Robotic left colectomy and intracorporeal overlap anastomosis for descending-sigmoid cancer with da Vinci Xi® robotic platform-a video vignette.

This video vignette illustrates the application of the da Vinci Xi® robotic platform for robotic left colectomy and intracorporeal overlap anastomosis in a 51-year-old patient diagnosed with sigmoid-descending colon junction cancer. Emphasizing the advantages of robotic surgery in colorectal procedures, the video showcases a complete mesocolic excision, involving steps such as medial-to-lateral dissection, mobilization of the splenic flexure, ligation of the left colic and sigmoid arteries, and resection of an abdominal wall nodule. The presentation highlights the surgical precision and efficiency achieved, including minimal blood loss and no complications, with an operation time of 190 min. The postoperative outcome was favorable, with the patient discharged on the eighth day and subsequent management involving chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC) for stage pT4bN1aM1c moderately differentiated adenocarcinoma. This case underscores the enhanced capabilities of robotic platforms in complex colorectal surgeries, particularly in achieving cytoreductive surgery (CRS) and ensuring anastomosis safety with improved R0 resection rates.

[A Case of Descending Colon Cancer with Local Recurrence Eight Years and Seven Months after Curative Resection and Favorable Response to Pharmacotherapy-A Case Report].

A 73-year-old woman underwent a descending colectomy for descending colon cancer. The tumor was graded as pStage Ⅲb(pT3[SS], pN1b, pM0, Cur A), according to the 9th edition of the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma. Postoperative treatment of adjuvant chemotherapy comprised oral tegafur/uracil and Leucovorin for 6 months with no evident recurrence. However, contrast-enhanced CT and FDG-PET/CT examination 8 years and 7 months after surgery revealed a 30 mm irregular recurrent tumor in the left iliac fossa. Since the tumor was adjacent to the left psoas muscle, it was considered that RM0(no tumor identified at the radial margin)could not be achieved in that region. Owing to the patient's good general condition, systemic chemotherapy with CAPOX+bevacizumab was administered. Although adverse events prompted discontinuation of the treatment during the first course, the recurrent tumor had significantly regressed. Systemic chemotherapy with mFOLFOX6+bevacizumab as selected subsequent treatment achieved a significant tumor shrinkage to date. Although a recurrence more than 5 years after curative resection of colorectal cancer is extremely rare, the possibility of late recurrence must be considered in patients with well-differentiated tumors who received adjuvant chemotherapy and had negative vascular invasion.

[A Case of Perforation at the Stump of Descending Colon after Hartmann's Operation Performed after Transverse Colostomy].

A 77-year-old man with complaining of anemia and abdominal pain was admitted to our hospital. An abdominal computed tomography showed the sigmoid colon tumor with bowel obstruction. Laparoscopic transverse colostomy was performed to release intestinal obstruction. After first operation, he was diagnosed the sigmoid colon cancer: cT4b(bladder), cN0, cM0, and cStage Ⅱc. Radical laparoscopic operation(Hartmann's operation)was performed. On the 4th postoperative day, fecal juice was discharged from the abdominal drain placed in the Douglas fossa, so emergency laparotomy was performed. The intraoperative findings showed perforation in the blind end of the descending colon. The descending colon was resected from a site approximately 5 cm anal side of the transverse colostomy to the blind end. It was thought that perforation occurred due to an increase in internal pressure in the residual intestinal tract after Hartmann's surgery without blood flow disorder. We believe that further attention is required to the management of residual intestinal tract at the blind end for the obstructive colorectal cancer.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis.

BACKGROUND: The clinical impact of single-incision laparoscopic surgery (SILS) for descending colon cancer (DCC) is unclear. The aim of this study was to evaluate the clinical outcomes of SILS for DCC compared with multi-port laparoscopic surgery (MPLS). METHODS: We retrospectively analyzed 137 consecutive patients with stage I-III DCC who underwent SILS or MPLS at two high-volume multidisciplinary tertiary hospitals between April 2008 and December 2018, using propensity score-matched analysis. RESULTS: After propensity score-matching, we enrolled 88 patients (n = 44 in each group). SILS was successful in 97.7% of the matched cohort. Compared with the MPLS group, the SILS group showed significantly less blood loss and a greater number of harvested lymph nodes. Morbidity rates were similar between groups. Recurrence pattern did not differ between groups. No significant differences were found between groups in terms of 3-year disease-free and overall survivals. CONCLUSION: SILS appears safe and feasible and can provide satisfactory oncological outcomes for patients with DCC.

Vascular variations encountered during laparoscopic surgery for transverse colon, splenic flexure, and descending colon cancer: a retrospective cohort study.

BACKGROUND: Laparoscopic surgery for cancer located in the transverse colon or splenic flexure is difficult because of vascular variability in this region and adjacent vital organs such as the pancreas, spleen, and duodenum. METHODS: This retrospective cohort study involved 51 patients who underwent laparoscopic surgery for colon cancer at Tokushima University Hospital from July 2015 to December 2020. Variations of the middle colic artery (MCA), left colic artery (LCA), middle colic vein (MCV), and first jejunal vein (FJV) and short-term outcomes of laparoscopic surgery in patients with each vascular variation were evaluated. RESULTS: Variations of the MCA, LCA, MCV, and FJV were classified into four, three, five, and three patterns, respectively. The short-term outcomes of laparoscopic surgery for transverse colon cancer in patients with MCA variations and those with FJV variations were evaluated, and no significant difference was found in the operation time, blood loss, postoperative complication rate, time from surgery to start of dietary intake, or time from surgery to discharge among the different variations. Additionally, no significant differences were found in the short-term outcomes of laparoscopic surgery for descending colon cancer in patients with LCA variations. CONCLUSION: Preoperative assessment of vascular variations may contribute to the stability of short-term outcomes of laparoscopic surgery for transverse colon, splenic flexure, and descending colon cancer.

Safety and effectiveness of high ligation of the inferior mesenteric artery for cancer of the descending colon under indocyanine green fluorescence imaging: a pilot study.

BACKGROUND: Complete mesocolic excision with central vascular ligation is a standard advanced technique for achieving favorable long-term oncological outcomes in colon cancer surgery. Clinical evidence abounds demonstrating the safety of high ligation of the inferior mesenteric artery (IMA) for sigmoid colon cancer but is scarce for descending colon cancer. A major concern is the blood supply to the remnant distal sigmoid colon, especially for cases with a long sigmoid colon. We sought to clarify the safety and feasibility of high ligation of the IMA in surgery for descending colon cancer using indocyanine green (ICG) fluorescence imaging. METHODS: In this prospective single-center pilot study, we examined 20 patients with descending colon cancer who underwent laparoscopic colectomy between April 2018 and September 2019. Following full mobilization and division of the proximal colonic mesentery, we temporarily clamped the root of the IMA and performed ICG fluorescence imaging of the blood flow to the sigmoid colon. The postoperative anastomosis-related complications (primary endpoint) and length of viable remnant colon, and the number of lymph nodes retrieved (secondary endpoints) were evaluated and compared with historical controls who underwent conventional IMA-preserving surgery (n = 20). RESULTS: Blood flow reached 40 (17-66) cm retrograde from the peritoneal reflection, even after IMA clamping. Accordingly, IMA high ligation was performed in all cases. No anastomotic anastomosis-related complications occurred in each group. Retrieved total lymph nodes were higher in number in the ICG-guided group than in the conventional group (p = 0.035). Specifically, more principal nodes were retrieved in the ICG-guided group, compared with the conventional group (p = 0.023). However, the distal margin was not as long compared with the conventional group. CONCLUSION: We demonstrated the safety and feasibility of high ligation of the IMA for descending colon cancer without sacrificing additional distal colon using fluorescence evaluation of blood flow in the remnant colon.

Variant Arterial Supply of the Descending Colon by the Coeliac Trunk: A Case Report.

Background and Objectives: Knowledge of arterial variations of the intestines is of great importance in visceral surgery and interventional radiology. Materials and Methods: An unusual variation in the blood supply of the descending colon was observed in a Caucasian female body donor. Results: In this case, the left colic artery that regularly derives from the inferior mesenteric artery supplying the descending colon was instead a branch of the common hepatic artery. Conclusions: Here, we describe the very rare case of an aberrant left colic artery arising from the common hepatic artery in a dissection study.

Risk factors for non-closure of an intended temporary defunctioning stoma after emergency resection of left-sided obstructive colon cancer.

PURPOSE: A substantial part (21-35%) of defunctioning stomas created during resection for colorectal cancer will never be reversed. Known risk factors for non-closure are age, peri- or postoperative complications, comorbidity, and tumor stage. However, studies performed to identify these risk factors mostly focus on rectal cancer and include both preoperative and postoperative factors. This study aims to identify preoperative risk factors for non-reversal of intended temporary stomas created during acute resection of left-sided obstructive colon cancer (LSOCC) with primary anastomosis. METHODS: All patients who underwent emergency resection for LSOCC with primary anastomosis and a defunctioning stoma between 2009 and 2016 were selected from the Dutch ColoRectal Audit, and additional data were collected in the local centers. Multivariable analysis was performed to identify independent preoperative factors for non-closure of the stoma. RESULTS: A total of 155 patients underwent acute resection for LSOCC with primary anastomosis and a defunctioning stoma. Of these, 51 patients (32.9%) did not have their stoma reversed after a median of 53 (range 7-104) months of follow-up. In multivariable analysis, hemoglobin < 7.5 mmol/L (odds ratio (OR) 4.79, 95% confidence interval (95% CI) 1.60-14.38, p = 0.005), estimated glomerular filtration rate (eGFR) ≤ 45 mL/min/1.73 m2 (OR 4.64, 95% CI 1.41-15.10, p = 0.011), and metastatic disease (OR 6.12, 95% CI 2.35-15.94, p < 0.001) revealed to be independent predictors of non-closure. CONCLUSIONS: Anemia, impaired renal function, and metastatic disease at presentation were found to be independent predictors for non-reversal of intended temporary stomas in patients who underwent acute resection for LSOCC. In patients who have an increased risk of non-reversal, the surgeon should consider a Hartmann's procedure.

Randomized controlled trial to evaluate laparoscopic versus open surgery in transverse and descending colon cancer patients.

BACKGROUND: The safety and efficacy of laparoscopic surgery for transverse and descending colon cancer remain controversial. This study aimed to evaluate the short- and long-term outcomes of this procedure. METHODS: We conducted a single-institutional randomized controlled trial. Patients with transverse or descending colon cancer were randomly allocated to receive laparoscopic surgery (LAC) or conventional open surgery (OC). The primary endpoint was the overall complication rate between the two groups. The secondary endpoints were the length of the postoperative hospital stay, the health-related quality of life (HRQOL) score (at 1, 6, and 12 months after surgery), the 5-year relapse-free survival (RFS), and the 5-year overall survival (OS). RESULTS: Between August 2008 and October 2012, a total of 66 patients were enrolled (33 in the LAC group and 33 in the OC group). The patient characteristics showed no significant differences between the two groups. The complication rates (≥ grade 3) were 6.1% in the LAC group and 12.1% in the OC group (p = 0.392). The length of postoperative stay was not significantly different between the two groups. Regarding the HRQOL, the physical functioning, role physical, bodily pain, social functioning, mental health, and role component summary at 1 month after surgery and the social functioning and mental health at 6 months after surgery were better in the LAC group than in the OC group. The 5-year RFS and OS rates were similar between the LAC and OC groups (RFS 90.5% and 87.3%, respectively, p = 0.752; OS 93.3% and 100.0%, respectively, p = 0.543). CONCLUSIONS: The short- and long-term outcomes of laparoscopic surgery for transverse and descending colon cancer are almost equal to those of open surgery. Laparoscopic resection is a better choice than open surgery for managing this cancer with regard to the short- and mid-term QOL. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01861691 .

Higher incidence of metachronous advanced neoplasia in patients with synchronous advanced neoplasia and left-sided colorectal resection for colorectal cancer.

BACKGROUND AND AIMS: There is an increased risk of developing metachronous colorectal cancer (CRC) in the remnant colorectum after surgical resection of CRC. We evaluated the incidence of metachronous advanced neoplasia (AN) after surgery for CRC according to resection type and synchronous AN. METHODS: This cohort study included patients who underwent surgical resection for initial CRC at a tertiary cancer center in Japan between September 2002 and December 2012. The cumulative probability of metachronous AN was calculated using the Kaplan-Meier method and was evaluated by the log-rank test. RESULTS: Metachronous AN was detected in 145 of 1731 included patients, and the 5-year cumulative probability of metachronous AN was 13.1%. There was no significant difference in the incidence of metachronous AN in the right-sided colorectal resection versus left-sided colorectal resection (LCR) groups (log-rank test P = .151), whereas the incidence of metachronous AN was significantly higher in patients with synchronous AN (log-rank test P < .001). In subgroup analysis of patients according to resection type and synchronous AN, the LCR group with synchronous AN showed a significantly higher incidence of metachronous AN than the other groups (log-rank test P < .001). CONCLUSIONS: We found that synchronous AN, but not resection type, was independently associated with the incidence of metachronous AN in patients who underwent surgical resection of CRC. In addition, subjects with synchronous AN after LCR had a potentially increased risk for metachronous AN. Thus, it may be useful to perform risk stratification according to synchronous AN and resection type.

Prognostic value of inferior mesenteric artery lymph node metastasis in cancer of the descending colon, sigmoid colon and rectum.

AIM: This study aimed to analyse the potential significance of metastasis to the inferior mesenteric artery lymph node (IMA-LN) in patients with malignancy of the left colon and rectum. METHOD: A retrospective analysis of a cohort of 890 patients collected prospectively who underwent radical resection of a primary tumour of the descending colon, sigmoid colon and rectum in our department from 1 January 2009 to 31 December 2015 was performed. Patients were divided into an IMA-LN metastasis (IMA-LN (+)) group (n = 51) and a non IMA-LN metastasis (IMA-LN (-)) group (n = 839). A total of 801 patients were followed by a designated member of the study staff. Clinical features, pathological characteristics, recurrence patterns and survival rates were compared between the two groups. RESULTS: In the IMA-LN (+) group, the risk ratio of overall recurrence and tumour related death was 7.786 (95% CI 4.142-14.637) and 7.756 (95% CI 4.142-14.525) respectively. Significant differences were found in overall survival (log-rank: χ2  = 69.06, P < 0.0001) and disease-free survival (log-rank: χ2  = 69.06, P < 0.0001) between the two groups. Furthermore, there were significant differences in overall survival (log-rank: χ2  = 18.47, P < 0.0001) and disease-free survival (log-rank: χ2  = 16.99, P < 0.0001) between the IMA-LN (-) and IMA-LN (+) subgroups of patients with Stage N2 disease. Multivariate survival analysis indicated that IMA-LN (+) was an independent risk factor of poor prognosis. There was no difference in the prognosis between high tie and low tie with IMA-LN dissection. CONCLUSION: Inferior mesenteric artery lymph node metastasis was an independent predictive factor for high systemic recurrence. Low ligation of the IMA with IMA-LN dissection was not inferior to high ligation.

[A Case of a One-Stage Resection and Anastomosis Procedure for a Descending Colon Cancer Ileus after Decompression with a Trans-Nasal Ileus Tube].

A 72-year-old man presented to our hospital with a chief complaint of constipation and hiccup. Computed tomography revealed a colonic obstruction due to descending colon cancer, and a transnasal ileus tube was inserted. On the 2nd day of hospitalization, we attempted transanal drainage, but it was difficult to cannulate. Abdominal findings and inflammatory response were normal; thus, the transanal drainage procedure was followed by only decompression with a transnasal ileus tube. On the 13th day of hospitalization, the tip of the ileus tube reached the vicinity of the occluded area. We performed a one-stage resection and anastomosis procedure. The patient was discharged from the hospital on the 16th postoperative day. Patients with left-sided colorectal cancer ileus are often immediately treated with colostomy when trans-anal decompression is difficult. We report a case of one-stage resection and anastomosis procedure for a descending colon cancer ileus after decompression with a transnasal ileus tube.

[Laparoscopy-Assisted Surgery for Descending Colon Cancer in a Patient with Persistent Descending Mesocolon-A Case Report].

Persistent descending mesocolon(PDM)is caused by absence of fusion of the descending colon to the retroperitoneum. We report a case of laparoscopy-assisted surgery for descending colon cancer in a patient with PDM. An 88-year-oldfemale patient complaining of abdominal pain was diagnosed with bowel obstruction, and referred to our hospital. A computed tomography(CT)scan showed bowel obstruction due to descending colon cancer. After decompression of the colon by insertion of a transanal drainage tube, she underwent laparoscopy-assistedleft hemicolectomy. Intraoperatively it was observed that the descending colon was not fixed to the retroperitoneum, and the patient was diagnosed with persistent descending mesocolon. The accessory middle colic artery and the inferior mesenteric vein branched radially. In patients with PDM, the inferior mesenteric artery often branches radially. However, the various morphologies of branching of the accessory middle colic artery and the inferior mesenteric vein have not been reported. It is not clear whether the radial branching of the accessory middle colic artery and the inferior mesenteric vein is characteristic of patients with PDM. We should however expect radial branching of the accessory middle colic artery and the inferior mesenteric vein in such cases.

Nonelective Left-Sided Colon Cancer Resections are Associated with Worse Postoperative and Oncological Outcomes: A Propensity-Matched Study.

Background: Emergency general surgery patients are at significant risk of postoperative complications and mortality compared with their elective counterparts. Although challenged by some studies, increasing evidence shows that emergency colectomy for cancer is associated with worse early postoperative and long-term outcomes. Methods: We have included all patients with colon cancer admitted to the Emergency Hospital of Bucharest between January 2011 and January 2016. SELECTION CRITERIA: (1) colon tumor; (2) left-sided localization of the tumor; (3) pathology exam revealing adenocarcinoma. EXCLUSION CRITERIA: (1) rectal cancers; (2) benign pathology (e.g. diverticulitis). Results: We included 615 patients with left-sided colon cancer. 275 (44.7%) patients presented complicated disease. The complication was represented by obstruction in 205 (33.3%) patients (OG), hemorrhage in 55 (8.9%) patients (HG), and perforation in 15 (2.4%) patients (PG). The anastomotic leakage rate was similar between obstructive and elective cases (6.2% versus 6.5%, P 0.05), but was significantly higher for hemorrhagic patients (16%) (P=0.046). The 30-day complication rate and mortality were significantly higher in emergency patients (P 0.05). Conclusions: We found significant worse short- and long-term outcomes for patients with nonelective left-sided colon cancer resections. Correlating the ominous prognosis with the high incidence of the complicated disease, we may emphasize the impact on de complicated colon cancer on the general population.

Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Twenty years after the first description of the technique, the debate is still open on the role of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery for symptomatic left-sided malignant colonic obstruction. The aim was to compare morbidity rates after colonic stenting bridge to surgery (SBTS) versus emergency surgery (ES) for left-sided malignant obstruction. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) on SBTS or ES for acute symptomatic malignant left-sided large bowel obstruction. The primary outcome was overall morbidity within 60 days after surgery. RESULTS: The meta-analysis included 8 RCTs and 497 patients. Overall mortality within 60 days after surgery was 9.6% in SBTS-treated patients and 9.9% in ES-treated patients (relative risk [RR], 0.99; P = .97). Overall morbidity within 60 days after surgery was 33.9% in SBTS-treated patients and 51.2% in ES-treated patients (RR, 0.59; P = .023). The temporary stoma rate was 33.9% after SBTS and 51.4% after ES (RR, 0.67; P < .001). The permanent stoma rate was 22.2% after SBTS and 35.2% after ES (RR, 0.66; P = .003). Primary anastomosis was successful in 70.0% of SBTS-treated patients and 54.1% of ES-treated patients (RR, 1.29; P = .043). CONCLUSIONS: SBTS was associated with lower short-term overall morbidity and lower rates of temporary and permanent stoma. Depending on multiple factors such as local expertise, clinical status including level of obstruction, and level of certainty of diagnosis, SBTS does offer some advantages with less risk than ES for left-sided malignant colonic obstruction in the short term.

Evaluation of intestinal perfusion by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis.

BACKGROUND: Decreased blood perfusion is an important risk factor for postoperative anastomotic leakage (AL). Fluorescence imaging with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. This study evaluated the utility of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery with double stapling technique (DST) anastomosis. METHODS: This was a prospective single-institution study of 68 patients with left-sided colorectal cancers who underwent laparoscopic colorectal surgery between August 2013 and December 2014. After distal transection of the bowel, the specimen was extracted extracorporeally and then the mesentery was divided along the planned transection line determined by the surgeons' judgement under normal q. After ICG was injected intravenously, intestinal perfusion of the proximal colon was assessed in the fluorescent imaging mode. Intestinal perfusion was examined in relation to the patient-, tumor- and surgery-related variables using univariate and multivariate analyses. RESULTS: ICG fluorescence imaging showed that intestinal perfusion was present at 3 mm (median) distal to the initially planned transection line. ICG fluorescence imaging resulted in a proximal change of the transection line by more than 5 mm in 18 patients (26.5 %) and, particularly, by more than 50 mm in 3 patients (4.4 %), compared with the initially planned transection line. Univariate analysis revealed that diabetes mellitus, anticoagulation therapy, preoperative chemotherapy and operative time were significantly associated with poor intestinal perfusion. Multivariate analysis identified anticoagulation therapy (P = 0.021) and preoperative chemotherapy (P = 0.019) as independent risk factors for poor intestinal perfusion. Three patients (4.5 %) with a change of transection line developed AL. CONCLUSIONS: ICG fluorescence imaging is useful for determining the transection line in laparoscopic colorectal surgery with DST anastomosis. Anticoagulation therapy and preoperative chemotherapy are important risk factors for poor intestinal perfusion.

A novel approach for robotic mobilization of the splenic flexure.

BACKGROUND: The techniques of robotic splenic flexure mobilization in the colorectal surgery setting are not well defined and have been challenging due to limited range of motion of the second-generation robotic platform in multiple quadrants. METHODS: This report describes a novel technique for robotic splenic flexure mobilization with medial-to-lateral approach without a need for robotic cart repositioning during left-sided colon and rectal surgery. The dissection is started with ligation of the inferior mesenteric artery and vein. Unique in this approach, entering the lesser sac is accomplished by extension of the dissection cranially by lifting up the mesocolon from the anterior surface of the pancreatic body toward the stomach. RESULTS: This technique presented in the video allows the mobilization of the splenic flexure without excessive tractions and avoidance of potential splenic injuries. CONCLUSIONS: The described novel approach demonstrates total robotic splenic flexure takedown without excessive traction, with improved visualization, and reduction of potential risk of splenic injury. This approach provides totally robotic mobilization of the splenic flexure at single docking without changing the patient's position.