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1.
Ann Ital Chir ; 92: 365-371, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34524113

RESUMO

AIM: Many laparoscopic techniques have been described for the treatment of right colon cancer. The purpose of this study is to communicate our experience in the totally laparoscopic treatment of right colon cancer and to report our short-term results in order to confirm the feasibility and safeness of this demanding procedure. MATERIAL OF STUDY: From November 2017 to April 2020, we performed 384 surgical operations for colorectal cancers, of these 81 have involved tumors of the right colon in urgent and elective conditions. Right hemicolectomies with a totally laparoscopic approach were performed, by the same surgical team, in 55 patients in elective surgery. RESULTS: During the study period we evaluated intra and postoperative complications in terms of: demographic data and preoperative clinical characteristics, intraoperative and postoperative outcomes (operative time, blood loss, conversion rate, surgical complications, hospitalization, readmission, and mortality), pathological outcomes. DISCUSSION: Our experience confirms that totally laparoscopic approach, with up to down dissection, for the treatment of right colon cancer, performed by expert surgeons is a safe and feasible technique. CONCLUSION: This procedure allows the mesocolon excision with outstanding number of harvested lymph nodes ensuring low complications and better oncological cleaning. KEY WORDS: Central Vascular Ligation, Colorectal Cancer, Fluorescence GLaparoscopy, Right Hemicolectomy, Complete Mesocolic Excision, Surgery.


Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Humanos , Excisão de Linfonodo , Mesocolo/cirurgia , Resultado do Tratamento
2.
World J Surg Oncol ; 19(1): 267, 2021 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-34479594

RESUMO

BACKGROUND: Extraskeletal osteosarcoma (ESOS) is a rare mesenchymal malignancy, which produces osteoid, bone, or chondroid material and is located in the soft tissue without attachment to skeletal bones and periosteum. One of the things that ESOS originated from mesentery is much rarer. CASE PRESENTATION: A 75-year female had a history of pain in the left lower abdomen for more than 4 months. Abdominal computerized tomography (CT) and magnetic resonance imaging revealed a large, irregular, and solid-cystic mass (largest diameter was 11.5 cm). The tumor was radically removed during an open operation. It was composed of abundant osteoid and polyhedral-shaped tumor cells with high atypia and high mitotic activity microscopically. The final pathological diagnosis was osteoblastic osteosarcoma, arising from the sigmoid mesocolon with negative margins. A 9-month follow-up by CT exhibited signs of peritoneal metastasis. CONCLUSIONS: Given the rarity of cases of mesenteric ESOS, diagnosis mainly depended on pathology findings or should be taken into consideration when the mesenteric mass was found. Its most effective treatment had not been determined, with surgical excision being generally accepted. Ensuring negative surgical margins may be an important factor affecting prognosis.


Assuntos
Neoplasias Ósseas , Mesocolo , Osteossarcoma , Neoplasias de Tecidos Moles , Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/cirurgia , Feminino , Humanos , Mesocolo/diagnóstico por imagem , Mesocolo/cirurgia , Osteossarcoma/diagnóstico por imagem , Osteossarcoma/cirurgia , Prognóstico
3.
Zhonghua Wei Chang Wai Ke Za Zhi ; 24(8): 704-710, 2021 Aug 25.
Artigo em Chinês | MEDLINE | ID: mdl-34412188

RESUMO

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.


Assuntos
Parede Abdominal , Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Fáscia , Feminino , Humanos , Masculino , Mesocolo/cirurgia , Estudos Retrospectivos
5.
Zhonghua Wei Chang Wai Ke Za Zhi ; 24(7): 560-566, 2021 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-34289537

RESUMO

The mesentery is a continuous unity and the operation of digestive carcinoma is the process of mesenteric resection. This paper attempts to simplify the formation process of all kinds of fusion fascia in the process of digestive tract embryogenesis, and to illuminate the continuity of fusion fascia with a holistic concept. This is helpful for beginners to reversely dissect the fusion fascia and maintain the correct surgical plane during operation, and to achieve the purpose of complete mesenteric resection.


Assuntos
Neoplasias do Colo , Neoplasias Gastrointestinais , Laparoscopia , Mesocolo , Neoplasias do Colo/cirurgia , Neoplasias Gastrointestinais/cirurgia , Humanos , Mesentério/cirurgia
6.
Zhonghua Wei Chang Wai Ke Za Zhi ; 24(7): 581-586, 2021 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-34289541

RESUMO

Like other solid tumors, colon cancer surgery has undergone a century-old journey from lumpectomy to organ resection and then to lymphadenectomy. From the Toldt fascia to complete mesenteric resection, and from local resection to D3 radical treatment, local recurrence rates have been reduced, but remain a nuisance to surgeons and patients. Based on the theory of membrane anatomy, radical surgery for colon cancer will focus more on removing the mesocolon from the mesentery bed while maintaining the integrity of the posterior fascia to avoid the occurrence of "fifth metastasis" as much as possible. Thanks to the membrane anatomy theory, its strong reproducibility and replicability, a new phase of colorectal surgery is on the horizon.


Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Humanos , Excisão de Linfonodo , Mesentério/cirurgia , Mesocolo/cirurgia , Recidiva Local de Neoplasia , Reprodutibilidade dos Testes
7.
Zhonghua Wei Chang Wai Ke Za Zhi ; 24(7): 619-625, 2021 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-34289547

RESUMO

Objective: To investigate the anatomic characteristics of the left parietal peritoneum and its surgical implementation while dissecting in left retro-mesocolic space. Methods: A descriptive case series research methods was used. (1) surgical videos of 35 patients who underwent laparoscopic radical resection (complete mobilization of splenic flexure) of colorectal cancer in Union Hospital of Fujian Medical University between January 2018 and December 2018 were reviewed; (2) four specimens after radical resection of rectal cancer performing in June 2020 were prospectively enrolled and reviewed; (3) five specimens of left parietal peritoneum from 5 cadaveric abdomen (3 males and 2 females) were enrolled and reviewed as well; Tissues of 3 unseparated regions, namely the root of the inferior mesenteric artery (IMA), the medial region and the lateral region (including kidney tissue), from above the 5 cadaveric abdominal specimens were selected to perform Masson staining and histopathological examination. Results: (1) Surgical video observation: "Staggered layer phenomenon" and typical left parietal peritoneum was found in 77.1% (27/35) of patients when the left retro-mesocolic space was separated from the lateral and central approaches. The left parietal peritoneum presented as a rigid fascia barrier between the lateral and central approaches, which was a translucent dense connective tissue fascia. After the splenic flexure were completely mobilized, the left parietal peritoneum stump continued to the cephalic side. (2) Observation of 4 surgical specimens: The dorsal side of the left mesocolon specimen was studied, and the left parietal peritoneum stump edge was identified. The outside of the stump edge was the left hemicolon dorsal layer, which was continuously downward to the rectal fascia propria. (3) Cadaveric abdominal specimens: The left retro-mesocolic space was separated through lateral and central approaches, and the rigid fascia barrier, essentially the left parietal peritoneum and Gerota fascia, was encountered. Cross-section view showed that the left parietal peritoneum could be further detached from the dorsal layer of the left mesocolon from the outside, but could not be further detached from the inside out. (4) Histological examination: There was no obvious fascia structure in the IMA root region, while outside the IMA root region, the left bundle of inferior mesenteric plexus penetrating Gerota fascia was observed. There were 4 layers of fascias in the medial region, including the ventral layer of the left mesocolon, the dorsal layer of the left mesocolon, left parietal peritoneum and Gerota fascia. Small vessels were observed between the dorsal layer of the left mesocolon and the left parietal peritoneum. In lateral region, renal tissue and renal fascia were observed. Three layers of fascia structures were observed clearly under high power field, including the dorsal layer of the left mesocolon, left parietal peritoneum, and Gerota fascia. Conclusions: The left parietal peritoneum is the anatomical basis of the "staggered layer phenomenon" from the lateral or central approaches during the separation of left retro-mesocolic space. The small vessels in the dissection plane are the anatomical basis of intraoperative microbleeding, which need pre-coagulation. The central part of Gerota fascia is penetrated by the branches of the inferior mesenteric plexus, which results in a relatively dense surgical plane. Thus, during the dissection through the central approach, it is easy to involve in wrong surgical plane by deeper dissection.


Assuntos
Colo Transverso , Neoplasias do Colo , Laparoscopia , Mesocolo , Neoplasias Retais , Neoplasias do Colo/cirurgia , Dissecação , Feminino , Humanos , Masculino , Peritônio , Neoplasias Retais/cirurgia
8.
Tech Coloproctol ; 25(9): 1079-1084, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34268652

RESUMO

Mesenteric closure following right colectomy remains controversial and, following the advent of laparoscopic surgery, many surgeons do not routinely close the mesentery after colorectal resection. Nevertheless, especially after the introduction of operations such as right colectomy with complete mesocolic excision and ileocolic resections with extensive mesentery removal for Crohn's disease, the wide mesenteric defect resulting from the dissections can certainly expose the patients to complications such as internal hernias or volvuli. In general, mesenteric closure requires intracorporeal suturing. We describe a simple technique for the closure of the mesentery after surgical resection using polymer-ligating clips. This novel technique seems to minimize the time, effort and risk inherent to the procedure, even after large mesenteric excisions.


Assuntos
Neoplasias do Colo , Doença de Crohn , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Doença de Crohn/cirurgia , Humanos , Mesentério/cirurgia , Mesocolo/cirurgia , Polímeros , Instrumentos Cirúrgicos
9.
Colorectal Dis ; 23(8): 1971-1981, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34314557

RESUMO

AIM: The aim was to investigate whether the previously reported causal treatment effect of complete mesocolic excision on the risk of recurrence was biased by inclusion of patients with potentially undiagnosed disseminated disease at the time of surgery, by non-specialist surgery, or caused by mesocolic plane dissection. METHOD: A population of 1069 patients, 813 undergoing conventional resection and 256 complete mesocolic excision for colon cancer during the period 2008-2013, was stepwise reduced in the following order by excluding patients with recurrence diagnosed within 6 months of the resection, having surgery performed by a non-specialist without supervision, and specimens assessed as not being mesocolic plane dissection. The primary outcome measure was risk of recurrence after 5.2 years using competing risk analyses. RESULTS: The absolute risk reduction of complete mesocolic excision was 6.0% (95% CI 1.8-10.2; P = 0.0049) after excluding patients with recurrence within 6 months of resection, 6.1% (95% CI 1.9-10.4; P = 0.0045) after excluding non-specialist surgery, and 7.5% (95% CI 2.9-12.0; P = 0.0013) after the exclusion of patients whose specimens were assessed as dissections not being performed in the mesocolic plane. CONCLUSION: The absolute risk reduction of recurrence after complete mesocolic excision for right-sided colon cancer in our previous study was not biased by potentially undiagnosed disseminated disease at the time of surgery or non-specialist surgery, and was not solely caused by dissection in the mesocolic plane. Central vascular dissection with central lymphadenectomy seems a major factor for better oncological results.


Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Dissecação , Humanos , Excisão de Linfonodo , Mesocolo/cirurgia , Recidiva Local de Neoplasia/cirurgia , Resultado do Tratamento
10.
World J Surg Oncol ; 19(1): 189, 2021 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-34183028

RESUMO

BACKGROUND: Understanding the vascular anatomy is critical for performing central vascular ligation (CVL) in right hemicolectomy with complete mesocolic excision (CME). This study aimed to investigate the predictive value of multi-slice spiral computed tomography (MSCT) with coronal reconstruction in right hemicolectomy with CME. METHODS: This is a retrospective descriptive study. Eighty patients with right colon cancer who underwent right hemicolectomy from December 2015 to January 2020 were included. The intraoperative reports (including imaging data) and MSCT images with coronal reconstruction were analysed and compared. The detection rates of the ileocolic vein (ICV) and ileocolic artery (ICA) roots and the accuracy in predicting their anatomical relationship were analysed. The detection rate and accuracy in predicting the location of the gastrocolic trunk of Henle (GTH), middle colic artery (MCA) and middle colic vein (MCV) were analysed. The distance from the ICV root to the GTH root (ICV-GTH distance) was measured and analysed. The maximum distance from the left side of the superior mesenteric artery (SMA) to the right side of the superior mesenteric vein (SMV), named the 'lsSMA-rsSMV distance', was also measured and analysed. RESULTS: In seventy-four (92.5%) patients, both the ICV and ICA roots were located; their anatomical relationship was determined by MSCT, and the accuracy of the prediction was 97.2% (72/74). The GTH was located by MSCT in 75 (93.7%) patients, and the accuracy of the prediction was 97.33% (73/75). The MCA was located by MSCT in 47 (58.75%) patients, and the accuracy was 78.72% (37/47). The MCV was located by MSCT in 51 (63.75%) patients, and the accuracy of the prediction was 84.31% (43/51). The ICV-GTH distance was measured in 73 (91.2%) patients, and the mean distance was 4.28 ± 2.5 cm. The lsSMA-rsSMV distance was measured in 76 (95%) patients, and the mean distance was 2.21 ± 0.6 cm. CONCLUSIONS: With its satisfactory accuracy in predicting and visualising the information of key anatomical sites, MSCT with coronary reconstruction has some predictive value in CME with CVL in right hemicolectomy.


Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/diagnóstico por imagem , Neoplasias do Colo/cirurgia , Humanos , Mesocolo/cirurgia , Prognóstico , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
11.
Zhonghua Wei Chang Wai Ke Za Zhi ; 24(6): 487-492, 2021 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-34148313

RESUMO

The incidence of anastomotic leak after right hemicolectomy for cancer is relatively low, but it may be misjudged. In recent years, the results of some multi-center or nationwide registration studies in Europe have shown that the incidence of anastomotic leak is significantly higher than that of eastern countries. The reasons of these differences may be the different nature of the studies, the lack of rigor in diagnostic criteria or diagnostic methods, the difference in the level of specialization of hospitals or surgeons, and so on. Timely treatment of preoperative comorbidities, reasonable selection of preoperative bowel preparation and anastomotic technique/method might reduce the occurrence of anastomotic leak. The current evidence shows complete mesocolic excision (CME) does not increase the risk of anastomotic leak. The clinical features of ileo-colic anastomotic leak are different from those of rectal surgery. The mild cases can be treated conservatively, and the severe cases are suggested to receive timely diverting ileostomy.


Assuntos
Mesocolo , Neoplasias , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/prevenção & controle , Fístula Anastomótica/cirurgia , Colectomia , Europa (Continente) , Humanos , Mesocolo/cirurgia , Estudos Retrospectivos , Fatores de Risco
12.
Tech Coloproctol ; 25(9): 997-1010, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34173121

RESUMO

BACKGROUND: The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT). METHODS: We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS: Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively. CONCLUSIONS: The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.


Assuntos
Mesocolo , Protectomia , Neoplasias Retais , Humanos , Mesocolo/patologia , Terapia Neoadjuvante , Recidiva Local de Neoplasia/terapia , Estadiamento de Neoplasias , Protectomia/efeitos adversos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Estudos Retrospectivos , Resultado do Tratamento
14.
Tech Coloproctol ; 25(10): 1099-1113, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34120270

RESUMO

BACKGROUND: The introduction of complete mesocolic excision (CME) for right colon cancer has raised an important discussion in relation to the extent of colic and mesenteric resection, and the impact this may have on lymph node yield. As uncertainty remains regarding the usefulness of and indications for right hemicolectomy with CME and the benefits of CME compared with a traditional approach, the purpose of this meta-analysis is to compare the two procedures in terms of safety, lymph node yield and oncological outcome. METHODS: We performed a systematic review of the literature from 2009 up to March 15th, 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two hundred eighty-one publications were evaluated, and 17 met the inclusion criteria and were included. Primary endpoints analysed were anastomotic leak rate, blood loss, number of harvested lymph nodes, 3- and 5-year oncologic outcomes. Secondary outcomes were operating time, conversion, intraoperative complications, reoperation rate, overall and Clavien-Dindo grade 3-4 postoperative complications. RESULTS: In terms of safety, right hemicolectomy with CME is not inferior to the standard procedure when comparing rates of anastomotic leak (RR 0.82, 95% CI 0.38-1.79), blood loss (MD -32.48, 95% CI -98.54 to -33.58), overall postoperative complications (RR 0.82, 95% CI 0.67-1.00), Clavien-Dindo grade III-IV postoperative complications (RR 1.36, 95% CI 0.82-2.28) and reoperation rate (RR 0.65, 95% CI 0.26-1.75). Traditional surgery is associated with a shorter operating time (MD 16.43, 95% CI 4.27-28.60) and lower conversion from laparoscopic to open approach (RR 1.72, 95% CI 1.00-2.96). In terms of oncologic outcomes, right hemicolectomy with CME leads to a higher lymph node yield than traditional surgery (MD 7.05, 95% CI 4.06-10.04). Results of statistical analysis comparing 3-year overall survival and 5-year disease-free survival were better in the CME group, RR 0.42, 95% CI 0.27-0.66 and RR 0.36, 95% CI 0.17-0.56, respectively. CONCLUSIONS: Right hemicolectomy with CME is not inferior to traditional surgery in terms of safety and has a greater lymph node yield when compared with traditional surgery. Moreover, right-sided CME is associated with better overall and disease-free survival.


Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Humanos , Excisão de Linfonodo , Linfonodos/cirurgia , Mesocolo/cirurgia , Resultado do Tratamento
15.
Tech Coloproctol ; 25(10): 1155-1161, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34095976

RESUMO

BACKGROUND: Complete mesocolic excision (CME) with central vascular ligation (CVL) requires the surgeon to sharply dissect the mesocolon and approach the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) for ligation of the supplying vessels relating to right-sided colon cancer at their origin. Even with preoperative images, it can still be challenging to identify these structures during laparoscopic surgery because of various intraoperative conditions. The aim of this study was to assess the efficacy of intraoperative ultrasound (IOUS) for identification of blood vessels during right-sided colon cancer surgery. METHODS: We performed IOUS on 19 patients diagnosed with right-sided colon cancer at our institution, in January-October 2020. Preoperatively, a three-dimensional computed tomography (3D-CT) angiogram was obtained for the majority of patients to visualize the SMA, SMV, and their respective branches. The running position of the ileocolic artery (ICA) and right colic artery (RCA) related to the SMV and the presence of the middle colic artery were identified and compared using preoperative 3D-CT, IOUS, and intraoperative findings. RESULTS: Nineteen patients [seven men and 12 women with a mean age of 73.9 ± 8.4 years (range 58-82 years)] were studied, including some with a body mass index of > 30 kg/m2, locally advanced cancer, and severe adhesion. There were IOUSs that detected the SMA, SMV, and their tributaries in all patients. The positional relationships between the SMV and the ICA and RCA revealed by IOUS were consistent with the preoperative and intraoperative findings. CONCLUSION: IOUS is a safe, feasible, and reproducible technique that can assist in detecting the branching of the SMA and SMV during CME with CVL in laparoscopic right-sided colon cancer surgery, regardless of individual conditions.


Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Idoso , Idoso de 80 Anos ou mais , Colectomia , Neoplasias do Colo/diagnóstico por imagem , Neoplasias do Colo/cirurgia , Feminino , Humanos , Ligadura , Masculino , Mesocolo/diagnóstico por imagem , Mesocolo/cirurgia , Pessoa de Meia-Idade
18.
J Gastrointest Surg ; 25(10): 2726-2727, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34109532

RESUMO

BACKGROUND: Intraoperative damage of pelvic autonomic nerves is the primary reason for postoperative sexual and urinary dysfunction after rectal cancer surgery,1,2 especially in patients with low rectal cancer. In the present study, we developed the nerve plane as a novel concept in rectal cancer surgery, which served as a landmark for better preservation of pelvic autonomic nerves in standardized total mesorectal excision (TME) surgery. The nerves never exist alone, and are always surrounded by tiny capillaries and adipose tissue, which are covered by a thin layer of membranous tissue, leading to a continuous plane, which we defined as the nerve plane. The nerve plane could be preserved from thermal damage, ischemic injury, nerve stretching, and chemical factors produced by local inflammatory effects. We also found loose connective tissue (the first gap) between the proper fascial of the rectum and the nerve plane, which was also a natural avascular holy's plane. Using the concept of nerve plane, the proposed functional TME procedure could help surgeons to better protect pelvic autonomic nerves from injury. Herein, we present a brief video to describe the technical aspects of a laparoscopic functional TME in rectal cancer surgery. METHODS: Fifty-eight consecutive male patients without preoperative sexual and urinary dysfunction underwent laparoscopic functional TME surgery for histologically confirmed adenocarcinoma at our hospital since 2018. The present study was approved by the institutional review board of the Renmin Hospital of Wuhan University (2018-X-08), and written informed consent was obtained from all patients. Urinary and sexual function was evaluated using the international prostatic symptom score (IPSS)3 and the 5-item version of International Index of Erectile Function (IIEF-5)4 questionnaires, respectively, which are internationally recognized as well-structured and reliable questionnaires to evaluate urinary and sexual function. Moderate-to-severe urinary dysfunction was defined as IPSS score >8 points,2 while erectile dysfunction was defined as IIEF-5 score ≤ 11points.5 The laparoscopic functional TME procedure shown in the video is described as follows. First, the incision line was marked on the peritoneum from the lower edge of the duodenum to the pelvic entrance with an electric hook using a medium approach. The holy's plane was divided into five structures by enforcing traction and anti-traction, which included fascia propria of the rectum, the loose areolar connective tissue over the nerve plane (the first gap), the nerve plane, the loose areolar connective tissue below the nerve plane (the second gap), and the Gerota's fascia or the presacral fascia. Second, dissection over the nerve plane was performed from the lower edge of the duodenum to the pelvic entrance. Superior hypogastric plexus nerve plane, abdominal aortic plexus nerve plane, and inferior mesenteric plexus nerve plane were clearly displayed. Dissection was continued in this way, and the left and right hypogastric nerve planes were also preserved. Finally, the pelvic cavity was entered, and posterior dissection was continued downward to the Waldeyer fascia. We selected to go over the Waldeyer fascia along the nerve plane instead of transecting it to enter the superior levator space, thereby some small nerves such as efferent branches of hypogastric nerves in this area were protected from injury. The lateral pelvic dissection was continued over the pelvic plexus nerve plane, anterior pelvic dissection was continued, and the Denonvillier's interfascial space was entered between the anterior layer and the posterior layer of Denonvilliers' fascia. The left and right neurovascular bundles (NVB) were avoided and not intentionally exposed during the operation, thereby protecting them from injury. Although some steps of the procedure are displayed very close to the anatomical landmarks, patience and higher-resolution laparoscopic equipment are needed for surgeons to find the nerve plane. For less experienced surgeons, we suggest that the harmonic with the "hot" blade should be as far away from the nerves as possible during the radical resection of tumor. After the rectum was dissected, superior hypogastric plexus nerve plane, abdominal aortic plexus nerve plane, inferior mesenteric plexus nerve plane, hypogastric nerve plane, pelvic plexus nerve plane, left ureter, and genital vessels were displayed and completely preserved. The intraoperative nerve plane and mesorectum of the postoperative specimen were intact and smooth. RESULTS: The median age of patients was 53 years, with a body mass index (BMI) of 24.0 kg/m2. The median total operation time was 198 min (range 128-248 min). The median volume of blood loss was 30 ml (range 10-50 ml). The median number of retrieved lymph nodes was 31 (range 13-65). No patient showed postoperative moderate-to-severe urinary dysfunction at 6 months. The incidence of postoperative erectile dysfunction was 5.17% (3/58) at 12 months. No patient was lost during 1-year of follow-up. CONCLUSION: Nerve plane is an optimal surgical landmark for laparoscopic functional total mesorectal excision in rectal cancer. It provides a superior surgical technique for pelvic autonomic nerve protection.


Assuntos
Laparoscopia , Mesocolo , Neoplasias Retais , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Pelve/cirurgia , Neoplasias Retais/cirurgia , Reto/cirurgia
19.
Ann Surg Oncol ; 28(13): 8823-8837, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34089109

RESUMO

BACKGROUNDS: Previous systematic reviews suggest that the implementation of 'complete mesocolon excision' (CME) for colon tumors entails better specimen quality but with limited long-term outcomes. We performed a meta-analysis to compare the pathological, perioperative, and oncological results of CME with conventional surgery (CS) in primary colon cancer. METHODS: Embase, MEDLINE and CENTRAL databases were searched using Medical Subject Headings for CME and D3 lymphadenectomy. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: A total of 18,989 patients from 27 studies were included. Postoperative complications were higher in the CME group (relative risk [RR] 1.13, 95% confidence interval [CI] 1.04-1.22, I2 = 0%), while no differences were observed in terms of anastomotic leak (I2 = 0%) or perioperative mortality (I2 = 49%). CME was associated with a higher number of lymph nodes harvested (I2 = 95%), distance to high tie (I2 = 65%), bowel length (I2 = 0%), and mesentery area (I2 = 95%). CME also had positive effects on 3- and 5-year overall survival (RR 1.09, 95% CI 1.04-1.15, I2 = 88%; and RR 1.05, 95% CI 1.02-1.08, I2 = 62%, respectively) and 3-year disease-free survival (RR 1.10, 95% CI 1.04-1.17, I2 = 22%), as well as decreased local (RR 0.35, 95% CI 0.24-0.51, I2 = 51%) and distant recurrences (RR 0.71, 95% CI 0.60-0.85, I2 = 34%). CONCLUSIONS: Limited evidence suggests that CME improves oncological outcomes with a higher postoperative adverse events rate but no increase in anastomotic leak rate or perioperative mortality, compared with CS.


Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Humanos , Excisão de Linfonodo , Mesocolo/cirurgia , Recidiva Local de Neoplasia , Resultado do Tratamento
20.
Int J Colorectal Dis ; 36(9): 1885-1904, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33983451

RESUMO

BACKGROUND: This meta-analysis aims to investigate the role of complete mesocolic excision (CME) in the treatment of right-side colon cancer when compared with standard right-side hemicolectomy, focusing on oncological outcomes, mortality and morbidity rates. MATERIALS AND METHODS: A systematic literature search was performed on MEDLINE and EMBASE archives, including studies on CME in right-side colon cancer. Primary outcomes were five-year disease-free survival and five-year overall survival. Secondary outcomes investigated were mortality and morbidity rates, intraoperative blood loss, anastomotic leakage, postoperative ileus, day of postoperative flatus, pulmonary infection, duration of hospital stay and number of lymph nodes harvested. RESULTS: Seventeen studies have been included in this meta-analysis for a total of 3918 patients. The five-year disease-free survival (DFS) and overall survival (OS) results improved in the CME group with respect to conventional right-side colectomy with an OR 1.88 (95% CI 1.02-3.45) and OR 2.77 (95% CI 1.33-5.74), respectively. The incidence of mortality and morbidity was comparable between the two groups. Moreover, conventional surgery time was faster than CME (MD 33.69 min, 95% CI 12.79-54.59), while no significant differences were reported in mean blood loss and hospital stay. Furthermore, the CME group showed a higher mean number of harvested lymph nodes (MD 7.08 lymph nodes 95% CI 4.90-9.27). CONCLUSION: Complete mesocolic excision of the right-side colectomy improves oncological outcomes without increasing mortality and morbidity rates compared to standard right-side hemicolectomy. CME should therefore be routinely performed in the treatment of right-side colon cancer.


Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Colectomia , Neoplasias do Colo/cirurgia , Humanos , Excisão de Linfonodo , Mesocolo/cirurgia , Resultado do Tratamento
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