.7) days vs. (2.0±0.7) days; (3.2±0.6) days vs. (3.3±0.7) days, P<0.05]. While the anastomosis time, operation time, intraoperative blood loss, the time of first ground activities, the number of bowel movements within 12 days after surgery, postoperative hospital stay, tumor size, the distal and proximal margins, the number of lymph node harvested and postoperative TNM stage in the ODA group did not differ from that of the control group (P>0.05). The postoperative complication rates of patients in the ODA group and the control group were 3.8% (4/104) and 4.3% (5/115), respectively, and the difference was not significant (P>0.05). Conclusion: The application of ODA technology in TLRHC can significantly shorten thelength of skin incisionand the recovery time of bowel function, and can obtain satisfactory short-term efficacy.

Progress in diagnosis and treatment of gastroparesis after colon cancer surgery / 中华胃肠外科杂志

At present, comprehensive treatment dominated by surgical procedures is an important measure for colon cancer to obtain the chance of cure. Surgical intervention, while removing the tumor, carries the risk of postoperative gastroparesis (PG) . Because of the low incidence rate and insignificant early clinical symptoms, early stage PG is often overlooked clinically. However, PG can increase the risk of malnutrition, delay postoperative antitumor treatment, and increase the risk of tumor recurrence and metastasis. This review focuses on the mechanisms, clinical risk factors, preventive measures, and advances in treatment of PG due to colon cancer. Aim to increase the clinician's adequate attention to PG in colon cancer and from a surgical point to reduce the risk of gastroparesis in colon cancer by optimizing the surgical strategy.

Delayed gastric emptying after surgery for transverse colon cancer: diagnosis, management and prevention / 中华胃肠外科杂志

Delayed gastric emptying is a syndrome of gastric motility disorder with slow gastric emptying as the main sign, provided that mechanical factors such as intestinal obstruction and anastomotic stricture are excluded. The incidence of delayed gastric emptying after colon cancer surgery is 1.4%, mainly after transverse colon cancer surgery. Most of the studies on delayed gastric emptying are case reports, lacking systematic studies. The diagnoses and treatments can be draw on the experience of delayed gastric emptying after pancreatic surgery. Our retrospective study indicated that the incidence of delayed gastric emptying after surgery for transverse colon cancer was 4.0%, higher than that for other colon cancer. Patients who underwent gastrocolic ligament lymph node dissection were at higher risk than those who did not (3.6% vs. 0.8%). Gastrocolic ligament lymph node dissection and stress are causative factors for delayed gastric emptying after surgery for transverse colon cancer. We add the gastrografin test upon the diagnostic criteria of the International Study Group for Pancreatic Surgery, which is simple and practical. Nasogastric tube decompression, enteral nutrition combined with parenteral nutrition, glucocorticoids, and prokinetic agents can cure most patients with postoperative delayed gastric emptying. All the patients with postoperative delayed gastric emptying were cured in our studies. Strict indications for gastrocolic ligament lymph node dissection (patients with cT3-4 and cN+) may decrease the occurrence of delayed gastric emptying after surgery for transverse colon cancer.

Clinical guidance on endoscopic management of colonic polyps in Singapore

Colonoscopy with endoscopic resection of detected colonic adenomas interrupts the adenoma-carcinoma sequence and reduces the incidence of colorectal cancer and cancer-related mortality. In the past decade, there have been significant developments in instruments and techniques for endoscopic polypectomy. Guidelines have been formulated by various professional bodies in Europe, Japan and the United States, but some of the recommendations differ between the various bodies. An expert professional workgroup under the auspices of the Academy of Medicine, Singapore, was set up to provide guidance on the endoscopic management of colonic polyps in Singapore. A total of 23 recommendations addressed the following issues: accurate description and diagnostic evaluation of detected polyps; techniques to reduce the risk of post-polypectomy bleeding and delayed perforation; the role of specific endoscopic resection techniques; the histopathological criteria for defining endoscopic cure; and the role of surveillance colonoscopy following curative resection.

Factores asociados a la supervivencia de pacientes operados de cáncer de colon con metástasis hepáticas sincrónicas / Factors Associated to Survival in Patients Operated on for Colon Cancer with Synchronic Liver Metastases

Introducción: La metástasis hepática del cáncer de colon es una entidad frecuente. Objetivo: Identificar los factores asociados a la supervivencia en pacientes intervenidos de cáncer de colon con metástasis hepática sincrónica. Métodos: Se realizó un estudio observacional, descriptivo y transversal a 34 pacientes operados con este diagnóstico, en el servicio de Cirugía General del Hospital Provincial Docente "Saturnino Lora" de Santiago de Cuba, desde 2010 hasta 2019. Fue estimada la supervivencia global y por diferentes periodos de tiempo en la cohorte, según el método de Kaplan-Meier. La comparación de las curvas de supervivencia para las covariables seleccionadas se realizó mediante la prueba de igualdad de distribuciones (Log-Rank de Mantel y Cox). Resultados: La supervivencia global a los seis meses y al año del diagnóstico fue de 66,5 por ciento y 66,2 por ciento, respectivamente, con mediana de dos años (IC 95 por ciento: 0,97-3,02). La supervivencia fue superior si el paciente presentó una metástasis versus dos o más, así como la de ambos lóbulos marca la menor probabilidad de supervivencia. Los tumores bien y moderadamente diferenciados mostraron mayor probabilidad de supervivencia al año que los pocos diferenciados, sin diferencias significativas. Conclusiones: La cirugía permite mejorar la sobrevida global y libre de enfermedad, aunque el uso de las distintas opciones terapéuticas para el cáncer colónico con metástasis hepática sincrónica continúa controvertido. La supervivencia de estos enfermos está condicionada por la estadificación, diferenciación histológica del tumor, localización y número de metástasis, entre otros factores(AU)

Introduction: Liver metastasis from colon cancer is a frequent entity. Objective: To identify the factors associated with survival in patients operated on for colon cancer with synchronic liver metastasis. Methods: An observational, descriptive and cross-sectional study was carried out, from 2010 to 2019, with 34 patients with this diagnosis operated on in the general surgery service of Saturnino Lora Provincial Teaching Hospital of Santiago de Cuba. Overall survival was estimated, as well as by different time periods in the cohort, using the Kaplan-Meier method. The comparison of the survival curves for the selected covariates was carried out using the test of equality of distributions (log-rank or Mantel-Cox test). Results: Overall survival six months and one year after diagnosis was 66.5 percent and 66.2 percent, respectively, with a median of two years (95 percent CI: 0.97-3.02). Survival was higher if the patient had one metastasis versus two or more, while metastasis in both lobules represents the lowest probability of survival. Well and moderately differentiated tumors showed higher probability of survival at one year than the little differentiated ones, without significant differences. Conclusions: Surgery improves overall and disease-free survival, although the use of different therapeutic options for colon cancer with synchronic liver metastases remains controversial. The survival of these patients is conditioned by staging, histological differentiation of the tumor, location and number of metastases, among other factors(AU)

Cáncer de colon con metástasis hepáticas sincrónicas / Colon Cancer with Synchronous Hepatic Metastases

Introducción: El cáncer de colon constituye un grave problema sanitario debido a su alta incidencia y mortalidad. Objetivo: Describir algunos aspectos epidemiológicos, etiopatogénicos, diagnósticos, terapéuticos y evolutivos del cáncer de colon con metástasis hepáticas. Métodos: Revisión documental en bases de datos bibliográficos biomédicas sobre el tema durante el período 2015-2020. Se seleccionaron 31 artículos relacionados con el objetivo propuesto. Desarrollo: Los pacientes con cáncer de colon con metástasis hepáticas sincrónicas son tratados mediante tres estrategias: la tradicional o clásica consiste en la resección quirúrgica del tumor primario y posteriormente, quimioterapia, radioterapia o ambas, para proceder a la resección de las lesiones hepáticas tres a seis meses después; la simultánea, consistente en la resección de la lesión tumoral primaria y de las metástasis hepáticas en un mismo acto quirúrgico, seguida de quimioterapia, radioterapia o ambas y la inversa, que administra de tres a seis ciclos de quimioterapia sistémica, seguidos por la resección de las metástasis hepáticas y en un segundo tiempo resecar el tumor primario, todo esto con quimioterapia durante el intervalo entre ambas cirugías. Conclusiones: El único tratamiento con potencial curativo en los pacientes con metástasis hepáticas debe ser la resección de todo el volumen tumoral hepático con márgenes adecuados y la suficiente preservación del parénquima sano (25 - 30 por ciento), según criterios oncológicos y anatómicos establecidos, lo que incide en la calidad de vida y la supervivencia de estos enfermos(AU)

Introduction: Colon cancer is a serious health concern due to its high incidence and mortality. Objective: To describe some epidemiological, etiopathogenic, diagnostic, therapeutic and evolutionary aspects of colon cancer with hepatic metastases. Methods: Documentary review about the subject carried out in biomedical bibliographic databases, during the period 2015-2020. Thirty-one articles related to the proposed objective were selected. Development: Colon cancer patients with synchronous hepatic metastases are treated using three strategies: the traditional, or classic, strategy consists in surgical resection of primary tumor and, subsequently, chemotherapy, radiotherapy or both, before proceeding then to resection of liver lesions three to three six months later; the simultaneous strategy consists in resection of primary tumor lesion and hepatic metastases in the same surgical procedure, followed by chemotherapy, radiotherapy or both; and the reverse strategy, in which three to six cycles of systemic chemotherapy are administered, followed by resection of hepatic metastases and, in a second stage, resection of primary tumor, all this with chemotherapy during the interval between both surgeries. Conclusions: The only treatment with curative potential in patients with hepatic metastases should be the resection of the entire hepatic tumor volume with adequate margins and sufficient preservation of the healthy parenchyma (25-30 percent), according to established oncological and anatomical criteria, which has an incidence on the quality of life and survival of these patients(AU)

Resección transmural endoscópica de adenoma colónico residual con fibrosis / Endoscopic full-thickness resection of residual colonic adenoma with fibrosis

Resumen La resección transmural endoscópica es una técnica que permite la resección en bloque de lesiones colónicas en pacientes en los cuales han fracasado los métodos endoscópicos convencionales como la resección mucosa endoscópica o la disección submucosa endoscópica. Presentamos el caso de un hombre de 75 años con antecedentes de adenoma de colon con fibrosis debido a dos intentos previos fallidos de resección endoscópica en otra institución. Realizamos con éxito el procedimiento de resección transmural endoscópica evitando así una cirugía.

Abstract Endoscopic full-thickness resection is a technique that allows in block resection of colonic lesions in patients in whom conventional endoscopic methods such as endoscopic mucosal resection or endoscopic submucosal dissection have failed. We present a case of a 75-year-old man with history of a difficult-to-resect colon adenoma. He had undergone two previous failed attempts of endoscopic mucosal resection due to non-lifting sign in another center. We successfully performed an endoscopic full-thickness resection procedure, avoiding unnecessary surgery.

Thirty years of the health care service for ostomy patients in Juiz de Fora and surroundings / Trinta anos do serviço de atenção à saúde da pessoa ostomizada de Juiz de Fora e região

ABSTRACT Objective: to establish the epidemiological profile of ostomized patients treated at the Health Care Service for Ostomy Patients in Juiz de Fora and region (SASPO/JF) and to quantify the pathologies that led to the stoma as well as the ostomy-related complications. Method: a retrospective study was carried out with the analysis of 496 medical records of patients registered at HCSOP/JF over 30 years and who remained in at the service in June 2018. The following variables were considered: age, sex, pathology that led to the stoma, type, time, location and complications of stomas. Results: 53.43% were male patients and 46.57% female. The average age was 56.24 years among men and 58.40 years among women. Eight patients had two types of ostomies simultaneously and a total of 504 ostomies were as follows: 340 colostomies (67.46%), 117 ileostomies (23.21%) and 47 urostomies (9.33%). Additionally, 47.65% of the colostomies and 76.92% of the ileostomies were temporary, while all urostomies were permanent. In 70.24% of cases, the reason for making the stoma was malignancy. There were 277 stomas with one or more complications (54.96%). Conclusions: most of the ostomized patients were over 50 years old and the main diagnosis that led to the stoma was malignancy. Ileostomies had a higher percentage of complications than colostomies and urostomies and, for all types of stomas, the most frequent complication was dermatitis.

RESUMO Objetivo: elaborar o perfil epidemiológico dos pacientes estomizados atendidos no Serviço de Atenção à Saúde da Pessoa Ostomizada de Juiz de Fora e região (SASPO/JF) e quantificar tanto as patologias que levaram à confecção, quanto as complicações presentes nas estomias. Método: realizado estudo retrospectivo com análise de 496 prontuários de pacientes cadastrados no SASPO/JF ao longo de 30 anos e que permaneciam em atendimento no serviço em junho de 2018. Foram consideradas as seguintes variáveis: idade, sexo, patologia que levou à confecção do estoma, tipo, caráter temporal, localização e complicações das estomias. Resultados: 53,43% dos pacientes eram do sexo masculino e 46,57% do sexo feminino. A média de idade entre os homens foi de 56,24 anos e entre as mulheres foi de 58,40 anos. Oito pacientes apresentaram dois tipos de estomias simultaneamente e o total de 504 estomias foi distribuído da seguinte forma: 340 colostomias (67,46%), 117 ileostomias (23,21%) e 47 urostomias (9,33%). Além disso, 47,65% das colostomias e 76,92% das ileostomias foram temporárias, enquanto todas as urostomias foram permanentes. Em 70,24% dos casos, o motivo para confecção do estoma foi a neoplasia maligna. Foram encontrados 277 estomas com uma ou mais complicações (54,96%). Conclusão: as estomias predominaram em pacientes com mais de 50 anos e o principal diagnóstico que levou à confecção dos estomas foi a neoplasia maligna. As ileostomias apresentaram maior percentual de complicações do que as colostomias e urostomias e, para todos os tipos de estomas, a complicação mais frequente foi a dermatite.

Efficacy observation of the caudal-medial approach combined with "page-turning" middle lymphadenectomy in the laparoscopic right hemicolectomy / 中华胃肠外科杂志

Objective: To investigate the safety and feasibility of caudal-medial approach combined with "page-turning" middle lymphadenectomy in the laparoscopic right hemicolectomy. Methods: A descriptive cohort study was conducted. Clinical data of 35 patients who underwent laparoscopic radical right hemicolectomy using caudal-medial approach combined with "page-turning" middle lymphadenectomy at Department of Gastrointestinal Surgery, Guangdong Hospital of Chinese Medicine from April 2018 to May 2020 were retrospectively analyzed. All operations were performed consecutively by the same surgeon. The caudal-medial approach was used to dissect the right Toldt's fascia and the anterior pancreaticoduodenal space in a caudal-to-cranial and medial-to-lateral manner guided by the duodenum. The "page-turning" middle lymphadenectomy was used to dissect the mesocolon along the superior mesenteric vein with ileocolic vein, Henle's trunk and pancreas exposed preferentially. Results: All the 35 patients completed the operation successfully, and there was no damage and bleeding of superior mesenteric vessels and their branches. The operative time was (186.9±46.2) minutes, and the blood loss was 50 (10-200) ml. The first time to flatus was (2.1±0.6) days, and the time to fluid intake was (2.5±0.8) days. The postoperative hospital stay was 6 (3-18) d. The overall morbidity of postoperative complication was 8.6% (3/35), including grade II in 1 cases (2.8%) and grade IIIa in 2 case (5.7%) according to the Clavien-Dindo grading standard. The total number of lymph node dissected was 30.2±5.6, and the positive lymph node was 0 (0-7). Tumor staging revealed 5 cases of stage I, 18 cases of stage II, 11 cases of stage III, and 1 case of stage IVA. In this study, the median follow-up time was 15 (4-29) months. One patient died due to cerebrovascular accident 12 months after surgery, and no tumor recurrence or metastasis was observed in all other patients. Conclusions: Laparoscopic radical right hemicolectomy using caudal-medial approach combined with "page-turning" middle lymphadenectomy is safe and feasible. The anterior pancreaticoduodenal space is preferentially mobilized, which reduces the difficulty of central vascular dissection.

Anatomical observation of the right retroperitoneal fascia and its clinical significance in complete mesocolic excision for right colon cancer / 中华胃肠外科杂志

Objective: To investigate the anatomic characteristics of the right retroperitoneal fascia and its surgical implementation while performing complete mesocolic excision (CME) for right colon cancer. Methods: A descriptive study was carried out. (1) Clinicopathological data and surgical videos of 17 non-consecutive patients undergoing laparoscopic right hemicolectomy (extended right hemicolectomy) with CME for right colon cancer at Department of Colorectal Surgery of Union Hospital, Fujian Medical University between January 2020 and October 2020 were retrospectively collected. The construction of right retroperitoneal fascia was observed from caudal dorsal direction and caudal ventral direction. (2) Three postoperative specimens from 3 cases undergoing laparoscopic right hemicolectomy with CME for right colon cancer in June 2020 were prospectively included to observe anatomy and examine histology. (3) Five abdominal cadaver specimens from the Department of Anatomy of Fujian Medical University were enrolled, including 3 males and 2 females. Anatomical observation and histological studies were performed from the cranial approach and the caudal dorsal approach. Masson staining was used to examine the histology. Results: (1) Surgical video observation: The typical structure of right retroperitoneal fascia could be observed in all the 17 patients. The fascia was a rigid barrier between the posterior space of the ascending colon and the anterior pancreaticoduodenal space behind the transverse colon. The right retroperitoneal fascia should be sharply cut to communicate between the two spaces to avoid entering the right mesocolon by mistake. The severed ventral stump of the right retroperitoneal fascia ran along the dorsal side of the right hemicolon to the lateral side, and the dorsal stump covered the level of the duodenum caudally, and continued to move downward, covering the surface of Gerota's fascia. (2) Observation of 3 surgical specimens: The dorsal side of the right mesocolon was smooth and intact, which could be anchored in the corresponding area of the lateral edge of the duodenum. The ventral stump of the right retroperitoneal fascia could be seen, which attached to the dorsal side of the right mesocolon semi-circularly. Masson staining observation: The ventral stump of the right retroperitoneal fascia ran cephalad, fused with the dorsal side of the right mesocolon tightly and curled. The caudal side of confluence and the dorsal side of the right mesocolon presented a bilobed structure. (3) Anatomy of 5 cadaveric specimens: The right retroperitoneal fascia was a thin fascia structure, which was a rigid barrier between the anterior pancreaticoduodenal space behind the transverse colon and the posterior space of the ascending colon. The ventral stump of the right retroperitoneal fascia (including the dorsal side of the right mesocolon), the dorsal stump of the right retroperitoneal fascia (including part of the duodenal wall) and the dorsal side of the right mesocolon were retrieved for histological examination. The ventral stump of the right retroperitoneal fascia fused with the dorsal side of the right mesocolon by the cephalic side, and the dorsal side of the right hemi-mesocolon on the fusion level by caudal side gradually separated into a double-layer loose fascial structure. The dorsal stump of the right retroperitoneal fascia covered the surface of the duodenum level, moved on from the ventral side to the surface of the prerenal fascia, and continued to the caudal side. Conclusions: The right retroperitoneal fascia is a rigid barrier between the anterior pancreaticoduodenal space behind the transverse colon and the posterior space of the ascending colon. The Toldt fascia formed by fusion with the dorsal lobe of the right colon travels to the edge of the descending and horizontal part of the duodenum and separates again. The right retroperitoneal fascia is attached to the edge of the duodenum, reversing and running on the surface of the prerenal fascia, while the dorsal lobe of the right colon runs in front of the pancreas and duodenum, and shifts to the pancreaticoduodenal fascia. During the operation, this fascia should be identified and cut to penetrate the anterior pancreaticoduodenal space behind the transverse colon and the posterior ascending colon space, which helps to ensure the integrity of the dorsal side of the right hemi-mesocolon.

A rare anatomical variation of ileocolic veins involving in gastrocolic vein trunk: case report and literature review / 中华胃肠外科杂志

Objective: Due to its various anatomical variations and numerous branches, the gastrocolic vein trunk (Henle trunk) is the most common site to develop bleeding and other complications in laparoscopic right hemicolectomy for colon cancer. This study aims to investigate the role of ileocolic vein (ICV) joining with Henle trunk, a rare anatomical variation. Methods: A rare case whose ICV was newly found to involve in the formation of Henle trunk during laparoscopic resection of right hemicolon cancer was reported as right gastroepiploic vein+ right colic vein+superior right colic vein+ICV. This anatomical variation was confirmed by multi-slice spiral CT coronal two-dimensional reconstruction of right hemicolon angiography. The literatures about ICV participating in formation of Henle trunk were systematically searched from PubMed, The Cochran Library, CNKI net and Wanfang database, and the occurrence probability and composition of its anatomical variation were analyzed. Results: This was a 47-year-old female patient who underwent laparoscopic right hemicolectomy. When the vessels were dissected during operation, it was found that ICV did not accompany the ileocolic artery, but directly flowed into Henle trunk. Two-dimensional reconstructed CT images of right hemicolon vessels showed that the composition of Henle trunk was rarely varied, which was composed of right gastroepiploic vein, right colonic vein, superior right colonic vein and ICV. Five literatures were enrolled from literature retrieval. A total of 12 cases with ICV participating in the construction of Henle trunk were reported, with a probability of 0.27%-6.31% and 6 forms of the formation of Henle trunk. In this case, Henle trunk was made up of right gastroepiploic vein, right colonic vein, upper right colonic vein and ICV, which was reported for the first time. Conclusions: ICV involving in Henle trunk is a rare vascular variation, and this type of variation should be fully recognized. Careful dissection during operation is necessary to prevent intraoperative bleeding caused by improper operation.