A Surgical Case of Inferior Mesenteric Arteriovenous Malformation

The treatment option for inferior mesenteric arteriovenous malformations is under debate because of the number of cases. We, herein, report about a 35-year-old man with congenital inferior mesenteric artery malformation (AVM) presenting with mucous stool and severe abdominal pain. The radical operation, after building the diverting stoma, minimized the extent of the resection. This is the first reported case where surgical management was used to control severe symptoms induced by inferior mesenteric AVM.

High versus low ligation of inferior mesenteric vessels in rectal cancer surgery: A retrospective cohort study

PURPOSE

To retrospectively evaluate the short-term and the long-term oncological outcome between two groups of patients who had undergone either high or low ligation of inferior mesenteric vessels (IMV) in rectal cancer surgery.

METHODS

Between January 2009 and December 2014, 120 patients with rectosigmoid and rectal adenocarcinoma were operated with curative intent as first therapeutic option. Patients were divided in two groups depending on the level of the inferior mesenteric artery (IMA) ligation. High ligation was defined as the division of the IMA less than 2cm from the aorta followed by the ligation of the inferior mesenteric vein at its origin from the lower border of the pancreas (n=76), while low ligation was defined as the division of IMA immediately distal to the origin of the left colic artery (n=44).

RESULTS

The median follow up was 51 months. Univariate analyses disclosed that low ligation was related to a higher postoperative complications rate, mainly related to the higher rate of urinary dysfunction but it was also related to a favorable 5-year overall survival (OS) rate. However, multivariate analyses among factors which might influence the short- and long-term outcomes did not disclose the level of ligation as a factor influencing the postoperative course, the recurrence, the disease free survival (DFS) and the 1-, 3- and 5-year OS rates.

CONCLUSIONS

The present study disclosed no differences in surgical, histological, short-term and long-term oncological outcomes between patients treated with either high or low ligation of IMA.

Vascular anatomy of inferior mesenteric artery in laparoscopic radical resection with the preservation of left colic artery for rectal cancer

AIM

To investigate the vascular anatomy of inferior mesenteric artery (IMA) in laparoscopic radical resection with the preservation of left colic artery (LCA) for rectal cancer.

METHODS

A total of 110 patients with rectal cancer who underwent laparoscopic surgical resection with preservation of the LCA were retrospectively reviewed. A 3D vascular reconstruction was performed before each surgical procedure to assess the branches of the IMA. During surgery, the relationship among the IMA, LCA, sigmoid artery (SA) and superior rectal artery (SRA) was evaluated, and the length from the origin of the IMA to the point of branching into the LCA or common trunk of LCA and SA was measured. The relationship between inferior mesenteric vein (IMV) and LCA was also evaluated.

RESULTS

Three vascular types were identified in this study. In type A, LCA arose independently from IMA (46.4%, n = 51); in type B, LCA and SA branched from a common trunk of the IMA (23.6%, n = 26); and in type C, LCA, SA, and SRA branched at the same location (30.0%, n = 33). The difference in the length from the origin of IMA to LCA was not statistically significant among the three types. LCA was located under the IMV in 61 cases and above the IMV in 49 cases.

CONCLUSION

The vascular anatomy of the IMA and IMV is essential for laparoscopic radical resection with preservation of the LCA for rectal cancer. To recognize different branches of the IMA is necessary for the resection of lymph nodes and dissection of vessels.

[Application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery in laparoscopic radical proctectomy]

OBJECTIVE

To investigate the application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery (LCA) in patients undergoing laparoscopic radical proctectomy.

METHODS

From August 2015 to August 2016, 97 consecutive middle-low rectal cancer patients underwent laparoscopic radical proctectomy using the clearance of No.253 lymph nodes with priority to fascial space and preserving LCA at Department of General Surgery, Tangdu Hospital. Among 97 patients, 45 were females , 52 were males, mean age was (64.3±5.5) years and mean BMI was (22.4±1.8) kg/m². Brief steps of this clearance: traditional medial approach was the commencement of the dissection at the membrane bridge line in front of iliac vascular bifurcation, then entering into the Toldt's space; superior rectal artery served as the top of the tent and the Toldt's space was extended as far as possible; blunt separation was developed caudally (reaching 2 cm below the sacral promontory), cephalad (reaching the lower part of the pancreas), left laterally (reaching Toldt's line), dextrally (reaching abdominal aorta); after giving priority to fascias space, from the root of inferior mesenteric artery, LCA was exposed and No.253 lymph nodes were dissected. This regimen was suitable for the rectal adenocarcinoma patients without distant metastasis.

RESULTS

There was no tension in the intestine and mesenteria after anastomosis in all the 97 patients. One patient received LCA ligation during the clearance, because of thinner LCA resulting in bleeding. The other 96 cases completed the clearance and operation successfully. The mean No.253 lymphadenectomy time was 11-27(17.1±5.3) minutes. The mean number of harvested No.253 lymph node was 0-6(4±2). The No.253 lymph nodes of 6 patients were positive. No.253 regional mesentery was complete in 95 patients. The total harvested number of lymph node was 11-26(17.3±5.3). Six patients with positive lymph nodes aged from 68 to 72 years old and all of them underwent TME operation 6-8 weeks after neoadjuvant chemoradiotherapy. The mean operative time was 89-189(125±35) minutes. The mean estimated blood loss was 10.5-38.6(22.4±10.5) ml. The first exhaust time was 3.0-6.0(5.6±2.1) days. The mean time to extracting the drainage tube was 3.0-5.0(4.5±2.5) days. Anastomotic fistula appeared in 1 case and hemorrhage appeared in 1 case, and these 2 cases were cured by conservative treatment. No perioperative death occurred. The mean postoperative hospital stay was 3.0-10.0(3.6±2.6) days.

CONCLUSION

The clearance of No.253 lymph nodes with priority to fascial space and preserving LCA in laparoscopic radical proctectomy is safe and feasible.

High tie versus low tie of the inferior mesenteric artery in colorectal cancer: A meta-analysis

BACKGROUND

Colorectal cancer surgery includes "high tie" and "low tie"of the inferior mesenteric artery(IMA). However, different ligation level is closely related to the blood supply of anastomosis, which may increase the leakage rate, and it is unclear which technique confers a lower anastomotic leakage rate(AL) and survival advantage.

OBJECTIVE

To compare the effectiveness and impact of inferior mesenteric artery (IMA) high ligation versus IMA low ligation on anastomotic leakage, lymph nodes yield rates and 5-year survival.

METHODS

A list of these studies, published in English from 1990 to 2017, was obtained independently by two reviewers from databases such as PubMed, Medline, ScienceDirect and Web of Science. Anastomotic leakage rate, the yield of lymph nodes and 5-year survival were compared using Review Manager 5.3.

RESULTS

There was no significant difference in anastomotic leakage, number of lymph nodes retrieved and 5-year survival rate for both techniques.

CONCLUSIONS

Neither the high tie nor the low tie strategy has an evidence in terms of anastomotic leakage rate, harvested lymph nodes, and the 5-year survival rate. Further RCT is needed.

[Significance of the preservation of left colic artery in laparoscopic resection of rectal cancer]

Controversy remains on how to manage left colic artery (LCA) when it comes to laparoscopic proctectomy. With regard to the level of detachment, a high tie of inferior mesenteric artery (IMA) is meant as a ligation at the origin of aorta, while the low tie is the ligation of IMA below the initiation part of left colic artery which is left. Several key points of LCA preservation, including clinical value, oncologic safety and the difficulty of operation, have always been debated. Some scholars hold the point of view that the preservation of LCA will hamper the lymph nodes dissection around the inferior mesenteric artery, resulting in incorrect pathological staging and dismal outcome. Of note, low tie prolongs the duration of operation and increases the anastomotic tension. However, increasing research results have established its clinical values. The value for reducing the risk of anastomotic leakage and the effect on the lymph nodes dissection at the root of inferior mesenteric artery will be discussed based on previous studies and our clinical practice. We came up with a novel concept of "the lymph nodes in the triangular domain of inferior mesenteric artery which consists of abdominal aorta, inferior mesenteric vein(IMV)/LCA and IMA" instead of traditional No.235 lymph nodes. In our innovative approach of total mesorectal excision guided by vessel, a crack was made at the root of aorta and the dissection was performed along IMA, reaching the origin of LCA. The lymph nodes will be harvested as a whole. After achieving process standardization, vessel-oriented approach and left colic artery preservation makes this region susceptible to lymphadenectomy, protecting submesenteric plexus and guarantying the oncological safety without increasing operative difficulty.

[Accurate low ligation of inferior mesenteric artery and root lymph node dissection according to different vascular typing in laparoscopic radical resection of rectal cancer]

OBJECTIVE

To explore the feasibility and clinical significance of precision low inferior mesenteric artery (IMA) ligation with the left colonic artery (LCA) preservation and root lymph node dissection in laparoscopic radical resection for rectal cancer, according to the inferior mesenteric artery (IMA) types.

METHODS

One Hundred and fore cases of rectal cancer patients who underwent laparoscopic resection in The Sixth Affiliated Hospital of Sun Yat-sen University from October 2015 to June 2016 were selected and divided into study group and control group according to different surgical methods. The study group (52 cases) accepted precision low IMA ligation with the LCA preservation and root lymph node (No.253) dissection, according to the IMA types and length examined by preoperative computed tomography angiography (CTA) reconstruction. The control group (52 cases) accepted the traditional high IMA ligation. The perioperative efficacy indexes and postoperative recovery situation of the two groups were compared.

RESULTS

The IMA types, IMA length and preoperative clinical stages were not significantly different between the two groups (all P>0.05). The surgery was completed smoothly for patients in both groups, with no conversion to open surgery. But two patients in the study group underwent left colonic artery ligation for intra-operative need. There were no significant differences in the operative time, intra-operative blood lose, the rate of protective ileostomy and post-operative pathological stages between the two groups (all P>0.05). More total lymph nodes [(24.9±5.7) vs. (16.9±4.2), P=0.001] and No.253 lymph nodes [(2.4±1.1) vs. (1.5±0.8), P=0.001] were harvested in study group as compared to control group. However, the positive rate of total harvested lymph nodes and No.253 lymph nodes between the two groups were not significantly different (P>0.05). There were no significant differences between the two groups in postoperative first anal exhaust time, postoperative hospital stay, total volume of postoperative intraperitoneal drainage, postoperative abdominal drainage tube retention time, postoperative anal drainage tube retention time and postoperative catheter retention time (All P>0.05). There were 2 cases of postoperative dysuria and 1 case of anastomotic bleeding in study group. There were 3 cases of postoperative dysuria and 2 cases of anastomotic leak in control group. Less postoperative complications (5.8% vs. 9.6%, P<0.05) in study group as compared to control group. There was no rehospitalization or death case in two groups within 30 days after operation.

CONCLUSIONS

In the laparoscopic radical resection of rectal cancer, preserving LCA and cleaning the root lymph nodes according to IMA types, which could increase the number of harvested lymph nodes and reduce the postoperative complications was safe and effective.

The long-term survival benefits of high and low ligation of inferior mesenteric artery in colorectal cancer surgery: A review and meta-analysis

BACKGROUND

The decision of ligation at the origin of the inferior mesenteric artery (IMA) or below the origin of the left colic artery (LCA) has remained a dilemma for surgeons in colorectal cancer surgery. The available studies are controversial. The objective of this meta-analysis is to compare the predictive significance of high versus low ligation in colorectal cancer surgery.

METHODS

A literature search done using Medline, EMBASE, GoogleScholar, and references. A meta-analysis was performed to analyze the 5-year overall survival (OS) of the high and low ligation using hazard ratio (HR) and 95% confidence interval (CI). We further analyzed 2 subgroups considering the level of lymph nodes (LNs) extension. That is IMA positive (+ve) and negative (-ve) LNs. Survival differences were analyzed.

RESULTS

A total of 3119 patients in 5 cohorts were included in this meta-analysis. The pooled HR results showed significant OS benefit of high ligation than low ligation (HR; 0.77, 95% CI: 0.66-0.89) in the "IMA +ve" group with 33% decreased risk, while there is no statistical significance in the "IMA -ve" (HR 0.66, 95% CI: 0.30-1.46) and the "all cases" group (HR 0.69, 95% CI: 0.41-1.15).

CONCLUSION

The pooled data showed high ligation of IMA has a better survival benefit for the patients with IMA positive LNs. It signifies high ligation should be recommended for the advanced cases or with the suspected high risk of IMA lymphatic metastasis. The limited number of articles demands future high-powered, well-designed randomized controlled trials (RCTs) for the further reliable conclusion.

[Clinical study of preserving left colic artery during laparoscopic total mesorectal excision for the treatment of rectal cancer]

OBJECTIVE

To evaluate the feasibility, safety, radicality and short-term outcome of preserving left colic artery (LCA) during laparoscopic total mesorectal excision (TME) for the treatment of rectal cancer.

METHODS

From January 2013 to December 2016,136 patients with mid-lower rectal cancer received laparoscopic TME in the Gastrointestinal Surgery Department of Taizhou People's Hospital of Jiangsu Province. Patients with rectal tumor within 10 cm to the anal verge were enrolled into the study. All the enrolled patients had complete data of pathology and follow-up. Those receiving neoadjuvant chemoradiotherapy, with severe base diseases, multifocal tumor, tumor invasion of surrounding tissues, fixation of tumor, recurrent tumor, complications such as acute ileus, bleeding, perforation were excluded. In this study, 72 patients did not undergo preservation of LCA (high ligation group) and 64 patients underwent preservation of LCA (low ligation group). Operative parameters, clinicopathological data and short-term outcome were collected and compared between two groups.

RESULTS

The baseline data including gender, age, body mass index, tumor stage, and distance of tumor from anal verge of two groups were comparable (P>0.05). The differences between two groups about the mean time of operation and the operative blood loss were not significant [(164.0±12.6) min vs. (167.3±9.4) min, (30.0±3.6) ml vs. (30.1±3.0) ml, all P>0.05]. There was no operative death in both groups. Differences in the lymph node dissection (13.7±2.6 vs. 13.3±2.1) and the specimen length of proximal resection margin [(16.4±1.9) cm vs. (16.7±2.1) cm] or distal resection margins [(3.9±0.6) cm vs. (4.1±0.9) cm] between high and low ligation groups were not significant (all P>0.05). Compared with high ligation group, the low ligation group had higher rate of sphincter preservation [92.2% (59/64) vs. 79.2% (57/72), χ²=4.580, P=0.032], lower rate of anastomotic leakage [1.6% (1/64) vs. 9.7% (7/72), χ²=4.075, P=0.044], anastomotic stenosis [3.1% (2/64) vs. 12.5%(9/72), χ²=4.006, P=0.045], and voiding and sexual dysfunction [6.3%(4/64) vs. 18.1%(13/72), χ²=4.317, P=0.038]. Mean time of follow-up was 19 months. In high ligation group, the local recurrent rate was 5.56%, distant metastasis rate was 13.89%, overall survival rate was 90.28%, disease-free survival rate was 80.56%, while in low ligation group, the local recurrence rate was 4.69%, distant metastasis rate was 12.50%, overall survival rate was 90.63%, disease-free survival rate was 82.81%, whose differences between two groups were not significant (all P>0.05).

CONCLUSION

Preservation of LCA during laparoscopic TME for the treatment of rectal cancer is safe and feasible, which can reduce the incidence of anastomotic leakage and stenosis, and voiding and sexual dysfunction.

Optimum level of inferior mesenteric artery ligation for the left-sided colorectal cancer. Systematic review for high and low ligation continuum

OBJECTIVES

To compares the effectiveness and impact of high inferior mesenteric artery (IMA) versus low IMA ligation on 5-year survival, lymph node yield rates, and peri-operative morbidity and mortality. 

METHODS

The databases of Educational Resources Information Centre (ERIC), the Web of Science, EBSCO and MEDLINE were searched using MeSH terms 'colorectal cancer', 'inferior mesenteric artery', 'high ligation', 'low ligation', 'mesenteric lymph nodes', 'prognosis', and 'survival'. Only clinical studies were selected and review articles and meta-analysis were excluded. In cases of duplicate cohorts, only the latest article was included. Irrelevant articles and the articles on both right and left sided CRC were excluded. The finally selected studies were analysed for the defined end-point outcomes. 

RESULTS

The published data has shown that high IMA ligation improves the yield of harvested lymph node that allows accurate tumor staging and a more reliable estimation of prognosis. High ligation was not found to be positively correlated with increased anastomotic leakage or impaired genito-urinary function. However, high ligation demands advanced surgical expertise and longer operating time. There was no significant difference in 5-year survival rates for both techniques. Some studies have reported fatal complications of high ligation such as proximal bowel necrosis.  

CONCLUSION

Although there is no consensus, this research signals the routine use of high ligation for left-sided CRC. However, the published fatal complications following high ligation and no significant difference in 5-year survival rates demand more studies to establishing a unified protocol.

Genito-Urinary Function and Quality of Life after Elective Totally Laparoscopic Sigmoidectomy after at Least One Episode of Complicated Diverticular Disease According to Two Different Vascular Approaches: the IMA Low Ligation or the IMA Preservation

The arterial ligation during elective laparoscopic sigmoidectomy for diverticular disease can affect genito-urinary function injuring the superior hypogastric plexus, and can weaken the distal colonic stump arterial perfusion. Ligation of the inferior mesenteric artery distal to the left colic artery or the complete preservation of the inferior mesenteric artery can therefore be compared in terms of preservation of the descending sympathetic fibres running along the aorta to the rectum resulting in a different post operative genito urinary function. From January 2015 to March 2016, 66 patients underwent elective laparoscopic sigmoidectomy for diverticular disease among two enrolling hospitals. In one centre 35 patients underwent laparoscopic sigmoidectomy with the ligation of the inferior mesenteric artery distal to the left colic artery (low ligation). In the other centre 31 patient were operated on the same procedure with complete inferior mesenteric artery preservation (IMA preservation). There was no difference in terms of major complication occurred, first passage of stool and length of hospital stay between the two groups. Time of surgery was significantly shorter in LL group compared to IMA preserving group and intra operative blood loss was significantly lower in the LL group. There were no differences in the genito urinary function between the two group pre operatively, at 1 and 9 months post operatively. Genito urinary function did not significantly change across surgery in each groups. The low ligation and the IMA preserving vascular approach are safe end feasible techniques in elective laparoscopic sigmoidectomy for diverticular disease. They both prevent from genito-urinary post-operative disfunction and allow good post operative quality of life. The low ligation approach is related to shorter operative time and slower intra operative blood loss.

Level of arterial ligation in sigmoid colon and rectal cancer surgery

BACKGROUND

Curative resection of sigmoid colon and rectal cancer includes "high tie" of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the leakage rate, and it is unclear whether this confers a survival advantage. Accordingly, the IMA may be ligated at a point just below the origin of the left colic artery (LCA) "low tie" combined with lymph node dissection (LND) around the origin of the IMA (low tie with LND). However, no study has investigated the detailed prognostic results between "high tie" and "low tie with LND." The aim of this study was to assess the utility of "low tie with LND" on survival in patients with sigmoid colon or rectal cancer.

METHODS

A total of 189 sigmoid colon or rectal cancer patients who underwent curative operation from 1997 to 2007 were enrolled in this study. The patient's medical records were reviewed to obtain clinicopathological information. Overall survival (OS) and relapse-free survival (RFS) rates were calculated using the Kaplan-Meier method, with differences assessed using log-rank test.

RESULTS

Forty-two and 147 patients were ligated at the origin of the IMA (high tie) and just below the origin of the LCA combined with LND around the origin of the IMA (low tie with LND), respectively. No significant differences were observed in the complication rate and OS and RFS rates in the two groups. Further, no significant difference was observed in the OS and RFS rates in the lymph node-positive cases in the two groups.

CONCLUSIONS

"Low tie with LND" is anatomically less invasive and is not inferior to "high tie" with prognostic point of view.

Successful endovascular treatment of mycotic aneurysms of the inferior mesenteric artery and the abdominal aorta

AIM

To report a case of successful endovascular treatment of mycotic aneurysms of the inferior mesenteric artery and the aorta.

CASE REPORT

Infrarenal aortitis in a 55-year-old multimorbid man resulted in formation of two mycotic aneurysms, one in the infrarenal aorta and the other in the inferior mesenteric artery. The patient was treated with a bifurcated aortic endograft. Antibiotic therapy was continued postoperatively for one year. Shrinkage of both aneurysms was obtained with no signs of infection or endoleaks at five year follow-up.

CONCLUSION

Aortic endografting combined with long-term antibiotic treatment may be considered as a treatment option in similar cases.

[Effect of ligation level of inferior mesenteric artery on postoperative defecation function in patients with rectal cancer]

OBJECTIVE

To investigate the effect of ligation level of inferior mesenteric artery (IMA) on postoperative defecation function in patients with rectal cancer.

METHODS

A total of 128 rectal cancer patients who were planned to undergo low anterior resection in the First Hospital of Zibo City between January 1, 2012 and December 31, 2013 were prospectively enrolled and randomly divided into IMA high ligation group(63 cases, cutting distance of 1.0 to 1.5 cm to the root of IMA) and low ligation group(65 cases, cutting distance of 0.5 to 1.0 cm to the root of left colic artery originated from IMA). The efficacy, especially the defecation function, was observed and compared 3 months and 1 year after surgery between the two groups.

RESULTS

No significant difference was found in the number of harvested lymph nodes between two groups[8(1-30) vs. 7(2-28), P=0.125], but high ligation group had greater number of metastatic lymph nodes[1(0-9) vs. 0(0-8), P=0.041]. Frequency of defecation in high ligation group was significantly higher than that in low ligation group during postoperative 3-month follow-up[5(2-10)/d vs. 3(1-8)/d, P=0.035], whereas other indexes of defecation function were not significantly different(all P>0.05). The proportion of patients needing laxatives in high ligation group was higher than that in low ligation group during postoperative 1-year follow-up [11.3%(6/53) vs. 1.7%(1/58), P=0.038], whereas other indexes of defecation function were not significantly different as well (all P>0.05). Three cases and 2 cases showed recurrence in high ligation group and low ligation group respectively during postoperative 1-year follow-up without significant difference(P=0.623).

CONCLUSION

Low ligation of IMA in low anterior resection for rectal cancer is beneficial to the protection against defecation function.

[Surgical Simulation-CT Colonography for Laparoscopic Assisted Sigmoid Colectomy Preserving the Inferior Mesenteric Artery and Vein]

D2 lymph node dissection in laparoscopic surgery for early colon cancer requires selective vessel dissection, making it technically very difficult. Using surgical simulation-CT colonography (simulation-CTC), we could perform laparoscopic assisted sigmoid colectomy preserving the inferior mesenteric artery (IMA) and vein (IMV) more accurately and safely. The case described here was a type 0-Ip sigmoid colon cancer with a tumor size of 13 mm. Endoscopic mucosal resection was performed to confirm a pathological diagnosis of pT1b (4,000 mm) and v1. Sigmoid colectomy was planned, and simulation-CTC was performed, which demonstrated that the cancer was located in the proximal sigmoid colon and supplied by the first sigmoid colon artery (S1). To maintain the blood flow to the distal sigmoid colon, selective S1 resection preserving the IMA and IMV was planned. At the operation, S1, which branches off from the IMA near the bifurcation of the abdominal aorta, was dissected, and the vein accompanying S1, which branches from the IMV in the same area as S1, was dissected. The operation was performed accurately according to the plan, showing that simulation-CTC can be very useful.

Anterior Resection for Rectal Cancer and Visceral Blood Flow: An Explorative Study

BACKGROUND AND AIMS

Impaired blood perfusion may be implicated in anastomotic leakage after anterior resection for rectal cancer. We investigated whether high ligation of the inferior mesenteric artery or total mesorectal excision compromises visceral blood flow in the colonic limb and the rectal stump, respectively.

MATERIAL AND METHODS

A prospective cohort study was conducted in a university hospital setting. We used Laser Doppler flowmetry to evaluate the impact of level of tie on colonic limb perfusion and the extent of the mesorectal excision on the rectal blood flow. In the rectum, different quadrants were also assessed. The Mann-Whitney U test was used to compare mean blood flow ratios between groups.

RESULTS

Some 23 patients were recruited in a convenience sample during a period in 2012-2013. The mean blood flow ratio was not decreased after high tie compared to low tie surgery (1.71 vs 1.19; p = 0.28). Total mesorectal excision reduced the mean blood flow ratio in the rectum, as compared with partial mesorectal excision (0.76 vs 1.28; p = 0.14). This was especially pronounced in the posterior aspect of the rectum (0.66 vs 1.68; p = 0.02).

CONCLUSION

High tie ligation did not seem to decrease colonic limb perfusion, while total mesorectal excision may decrease rectal blood flow. The posterior quadrant of the rectum might be particularly vulnerable to the dissection involved in total mesorectal excision.

Observational study on preservation of the superior rectal artery in sigmoid resection for diverticular disease

AIM

Recent investigations have shown improved patient reported outcome after preservation of the inferior mesenteric artery in sigmoid resection for diverticular disease. We report on our experience with preservation of the superior rectal artery (SRA).

METHODS

This is an observational single center study in a high-volume, level II inner city hospital from 2006 to 2008. Inclusion criteria were all patients with diverticular disease. Exclusion criteria were stoma formation, cancer, and iatrogenic perforation. Patients were investigated in group A with preservation of the SRA, and group B ligation of the SRA. Outcomes assessed, included incidence of anastomotic breakdown, intraoperative complications, hospital stay, and risk factors.

RESULTS

The patient population included 259 patients, 46 patients were excluded, leaving 100 patients in group A and 113 patients in group B. Patients in both groups were comparable regarding age, gender, co-morbidities and stage of disease. Anastomotic breakdown occurred in one patient in group A and in eight patients in group B (p = 0.038). Incidence of intraoperative bleeding, wound dehiscence, and length of stay was increased in group B (p < 0.03; p < 0.04; p = 0.05). Obesity was an independent risk factor for anastomotic dehiscence in group B (p < 0.04).

CONCLUSION

Our data comprise the largest patient population reported so far on vascular preservation in surgery for diverticular disease. The results of this study support the establishment of evidence based recommendations on the level of dissection in diverticular disease. Specifically obese patients are at risk of anastomotic breakdown with ligation of the SRA.

LAPAROSCOPIC TREATMENT OF RECTAL CANCER

There is an established standard for the surgical treatment of rectal neoplasms. Every conventional operation can be performed by means of laparoscopy, if the complex approach to the disease and classical oncological principles are observed. Depending on the height of tumor, surgical operations, different in tactical and technical terms, are performed. The correct preoperative staging, planning, and securing of resources guarantee the favorable outcome of therapy. The main advantages are the less postoperative pain and briefer hospital stay. The better visualization of pelvic organs and routine use of high-energy sources reduce the blood loss and potential complications. With a view to ensure modern treatment of this major group of patients, the input of the required resources, for turning into one of the routine methods of rectal cancer treatment, is a necessity. ABBREVIATIONS USED: LAR (laparoscopic anterior resection), LLAR (low laparoscopic anterior resection), LIsRR (laparoscopic intersphincteric resection of the rectum), TME (total mesorectal excision), TATME (transanal total mesorectal excision), LER (laparoscopic extirpation of the rectum), IMA (inferior mesenteric artery), and IMV (inferior mesenteric vein).

Clinical and surgical aspects of high and low ligation of inferior mesenteric artery in laparoscopic resection for advanced colorectal cancer in elderly patients

AIM

Objective of the present study was the evaluation of the efficacy of the low ligation of the inferior mesenteric artery with lymphadenectomy at the root in rectosigmoid resection for advanced cancer by laparoscopic approach.

METHODS

Ninety-two elderly patients with stage III tumors were retrospectively divided into three groups: low ligation of inferior mesenteric artery with and without lymphadenectomy at its root and high ligation. Anastomotic fistula, lymph nodes harvested and oncologic outcome were examined.

RESULTS

Significant differences were registered in the number of lymph nodes comparing high and low ligation with lymphadenectomy to simple low ligation. Only 8.3% of patients treated by lymphadenectomy had metastasis at the root of mesenteric artery. Not significant shorter operative time was observed in the high compared to low ligation. Significantly longer time was observed in low ligation when it was associated to lymphadenectomy. Not significant difference was observed in term of anastomotic leakage. Significant increase in cancer related deaths was observed in the low ligation group without lymphadenectomy. Not significant difference in morbidity was observed in the different groups.

CONCLUSION

Low ligation of the inferior mesenteric artery with lymphadenectomy is a safe and effective procedure in the treatment of advanced rectosigmoid cancer with similar results compared to high ligation. It might be especially indicated in elderly patients with advanced tumors to better define lymph nodes involvement and to improve vascular flow to the anastomosis.

Single access laparoscopic left hemicolectomy with or without inferior mesenteric artery preservation: our preliminary experience

AIM

We report our preliminary experience in single access laparoscopic left hemicolectomy (SALLH) with or without inferior mesenteric artery preservation, showing the results of a selected group of patients.

METHODS

This retrospective case series enclosed all patients operated between October 2009 and June 2012 of a left hemicolectomy with single laparoscopic access for benign and malignant diseases. The mean follow-up was 18 months. Intraoperative and postoperative results were recorded.

RESULTS

This retrospective case series enclosed 24 patients. Mean operative time was 157.8 min. The mean final skin incision length was 3.65 cm. All operations were completed by a single access laparoscopic approach. There were no conversion or intraoperative mortality. There were no required any intraoperative blood transfusion. Only three cases of postoperative complication were registered. The mean flatus canalization was two days. The mean discharge time was seven days. At a mean 18-month follow-up there were no incisional hernia or deaths.

CONCLUSION

As best of our knowledge, we report one of the largest experience gained in Italy about SALLH. We think that although SALC could be safe and feasible, it cannot be considered as a "new standard" procedure used by anyone. In contrast we retain that it is mandatory that SALC continued to be evaluated into larger multicentric RCT.

The vascularization pattern of the colon and surgical decision in esophageal reconstruction with colon. A selective SMA and IMA arteriographic study

INTRODUCTION

No matter the reconstructive technique, the fundamental concepts in visceral reconstruction have as main grounds the mandatory vascular support for the graft replacement. Individual vascular particularities can influence or even oblige the surgeon to choose a certain procedure. This is why the vascularization is beyond doubt the dominant factor in mobilizing the colon for reconstruction.

MATERIAL AND METHOD

Our arteriographic study entails an investigation upon the vascularization pattern of the two main sources that participate in the arterial irrigation of the colon via the emerging vessels: superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). We did not consider certain patients upon a specific criterion; also, we did not exclude any patients due to various reasons. We took into account 49 patients as study group, all of them having registered into the clinic for a reconstructive technique, throughout the years from 2000 to 2010. From 1981 to 2012 there have been 187 reconstructive techniques performed due to post caustic pathology. From a total of 49 patients, 11 had suffered major abdominal surgeries, 5 of which had had unsuccessful reconstructive attempts.

RESULTS

Out of the 49 patients on whom we have performed the exploration, arteriography showed a favorable situation for reconstruction in 31 of them. In the other 18 patients anomalies or atypical distributions were identified, in 5 of the SMA and in 13 of the IMA, respectively. Operative decision was modified in 22 patients. One important thing to note from the point of view of the segment to be moved: we had no graft necrosis in patients with preoperative arteriographic examination.

CONCLUSIONS

Due to the need for good mobilization, arterial ligations should be adjusted and modified depending on the particular vascular distribution, to maintain a sufficient blood flow in the marginal artery, in order to reach the colic sections and the straight arteries near them.

Lengthening of the colon for low rectal anastomosis in a cadaveric study: how much can we gain?

BACKGROUND

Lengthening of the colon for tension-free low rectal anastomosis comprises ligation of the inferior mesenteric vessels and splenic flexure mobilization. The aim of our study was to evaluate the length gained after each level of mesenteric vessel ligation with or without splenic flexure mobilization.

METHODS

The length of the colon after each mobilization technique, that is, low ligation of the inferior mesenteric artery (IMA), high ligation of IMA, high ligation of the inferior mesenteric vein (IMV), and mobilization of splenic flexure, was measured in 13 cadaveric specimens. After each step, the colon and vessels were placed back in their original position.

RESULTS

The distance from the colosigmoid junction (CSJ) to the pubic symphysis (PS) was measured after each mobilization technique. The average elongation of the colon from original CSJ-PS distance to the CSJ-PS distance after low ligation of IMA, high ligation of IMA, high ligation of IMA plus splenic flexure mobilization, and high ligation of IMV was 2.08 ± 4.39 cm, 5.02 ± 5.51 cm, 8.20 ± 5.95 cm, and 17.98 ± 6.80 cm, respectively. The length of colon gained after IMV ligation was greater than the length obtained after low ligation of IMA, high ligation of IMA, and high ligation of IMA plus splenic flexure mobilization (p < 0.0001).

CONCLUSIONS

This study shows the objective length gained following each standard surgical technique in colonic mobilization for low rectal anastomosis. The maximum length gained is after high ligation of IMV.

High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a RCT is needed

Nowadays left colon and rectal cancer treatment has been well standardized in both open and laparoscopy. Nevertheless, the level of the ligation of the inferior mesenteric artery (IMA), at the origin from the aorta (high tie) or below the origin of the left colic artery (low tie), is still debated. The objective of the systematic review is to evaluate the current scientific evidence of high versus low tie of the IMA in colorectal cancer surgery. The outcomes considered were overall 30-days postoperative morbidity, overall 30-days postoperative mortality, anastomotic leakage, 5-years survival rate, and overall recurrence rate. A total of 8.666 patients were included in our analysis, 4.281 forming the group undergoing high tie versus 4.385 patients undergoing low tie. Neither the high tie nor the low tie strategy showed an evidence based success, as no statistically significant differences were identified for all outcomes measured. Future high powered and well designed randomized clinical trials are needed to draw definitive conclusion on this dilemma.

[The paraaortic lymphadenectomy with the lower mesenteric artery sceletonization for the sigmoid cancer treatment]

43 patients with sigmoid cancer stage I--III were operated on. The mean operative time was 206.2±73.0 min, considering the sceletonization of the lower mesenteric artery together with the paraaortic lymphadenectomy took 28±9 min. The long-term follow-up was performed in all the patients. The median follow-up time was 39.35±13.1 months. 4 patients had died, 3 of them because of the cancer progression. The paraaortic lymphadenectomy with the lower mesenteric artery sceletonization is now considered to be the method of choice in treatment of sigmoid cancer. The operation is reasonably safe considering the rate of intra- and postoperative complication rate.