Are Metastatic Central Lymph Nodes (D3 volume) in right-sided Colon Cancer a Sign of Systemic Disease? A sub-group Analysis of an Ongoing Multicenter Trial.

OBJECTIVE: Assess outcomes of patients with right-sided colon cancer with metastases in the D3 volume after personalized surgery. BACKGROUND: Patients with central lymph node metastasis (D3-PNG) are considered to have a systemic disease with a poor prognosis. A 3-dimensional definition of the dissection volume allows the removal of all central nodes. MATERIALS AND METHODS: D3-PNG includes consecutive patients from an ongoing clinical trial. Patients were stratified into residual disease negative (D3-RDN) and residual disease positive (D3-RDP) groups. D3-RDN was further stratified into 4 periods to identify a learning curve. A personalized D3 volume (defined through arterial origins and venous confluences) was removed " en bloc" through medial-to-lateral dissection, and the D3 volume of the specimen was analyzed separately. RESULTS: D3-PNG contained 42 (26 females, 63.1 SD 9.9 y) patients, D3-RDN:29 (17 females, 63.4 SD 10.1 y), and D3-RDP:13 (9 females, 62.2 SD 9.7 y). The mean overall survival (OS) days were D3-PNG:1230, D3-RDN:1610, and D3-RDP:460. The mean disease-free survival (DFS) was D3-PNG:1023, D3-RDN:1461, and D3-RDP:74 days. The probability of OS/DFS were D3-PNG:52.1%/50.2%, D3-RDN:72.9%/73.1%, D3-RDP: 7.7%/0%. There is a significant change in OS/DFS in the D3-RDN from 2011-2013 to 2020-2022 (both P =0.046) and from 2014-2016 to 2020-2022 ( P =0.028 and P =0.005, respectively). CONCLUSION: Our results indicate that surgery can achieve survival in most patients with central lymph node metastases by removing a personalized and anatomically defined D3 volume. The extent of mesenterectomy and the quality of surgery are paramount since a learning curve has demonstrated significantly improved survival over time despite the low number of patients. These results imply a place for the centralization of this patient group where feasible.

Bowel Motility After Injury to the Superior Mesenteric Plexus During D3 Extended Mesenterectomy.

BACKGROUND: Improvement of lymphadenectomy in right colectomy requires removal of all tissue surrounding the superior mesenteric vessels beneath the pancreatic notch. Short- and long-term bowel motility disorders after D3 extended mesenterectomy with consecutive superior mesenteric plexus transection are studied. METHODS: Patients without pre-existing motility disorders undergoing D3 extended mesenterectomy were examined 3 times using the wireless motility capsule: before, at 3 wk, and 6 mo after surgery. Segmental transit times and contractility were analyzed using mixed effect modeling. Correlation between contractility and transit time was assessed by the Pearson correlation coefficient. RESULTS: Fifteen patients (4 men), with median age 62 y, were included. Mean values for the three consecutive examinations are as follows. Gastric transit time increased from 237 to 402 and 403 min, respectively. Small bowel transit time decreased from 246 to 158 (P < 0.01) and 199 (P = 0.03) min, respectively. Colonic transit time decreased from 1742 to 1450 and 1110 (P = 0.02) min, respectively. Gastric contractions per minute (CPM) varied from 1.73 to 1.05 (P = 0.01) and 2.47 (P < 0.01), respectively. Small bowel CPM decreased from 3.43 to 2.68 and 3.34, respectively. Colonic CPM ranged from 1.59 to 1.45 and 1.91 (P = 0.08), respectively. Correlation between small bowel (SB) transit time and CPM was -0.45 (P = 0.09) preoperatively, and -0.03 (P = 0.91) 6 mo postoperatively. CONCLUSIONS: Extrinsic SB denervation leads to significantly accelerated SB transit, reduced contractility, and disturbed correlation between transit time and contractility early after denervation. Both number of contractions and transit time in the denervated SB show a clear tendency toward normalization at 6 mo.

Introducing Anatomically Correct CT-Guided Laparoscopic Right Colectomy with D3 Anterior Posterior Extended Mesenterectomy: Initial Experience and Technical Pitfalls.

BACKGROUND: Laparoscopic D3 anterior posterior extended mesenterectomy (D3APEM) in right colectomy has received increased attention. The aim of this study is to prove feasibility, systemize technical accomplishment, and provide short-term outcomes data. METHODS: From July 2013 to February 2017, 18 patients with adenocarcinoma in the right colon underwent right colectomy with laparoscopic D3APEM, including lymph nodes anterior and posterior to the superior mesenteric vessels. A reconstructed three-dimensional anatomy map derived from the staging computed tomography was used as a road map at surgery. The procedure was systematized into seven operative steps: Step 1, trocar placement and inspection; Step 2, release of the transverse colon; Step 3, identification of the terminal mesenteric vessels; Step 4, release of the anterior flap; Step 5, division of the transverse mesocolon; Step 6, release of the posterior flap; and Step 7, anastomosis and specimen removal. Patient disposition and variations regarding vascular anatomy and ability to expose consequentially may necessitate a variation in the sequence of the steps. RESULTS: A total of 7 (39%) cases were converted, 3 due to bleeding and 4 due to challenging dissection. Median operative time and blood loss were 276 minutes (168-439 minutes) and 200 mL (< 50-1300 mL), respectively. Postoperative complications occurred in 6 (33%), including 2 (11%) major complication requiring reoperation. Median hospital stay was 5 days (3-13 days). R0 resection was achieved in all cases. Median number of the lymph nodes harvested was 40 (25-86), including 11.5 (4-35) in the D3 volume. Six patients (33%) had positive nodes, 3 of them affecting the D3 zone, including 1 case of a skip metastasis. There was no mortality, and at present all the patients are alive. One patient developed distant lymph node metastases. CONCLUSION: Laparoscopic right colectomy with D3APEM is feasible, associated with acceptable morbidity and fast recovery; now in readiness for introduction in specialized colorectal institutions.

D3 Extended Mesenterectomy in Right Colectomy for Cancer: A Cadaver Simulation Model.

BACKGROUND: D3 extended mesenterectomy (D3EM) for right colon cancer has received increased attention owing to suggested improvement of oncological outcomes. The aim of this study was to evaluate the proficiency-based progression of content-valid metrics in a cadaveric model for right colectomy with D3EM. MATERIALS AND METHODS: Three expert surgeons were enrolled. Surgeon one performed the procedure robotically and surgeons two and three performed open D3EM. Proficiency-based progression was recorded for eight content-valid outcomes. The superior mesenteric vein (SMV) and artery were cannulated by independent observers to evaluate vascular tears. The specimens were analyzed for lymph node harvest by a pathologist blinded to surgical access and to the surgeon. RESULTS: Operating times did not differ among surgeons (50.2, 32.4 and 43.7 min). SMV tears occurred in procedures A and B only. There was no significant progression in lymph node harvest for D2 (p=0.913) and D3EM (p=0.264). CONCLUSIONS: Cadaveric training in D3EM was associated with progression in avoidance of vascular tears with no significant changes in operating time and lymph node harvest.

Defining minimal clearances for adequate lymphatic resection relevant to right colectomy for cancer: a post-mortem study.

BACKGROUND: There has been a lengthy discussion on the extent of lymphatic resection for right-sided colon cancer and the central borders of the mesentery that are not yet defined. The objectives of this study are to define minimal clearances for adequate lymphatic resection in regard to colic artery origins and the superior mesenteric artery (SMA) and vein (SMV) relevant to right colectomy. METHODS: Central mesenteric lymph vessels, nodes, and blood vessels were dissected in 16 cadavers. Cranial-caudal clearances were defined as distances between an individual colic artery origin (ileocolic, right colic, and median colic artery) and the outermost lymphatic vessel within its lymphovascular bundle, cranial and caudal along the SMA. Long lymphatic vessels crossing the SMV between arterial bundles were counted and they constituted the medial clearances. An arbitrary watershed between small bowel and colonic lymph was localized. Immunohistochemistry was performed to histologically verify lymphatic vessels. RESULTS: Cranial-caudal clearances were ileocolic 3.6 ± 1.9 and 5.7 ± 1.9; right colic 2.8 ± 1.6 and 3.3 ± 1.0; middle colic artery bundle 6.3 ± 2.7 and 5.9 ± 2.4 mm, respectively. Long lymphatic vessels crossing the SMV between arterial buntles and approaching the SMA were found in all cadavers (antero/posteriorly in 12, only anteriorly in 4), median 3.5 (1-7) long lymphatic vessels anteriorly, and 1.5 (0-5) posteriorly per cadaver. CONCLUSIONS: Right colonic lymphovascular bundles are volumes of mesenteric tissue that surround the superior mesenteric vessels anteriorly and posteriorly. Long lymphatic vessels traverse the superior mesenteric vein anteriorly/posteriorly approaching the superior mesenteric artery between arterial bundles and placing the medial clearance on the left side of the artery. These do not correlate to arterial crossing patterns. Cranial-caudal clearances determine the tissue to be removed superior/inferior to arterial origins together with long lymphatic vessels transversing independently between the lymphovascular bundles placing the weight of lymphatic resection on the mesenteric tissue and not on the level of vessel division (High tie).

Single-incision laparoscopic versus conventional laparoscopic ventral hernia repair: a comparison of short-term surgical results.

AIM: To demonstrate the feasibility of single-port incisional hernia repair, quantify incision size, and compare results of patients operated by standard laparoscopy (SL) with those operated by the single-port technique [laparoendoscopic single-site surgery (LESS)]. METHODS: Prospective data collected on patients operated from March 2008 to June 2010. Indication for surgery was incisional hernia >3 cm. There were no selection criteria for the enrollment of patients or the operative technique used. RESULTS: Thirty-four patients were operated (18 women and 16 men): 15 with LESS and 19 with SL. There was no difference for age, body mass index, ASA scores, or number of previous surgical procedures. LESS patients had slightly larger (82 ± 54 vs. 64 ± 34 mm) and more numerous hernias: 3 (1 to 7) versus 1 (1 to 3). Adhesion grades, severity scores, and operating times (78.2 SD ± 31.2 vs. 73.5 SD ± 25.4 min, P=0.76) did not differ between the groups. The mean fascia incision size in LESS was digitally measured as 12.93 ± 2.01 mm. The hospital stay was a median of 1 day in both groups. There was 1 conversion in the SL group. The median follow-up time was 26 months (range, 25 to 31 mo) for LESS and 34 months (range, 31 to 42 mo) for SL. COMPLICATIONS: There were 2 seromas and 1 hematoma in the LESS group. In the SL group, there were 2 small-bowel injuries and 2 seromas. There were no recurrences in the SL group, 1 in LESS, and no port-site hernia so far. CONCLUSIONS: LESS incisional hernia repair through 1 minimal fascia incision is feasible. Early results do not indicate a longer operation time, higher complication, or higher recurrence rates.

The anatomical and surgical consequences of right colectomy for cancer.

BACKGROUND: Current practice when performing right colectomy for cancer is to divide the feeding vessels for the right colon on the right side of the superior mesenteric vein. OBJECTIVE: This study aims to show that arterial stumps can be visualized through an early postoperative CT and analyze their anatomical and surgical characteristics. DESIGN: This study presents a retrospective review of prospective data. SETTINGS: :The study was conducted at the Department of Surgery, Vestfold Hospital, Tonsberg, Norway. PATIENTS: Patients with leakage after a right colectomy for cancer (2003-2011) were identified through a local prospective complication registry (FileMaker Pro 9.0v3 software). INTERVENTIONS: Both preoperative and postoperative CTs were retrieved, reanalyzed, and 3-dimensionally reconstructed (Osirix v.3.0.2./Mimics v.13.1.). Patients without postoperative CTs were excluded. MAIN OUTCOME MEASURES: The main outcomes measured were length, caliber of presumed and actual arterial stumps, and their position relative to the superior mesenteric vein. RESULTS: Eighteen patients, median age 69 (10 men) were included. All patients had postoperative CTs, and 15 patients had preoperative CTs. Median time from operation to postoperative CT was 5 days. The ileocolic artery was found in 14 (11 CT pairs) patients, and the right colic artery was found in 5 (4 pairs) patients. Actual stump lengths were 28.0 mm (SD 9.3) and 37.3 mm (SD 14.9). A significant statistical difference between presumed and actual ileocolic artery stump lengths was found (P = .002). Posterior crossing to the superior mesenteric vein was noticed in 8 of 14 ileocolic arteries and in 3 of 5 right colic arteries. There was no statistical difference in mean caliber for the preoperative and postoperative right colic artery (P = .505) and ileocolic artery (P = .474). LIMITATIONS: Difficulties when interpreting the postoperative images, due to intra-abdominal effusion, staples, edema, and altered syntopy of blood vessels, were overcome through comparison with preoperative CTs. CONCLUSION: An early postoperative CT can show arterial stumps after right colectomy for cancer. These stumps appear to be significantly longer than presumed; implying a significant improvement potential when specimen size is concerned.

Intra-abdominal administration of bevacizumab diminishes intra-peritoneal adhesions.

AIM: To determine the effect of a single dose of bevacizumab on adhesion formation in the rat cecum abrasion model. METHODS: The cecum and parietal peritoneum of 38 male Wistar rats were abraded to promote adhesion formation. The rats were randomized into 2 groups: group 1 received bevacizumab (2.5 mg/kg) intraperitoneally, and group 2 received saline. On day 30 animals were killed, adhesions scored, and histopathological samples taken. RESULTS: There was no wound dehiscence; there were 2 incision hernias (5.3%), 1 per group. Thirty-seven animals developed adhesions (97.4%). Adhesion grade and severity scores were significantly different between groups 1 and 2 at 2.7:1.6 (P = .018) and 3.8:2.7 (P = .007), respectively. There was no difference in adhesion square area (27.7:25.0%; P = .16), location (P = 1.00), or number (2.1:1.3; P = .06). Histopathology confirmed the statistical difference between groups (P = .049), and a highly significant correlation between results was shown (r = .758; P = .0001). CONCLUSION: A single dose of intraperitoneal bevacizumab significantly reduces grade and severity of abdominal adhesions in the cecum abrasion rat model.