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Chen W, Cai Z, Zhou J, Xu Z, Li Z, Guo Z, Li J, Guo Z, Wu H, Xu Y. Construction of a nomogram based on clinicopathologic features to predict the likelihood of No. 253 lymph node metastasis in rectal cancer patients. Langenbecks Arch Surg 2024; 409:161. [PMID: 38761214 DOI: 10.1007/s00423-024-03353-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE To explore the high-risk factors for rectal cancer No.253 lymph node metastasis (LNM) and to construct a risk nomogram for the individualized prediction of No.253 LNM. METHODS This was a retrospective analysis of 425 patients with rectal cancer who underwent laparoscopic-assisted radical surgery. Independent risk factors for rectal cancer No.253 LNM was identified using multivariate logistic regression analysis, and a risk prediction nomogram was constructed based on the independent risk factors. In addition, the performance of the model was evaluated by discrimination, calibration, and clinical benefit. RESULTS Multivariate logistic regression analysis showed that No.253 lymphadenectasis on CT (OR 10.697, P < 0.001), preoperative T4-stage (OR 4.431, P = 0.001), undifferentiation (OR 3.753, P = 0.004), and preoperative Ca199 level > 27 U/ml (OR 2.628, P = 0.037) were independent risk factors for No.253 LNM. A nomogram was constructed based on the above four factors. The calibration curve of the nomogram was closer to the ideal diagonal, indicating that the nomogram had a better fitting ability. The area under the ROC curve (AUC) was 0.865, which indicated that the nomogram had high discriminative ability. In addition, decision curve analysis (DCA) showed that the model could show better clinical benefit when the threshold probability was between 1% and 50%. CONCLUSION Preoperative No.253 lymphadenectasis on CT, preoperative T4-stage, undifferentiation, and elevated preoperative Ca199 level were found to be independent risk factors for the No.253 LNM. A predictive model based on these risk factors can help surgeons make rational clinical decisions.
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Affiliation(s)
- Weixiang Chen
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, 350122, China
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Zhiming Cai
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, 350122, China
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Jinfeng Zhou
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, 350122, China
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Zhengnan Xu
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, 350122, China
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Zhixiong Li
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Zhixing Guo
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Junpeng Li
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Zipei Guo
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, 350122, China
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Haiyan Wu
- Department of Pathology, The First Hospital of Putian City, Putian, Fujian, 351100, China
| | - Yanchang Xu
- Gastrointestinal Surgery Unit 1, The First Hospital of Putian City, Putian, Fujian, 351100, China.
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Lee MW, Park SS, You K, Lee DE, Lee DW, Park SC, Han KS, Sohn DK, Hong CW, Kim B, Kim BC, Chang HJ, Kim DY, Oh JH. Long-term clinical outcomes after high and low ligations with lymph node dissection around the root of the inferior mesenteric artery in patients with rectal cancer. Ann Coloproctol 2024; 40:62-73. [PMID: 38414122 PMCID: PMC10915527 DOI: 10.3393/ac.2023.00094.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 02/29/2024] Open
Abstract
PURPOSE This study aimed to evaluate the long-term clinical outcomes based on the ligation level of the inferior mesenteric artery (IMA) in patients with rectal cancer. METHODS This was a retrospective analysis of a prospectively collected database that included all patients who underwent elective low anterior resection for rectal cancer between January 2013 and December 2019. The clinical outcomes included oncological outcomes, postoperative complications, and functional outcomes. The oncological outcomes included overall survival (OS) and relapse-free survival (RFS). The functional outcomes, including defecatory and urogenital functions, were analyzed using the Fecal Incontinence Severity Index, International Prostate Symptom Score, and International Index of Erectile Function questionnaires. RESULTS In total, 545 patients were included in the analysis. Of these, 244 patients underwent high ligation (HL), whereas 301 underwent low ligation (LL). The tumor size was larger in the HL group than in the LL group. The number of harvested lymph nodes (LNs) was higher in the HL group than in the LL group. There were no significant differences in complication rates and recurrence patterns between the groups. There were no significant differences in 5-year RFS and OS between the groups. Cox regression analysis revealed that the ligation level (HL vs. LL) was not a significant risk factor for oncological outcomes. Regarding functional outcomes, the LL group showed a significant recovery in defecatory function 1 year postoperatively compared with the HL group. CONCLUSION LL with LNs dissection around the root of the IMA might not affect the oncologic outcomes comparing to HL; however, it has minimal benefit for defecatory function.
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Affiliation(s)
- Min Wan Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Sil Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kiho You
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong Eun Lee
- Biostatistics Collaboration Team, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Bun Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Maruta H, Tominaga T, Nonaka T, Hisanaga M, Takeshita H, Fukuoka H, To K, Tanaka K, Sawai T, Nagayasu T. Efficacy of left colic artery preservation with D3 lymph node dissection in laparoscopic surgery for advanced sigmoid and rectal cancer. Surg Today 2023; 53:1335-1342. [PMID: 37072524 DOI: 10.1007/s00595-023-02689-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/24/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE For advanced left colon cancer, lymph node dissection at the root of the inferior mesenteric artery is recommended. Whether the left colic artery (LCA) should be preserved or resected remains contentious. METHODS The 367 patients who underwent laparoscopic sigmoidectomy or anterior resection and who were pathologically node-positive were reviewed. Patients were divided into LCA-preserving group (LCA-P, n = 60) and LCA-non-preserving group (LCA-NP, n = 307). Propensity score matching was applied to minimize selection bias and 59 patients were matched. RESULTS Before matching, the rates of poor performance status and cardiovascular disease were higher in the LCA-P group (p < 0.001). After matching, operation time was longer (276 vs. 240 min, p = 0.001), the frequency of splenic flexure mobilization (62.7% vs. 33.9%, p = 0.003) and lymphovascular invasion (84.7% vs. 55.9%, p = 0.001) was higher in the LCA-P group. Severe postoperative complications (CD ≥ 3) occurred only in the LCA-NP group (0% vs. 8.4%, p = 0.028). The median follow-up period was 38.5 months (range 2.0-70.0 months). The 5-year RFS rates (67.8% vs. 66.0%, p = 0.871) and OS rates (80.4% vs. 74.9%, p = 0.308) were comparable between the groups. CONCLUSIONS Laparoscopic LCA-sparing surgery for left-sided colorectal cancer reduces the risk of severe complications and offers a favorable long-term prognosis.
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Affiliation(s)
- Hiroshi Maruta
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuro Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Takashi Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Makoto Hisanaga
- Department of Surgery, Sasebo City General Hospital, Nagasaki, Japan
| | - Hiroaki Takeshita
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | | | - Kazuo To
- Department of Surgery, Ureshino Medical Center, Ureshino, Japan
| | - Kenji Tanaka
- Department of Surgery, Saiseikai Nagasaki Hospital, Saiseikai, Japan
| | - Terumitsu Sawai
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Feng W, Miao Y, Li W, Xu Z, Chen F, Lv Z, Liu W, Zheng M, Zhao J, Zong Y, Lu A. High ligation versus low ligation of the inferior mesenteric artery in laparoscopic rectal cancer surgery: a retrospective study on surgical and long-term outcome. Langenbecks Arch Surg 2023; 408:249. [PMID: 37380790 DOI: 10.1007/s00423-023-02980-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND In laparoscopic low anterior resection for rectal cancer surgery, there has been controversy to whether the inferior mesenteric artery (IMA) should be ligated at the origin of its aorta (high ligation (HL)) or below the branches of the left colonic artery (LCA) (low ligation (LL)). This study was intended to clarify oncological outcome and long-term prognosis of retrospective analysis. METHODS Analyzed the cases who underwent laparoscopic low anterior resection (LAR) in Shanghai Ruijin Hospital from January 2015 to December 2016, 357patients scheduled into 2 groups according to the level of IMA ligation: HL (n = 247) versus LL (n = 110). RESULTS The primary endpoint is long-term outcomes, and the secondary endpoint is the incidence rate of major postoperative complications. There were no significant differences in 5-year overall survival (P = 0.92) and 5-year disease-free survival (P = 0.41). There were no differences between the clinical baseline levels in each group. The incidence of low anterior resection syndrome (LARS) in the two groups was statistically significant (P = 0.037). No significant differences were observed in operative time (P = 0.092) and intraoperative blood loss (P = 0.118). In the HL group, 6 cases (2.4%) had additional colonic excision due to poor anastomotic blood supply; none of the colonic anastomosis in the low ligation group had ischemic manifestations, and length from the proximal margin (P = 0.076), length from the distal margin (P = 0.184), the total number of lymph nodes excised (P = 0.065), and anastomotic leakage incidence (P = 0.33). CONCLUSION Low ligation of the IMA which reserved LCA with vascular root lymph node dissection in laparoscopic low anterior resection for rectal cancer surgery may help protect the blood supply of the anastomosis, and will not increase postoperative complications while enhance recovery, without compromising radical excision and long-term prognosis.
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Affiliation(s)
- Wenqing Feng
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Yiming Miao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Wenchang Li
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Zifeng Xu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Fangqian Chen
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Zeping Lv
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Wangyi Liu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Minhua Zheng
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Jingkun Zhao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Yaping Zong
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Aiguo Lu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China.
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Ren H, Liu Y, Zhang M, An L. Feasibility of preservation of superior rectal artery plus dissection of lymph nodes around inferior mesenteric artery in laparoscopic resection for sigmoid colon cancer. Front Surg 2023; 10:1086868. [PMID: 36865630 PMCID: PMC9971221 DOI: 10.3389/fsurg.2023.1086868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023] Open
Abstract
Background Limited data are available about superior rectal artery (SRA) preservation in laparoscopic resection for sigmoid colon cancer (SCC). This study aimed to evaluate the short-term and long-term efficacies of SRA preservation in laparoscopic radical resection for SCC. Methods We retrospectively analyzed 207 patients with SCC who underwent laparoscopic radical resection for SCC from January 2017 to June 2021. A total of 84 patients received lymph node clearance around the inferior mesenteric artery (IMA) root (D3 lymph node dissection) with preservation of SRA (SRA preservation group), and 123 patients received high ligation of the IMA (control group). The clinicopathological data of the two groups were compared, and Kaplan-Meier method was performed to estimate patient survival. Results Compared with the control group, the operation time of the SRA preservation group was longer (p < 0.001), but the postoperative exhaust and defecation times were significantly shorter (p = 0.003, p < 0.001). Two cases of postoperative ileus and four cases of anastomotic leakage were observed in the control group, whereas the SRA preservation group had none. However, no statistical difference was observed between the groups (p = 0.652, p = 0.248). The overall survival also showed no significant difference in (p = 0.436). Conclusion Preservation of SRA plus dissection of lymph nodes around IMA did not increase postoperative morbidity and mortality nor affect the prognosis of patients but increased the bowel blood supply, which may have a significant positive effect on the recovery of postoperative intestinal function and reduction of anastomotic leakage.
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Affiliation(s)
| | - Yong Liu
- Correspondence: Haoyuan Ren Yong Liu
| | - Mingran Zhang
- Department of Gastrointestinal Surgery, The People's Hospital of Deyang, Deyang, China
| | - Liang An
- Department of Gastrointestinal Surgery, The People's Hospital of Deyang, Deyang, China
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Hsu CC, Hsu YJ, Chern YJ, Jong BK, Liao CK, Hsieh PS, Tsai WS, You JF. Potential short-term outcome advantage of low vs. high ligation of inferior mesenteric artery for sigmoid and rectal cancer: propensity score matching analysis. BMC Surg 2023; 23:33. [PMID: 36755252 PMCID: PMC9909897 DOI: 10.1186/s12893-023-01932-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Whether to ligate the inferior mesenteric artery at its root during anterior resection for sigmoid colon or rectal cancer is still under debate. This study compared the surgical outcomes, postoperative recovery, and anastomotic leakage between high and low ligation of the inferior mesenteric artery through a subgroup analysis. METHODS This was a retrospective analysis of prospectively collected data. All patients who underwent colorectal resection for rectosigmoid cancer between December 2016 and December 2019 were enrolled. According to the surgical ligation level of the inferior mesenteric artery, the patients were categorized into either the high or low ligation group. The investigated population was matched using the propensity score method. RESULTS Overall, 894 patients with sigmoid or rectal cancer underwent elective anterior resection with high (577 patients) or low (317 patients) ligation of the inferior mesenteric artery. After the propensity score matching, 245 patients in each group were compared. High ligation of the inferior mesenteric artery was associated with higher incidence of anastomotic leakage (14.9% vs. 5.6%, P = 0.041) for mid- to low-rectum tumors and a higher incidence of complications (8.6% vs. 3.3%, P = 0.013) of grades 1-2 according to the Clavien-Dindo classification system. CONCLUSION Compared with high ligation, low ligation of the inferior mesenteric artery resulted in lower likelihood of morbidity and mortality in rectal and sigmoid cancers. Moreover, low ligation was less likely to result in anastomosis leakage in mid- to low-rectal cancers.
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Affiliation(s)
- Chia-Chen Hsu
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Yu-Jen Hsu
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Yih-Jong Chern
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Bor-Kang Jong
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Chun-Kai Liao
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Pao-Shiu Hsieh
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Wen-Sy Tsai
- grid.145695.a0000 0004 1798 0922Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305 Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan.
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WANG C, HUANG T, WANG X. Ligation level of inferior mesenteric artery in rectal cancer: a meta-analysis. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2023. [DOI: 10.23736/s0393-3660.22.04868-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Wang Y, Wang Y, Zou L, Deng L, Wu T, Liu L, Jiang J, An T. Does the level of inferior mesenteric artery ligation affect short-term and long-term outcomes of patients with sigmoid colon cancer or rectal cancer? A single-center retrospective study. World J Surg Oncol 2022; 20:274. [PMID: 36045369 PMCID: PMC9434919 DOI: 10.1186/s12957-022-02741-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background For sigmoid colon or rectal cancer, a definite consensus regarding the optimal level ligating the inferior mesenteric artery (IMA) has not been reached. We performed this study to determine whether the ligation level significantly affected short-term and long-term outcomes of patients with sigmoid colon or rectal cancer after curative laparoscopic surgery. Methods Medical records of patients with sigmoid colon or rectal cancer who had undergone curative laparoscopic surgery between January 2008 and December 2014 at the Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine were reviewed. Then, the high tie group (HTG) was compared with the low tie group (LTG) in terms of short-term and long-term outcomes. Results Five-hundred ninety patients were included. No significant differences between two groups regarding baseline characteristics existed. HTG had a significantly higher risk of anastomotic fistula than LTG (21/283 vs 11/307, P = 0.040). Additionally, high ligation was proven by multivariate logistic regression analysis to be an independent factor for anastomotic fistula (P = 0.038, OR = 2.232, 95% CI: 1.047–4.758). Furthermore, LT resulted in better preserved urinary function. However, LTG was not significantly different from HTG regarding operative time (P = 0.075), blood transfusion (P = 1.000), estimated blood loss (P = 0.239), 30-day mortality (P = 1.000), ICU stay (P = 0.674), postoperative hospital stay (days) (P = 0.636), bowel obstruction (P = 0.659), ileus (P = 0.637), surgical site infection (SSI) (P = 0.121), number of retrieved lymph nodes (P = 0.501), and number of metastatic lymph nodes (P = 0.131). Subsequently, it was revealed that level of IMA ligation did not significantly influence overall survival (OS) (P = 0.474) and relapse-free survival (RFS) (P = 0.722). Additionally, it was revealed that ligation level did not significantly affect OS (P = 0.460) and RFS (P = 0.979) of patients with stage 1 cancer, which was also observed among patients with stage 2 or stage 3 cancer. Ultimately, ligation level was not an independent predictive factor for either OS or RFS. Conclusions HT resulted in a significantly higher incidence of anastomotic fistula and worse preservation of urinary function. Level of IMA ligation did not significantly affect long-term outcomes of patients with sigmoid colon or rectal cancer after curative laparoscopic surgery.
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Affiliation(s)
- Yawei Wang
- The First Department of Surgery, Shenzhen Traditional Chinese Medicine Hospital, Fuhua Road 1, Futian District, Shenzhen, 518033, Guangdong, People's Republic of China
| | - Yan Wang
- Department of Radiology, Shenzhen People's Hospital, Dongmen Road 1017, Luohu District, Shenzhen, 518020, Guangdong, People's Republic of China
| | - Liaonan Zou
- Department of General Surgery, The Affiliated Zhuhai Hospital, Guangdong Provincial Hospital of Traditional Chinese Medicine, Jingle Road 52, Xiangzhou District, Zhuhai, 519015, Guangdong, China.,Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine, Dade Road 111, Yuexiu District, Guangzhou, 510006, Guangdong, China
| | - Lingna Deng
- Department of Pathology, Qingyuan People's Hospital, Yinquan Road B24, Qingcheng District, 511518, Qingyuan, Guangdong, People's Republic of China
| | - Tianchong Wu
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital, Dongmen Road 1017, Luohu District, Shenzhen, 518020, Guangdong, People's Republic of China
| | - Linsen Liu
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital, Dongmen Road 1017, Luohu District, Shenzhen, 518020, Guangdong, People's Republic of China
| | - Jiling Jiang
- The First Department of Surgery, Shenzhen Traditional Chinese Medicine Hospital, Fuhua Road 1, Futian District, Shenzhen, 518033, Guangdong, People's Republic of China.
| | - Tailai An
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital, Dongmen Road 1017, Luohu District, Shenzhen, 518020, Guangdong, People's Republic of China.
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Cheong JY, Rusli SM, Choo JM, Kim JS, Kim J, Kim SH. How to do: superior rectal artery sparing anterior resection for sigmoid colon cancer - surgical option for vasculopathic patients. ANZ J Surg 2022; 92:2318-2319. [PMID: 35488510 DOI: 10.1111/ans.17753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/05/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
Abstract
Superior rectal artery sparing oncological anterior resection in vasculopathic patients.
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Affiliation(s)
- Ju Yong Cheong
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Siti Mayuha Rusli
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jeong Min Choo
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Ji-Seon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jin Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Seon Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
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Yu JH, Huang XW, Song YC, Lin HZ, Zheng FW. Analysis of Prevention and Treatment of Anastomotic Leakage after Sphincter-Preserving Surgery for Middle- and Low-Grade Rectal Cancer under Laparoscopy. Int J Clin Pract 2022; 2022:6231880. [PMID: 36567776 PMCID: PMC9750781 DOI: 10.1155/2022/6231880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Anastomotic leakage is one of the most serious complications that can occur after laparoscopic-assistedsphincter-preserving surgery for middle- and low-grade rectal cancer. OBJECTIVES To explore the cause, prevention, and treatment of anastomotic leakage after sphincter-preserving surgery for middle- and low-grade rectal cancer under laparoscopy. METHODS The clinical data from patients with mid- and low-grade rectal cancer who underwent laparoscopic-assistedanus-preserving surgery in the anorectal surgery department of our hospital have been analyzed. Patients with a definite diagnosis, indications for laparoscopic surgery, and sphincter-preserving surgery were included in the analysis, and patients with a protective loop ileostomy and laparotomy were excluded. RESULTS Among the 126 patients with middle- and low-grade rectal cancer undergoing sphincter-preserving surgery under laparoscopy. There were 75 male patients and 51 female patients, ranging in age from 37 to 89 years old, with an average age of 60.2 ± 6.7. The distance from the lower edge of the rectal tumor to the anal edge was ≤10 cm. 6 developed anastomotic leakage after the operation (leakage rate of 4.7%). Moreover, turbid purulent fluid was drained from the abdominal drainage tube in three patients on the third and fourth days after the operation, and the abdominal drainage tube drained serous drainage in three more patients on the fifth and sixth days, with signs of peritonitis appearing locally. All patients received continuous flushing and negative pressure drainage with a self-made double cannula and symptomatic treatment, and all were cured and discharged. CONCLUSION Many factors can cause anastomotic leakage after this operation, and adequate perioperative preparation, meticulous operation during surgery, and careful postoperative management are key factors in preventing it.
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Affiliation(s)
- Jia-He Yu
- The School of Clinical Medicine, Fujian Medical University, Fuzhou 350122, China
- Department of Anorectal Surgery, The Affiliated Hospital of Putian University, No. 999 Dongzhen East Road, Licheng District, Putian 351100, China
| | - Xiang-Wu Huang
- The School of Clinical Medicine, Fujian Medical University, Fuzhou 350122, China
- Department of Anorectal Surgery, The Affiliated Hospital of Putian University, No. 999 Dongzhen East Road, Licheng District, Putian 351100, China
| | - Yu-Cheng Song
- Department of Anorectal Surgery, The Affiliated Hospital of Putian University, No. 999 Dongzhen East Road, Licheng District, Putian 351100, China
| | - Hui-Zhong Lin
- Department of Anorectal Surgery, The Affiliated Hospital of Putian University, No. 999 Dongzhen East Road, Licheng District, Putian 351100, China
| | - Feng-Wu Zheng
- Department of Anorectal Surgery, The Affiliated Hospital of Putian University, No. 999 Dongzhen East Road, Licheng District, Putian 351100, China
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11
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Zheng Z, Wang X, Huang Y, Lu X, Zhao X, Chi P. An Intrasheath Separation Technique for Nerve-Sparing High Ligation of the Inferior Mesenteric Artery in Colorectal Cancer Surgery. Front Oncol 2021; 11:694059. [PMID: 34249749 PMCID: PMC8264435 DOI: 10.3389/fonc.2021.694059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/08/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose To investigate the relationship between the left trunk of the inferior mesenteric plexus (IMP) and the vascular sheath of the inferior mesenteric artery (IMA) and to explore anatomical evidence for autonomic nerve preservation during high ligation of the IMA in colorectal cancer surgery. Methods We evaluated the relationship in 23 consecutive cases of laparoscopic or robotic colorectal surgery with high ligation of the IMA at our institute. Anatomical dissection was performed on 5 formalin-fixed abdominal specimens. A novel anatomical evidence-based operative technique was proposed. Results Anatomical observation showed that the left trunk of the IMP was closely connected with the IMA and was involved in the composition of the vascular sheath. Based on anatomical evidence, we present a novel operative technique for nerve-sparing high ligation of the IMA that was successfully performed in 45 colorectal cancer surgeries with no intraoperative complications and satisfactory postoperative urogenital functional outcomes. Conclusion The left trunk of the IMP is involved in the composition of the IMA vascular sheath. This novel anatomical evidence-based operative technique for nerve-sparing high ligation of the IMA is technically safe and feasible.
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Affiliation(s)
- Zhifang Zheng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xiaojie Wang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xingrong Lu
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xiaozhen Zhao
- Laboratory of Clinical Applied Anatomy, Fujian Medical University, Fuzhou, China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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12
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Hu S, Li S, Teng D, Yan Y, Lin H, Liu B, Gao Z, Zhu S, Wang Y, Du X. Analysis of risk factors and prognosis of 253 lymph node metastasis in colorectal cancer patients. BMC Surg 2021; 21:280. [PMID: 34082744 PMCID: PMC8176614 DOI: 10.1186/s12893-021-01276-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/19/2021] [Indexed: 12/22/2022] Open
Abstract
Background This study aimed to explore potential risk factors for 253 lymph node metastasis, and to identify the prognostic impact of 253 lymph node metastasis in colorectal cancer patients. Methods A retrospective study was conducted of 391 colorectal cancer patients who underwent surgical treatments that included 253 lymph node dissection. Clinicopathological features, molecular indexes and 1-year overall survival rates were analyzed. Results Univariate analyses revealed the following risk factors for 253 lymph node metastasis: high preoperative levels of CEA, large tumour max diameters, and numbers of harvested lymph nodes, presence of vessel carcinoma emboli, low level of MSH6 and MLH1 immunohistochemical staining intensity. Multivariate analysis showed that elevated MLH1 immunohistochemical staining intensity was an independent protective factor for 253 lymph node metastasis (OR: 0.969, 95% CI 0.945, 0.994, P = 0.015). A significant difference was found in 1-year overall survival rate between 253 lymph node-positive and lymph node-negative colorectal cancer patients (88.9% vs.75.0%, P < 0.001). Conclusions 253 lymph node-positive colorectal cancer patients had a worse prognosis than the 253 lymph node-negative patients. 253 lymph node dissection may improve the prognosis of colorectal cancer patients with high risk factors for 253 lymph node metastasis.
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Affiliation(s)
- Shidong Hu
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Songyan Li
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Da Teng
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Yang Yan
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Haiguan Lin
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Boyan Liu
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Zihe Gao
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Shengyu Zhu
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Yufeng Wang
- Department of Hospital Management, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiaohui Du
- Department of General Surgery, the First Medical Centre, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China. .,Department of Hospital Management, the First Medical Centre, Chinese PLA General Hospital, Beijing, China.
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13
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Kuzu MA, Güner MA, Kocaay AF, İsmail E, Arslan MN, Tekdemir İ, Açar Hİ. Redefining the collateral system between the superior mesenteric artery and inferior mesenteric artery: a novel classification. Colorectal Dis 2021; 23:1317-1325. [PMID: 33382167 DOI: 10.1111/codi.15510] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/15/2020] [Accepted: 12/19/2020] [Indexed: 12/28/2022]
Abstract
AIM The aim of this study was to evaluate the arterial collateral vasculature between the superior mesenteric artery and the inferior mesenteric artery (IMA) from a surgical perspective. METHOD A total of 107 fresh adult cadavers (94 male) were studied with emphasis on the vascular anatomy of the left colon. Dissections were carried out mimicking the anterior resection technique. The vasculature of the left mesocolon and the collaterals between the superior mesenteric artery and the IMA with respect to their relationship to the inferior mesenteric vein (IMV) were assessed and classified. Collaterals were classified into three different groups: marginal anastomoses (via the marginal = pericolic artery), intermediate mesocolic anastomoses (parallel to the marginal artery but neither adjacent to the IMV nor close to the duodenum) and central mesocolic anastomoses (next to the IMV at the level of the duodenojejunal junction and the lower border of the pancreas). RESULTS All patients had a marginal anastomosis. However, the marginal anastomosis, as the only anastomosis between the superior and inferior mesenteric arteries at the splenic flexure, was observed in 41 cases (38%). In addition to the marginal artery, intermediate mesocolic anastomoses were found in 49 (46%) and a central mesocolic anastomosis was observed in 17 (16%) of the 107 cases in the splenic flexure mesocolon. It is in this latter variant that collateral vessels can be compromised during ligation/transection of the IMV. CONCLUSION This new classification can contribute to a precise mesocolic dissection technique and splenic flexure mobilization and help prevent ischaemic damage to the descending colon.
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Affiliation(s)
- Mehmet Ayhan Kuzu
- General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Mehmet Ali Güner
- Department of Anatomy, Gülhane Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Akın Fırat Kocaay
- General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Erkin İsmail
- General Surgery, Acibadem Hospital, Ankara, Turkey
| | | | - İbrahim Tekdemir
- Department of Anatomy, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Halil İbrahim Açar
- Department of Anatomy, Faculty of Medicine, Ankara University, Ankara, Turkey
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14
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Jansen-Winkeln B, Mehdorn M, Lange U, Köhler H, Chalopin C, Gockel I. Precision Surgery In Rectal Resection With Hyperspectral and Fluorescence Imaging And Pelvic Intraoperative Neuromonitoring (With Video). Surg Technol Int 2021; 38:154-158. [PMID: 34081769 DOI: 10.52198/21.sti.38.cr1383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Oncologic visceral surgery has recently been revolutionized by robotics, artificial intelligence (AI), sparing of functionally important structures and innovative intraoperative imaging tools. These techniques enable new dimensions of precision surgery and oncology. Currently, data-driven, cognitive operating rooms are standing at the forefront of the latest technical and didactic developments in abdominal surgery. Rectal low anterior resection with total mesorectal excision (TME) for lower- and middle-third rectal cancer is a challenging operation due to the narrow pelvis and the tender guiding structures. Thus, new approaches have been needed to simplify the procedure and to upgrade the results. The combination of robotics with pelvic intraoperative neuromonitoring (pIONM) and new possibilities of visualization, such as multi- and hyperspectral imaging (MSI / HSI) or fluorescence imaging (FI) with indocyanine green (ICG) is a forward-looking modality to enhance surgical precision and reduce postoperative complications while improving oncologic and functional outcomes with a better quality of life. The aim of our video-paper is to show how to achieve maximum precision by combining robotic surgery with pelvic intraoperative neuromonitoring and new imaging devices for rectal cancer.
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Affiliation(s)
- Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Mathias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Undine Lange
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Leipzig, Germany
| | - Claire Chalopin
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
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15
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Luo Y, Yu MH, Huang YZ, Jing R, Qin J, Qin SL, Shah JN, Zhong M. Lymphadenectomy Around Inferior Mesenteric Artery in Low-Tie vs High-Tie Laparoscopic Anterior Resection: Short- and Long-Term Outcome of a Cohort of 614 Rectal Cancers. Cancer Manag Res 2021; 13:3963-3971. [PMID: 34017199 PMCID: PMC8131009 DOI: 10.2147/cmar.s282986] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 12/10/2020] [Indexed: 11/23/2022] Open
Abstract
Background Preservation of the left colic artery in low-tie (LT) of inferior mesenteric artery remains controversial compared to high-tie (HT) in the colon and rectal cancers, for lymph node dissection, anastomotic leakage, and oncological outcome. This cohort study aims to analyze short- and long-term outcomes of laparoscopic anterior resections in LT vs HT for rectal cancers. Methods We analyzed a cohort of laparoscopic AR for RC from 2013 to 2016 at Renji Hospital, Shanghai, China. Short- and long-term outcome in LT vs HT group were compared for clinico-demographic characteristics, operative-time, lymph node dissection, short-term 30-day outcome, and long-term 3- and 5-year overall survival as well as disease-free survival. The x2, t-test, and logistic regressions analysis were used and p<0.05 was considered significant. Results The cohort consisted of 614 laparoscopic AR with LT (236) and HT (378). The clinicodemographic characteristics were comparable among the groups. The surgery took longer in LT. The yield of LND was similar. Leakage occurred in 12.21% (n=75). Leakage was fewer in LT than HT, 8.89% vs 14.28%, p=0.047. The postoperative severe complications were higher in HT. The 30-day mortality was nil. The long-term 3- and 5-year overall survival and disease-free survival were similar in LT and HT. Conclusion The LT with preservation of left colic artery had similar lymph node yield, but lower leakage and complications than HT in laparoscopic anterior resections for rectal cancers. The long-term 3- and 5-year overall and disease-free survival were similar in the two groups.
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Affiliation(s)
- Yang Luo
- Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People's Republic of China
| | - Min-Hao Yu
- Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People's Republic of China
| | - Yi-Zhou Huang
- Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People's Republic of China
| | - Ran Jing
- Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People's Republic of China
| | - Jun Qin
- Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People's Republic of China
| | - Shao-Lan Qin
- Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People's Republic of China
| | - Jay N Shah
- Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People's Republic of China.,Department of Surgery, Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Kathmandu, 44700, Nepal
| | - Ming Zhong
- Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People's Republic of China
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16
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Wikner F, Matthiessen P, Sörelius K, Legrell P, Rutegård M. Discrepancy between surgeon and radiological assessment of ligation level of the inferior mesenteric artery in patients operated for rectal cancer-impacting registry-based research and surgical practice. World J Surg Oncol 2021; 19:115. [PMID: 33849560 PMCID: PMC8045315 DOI: 10.1186/s12957-021-02222-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/31/2021] [Indexed: 12/12/2022] Open
Abstract
Background The reliability of the registered ligation level of the inferior mesenteric artery (IMA) in the Swedish Colorectal Cancer Registry has been questioned. The primary aim of this study was to evaluate this parameter in the registry by comparing the registered ligation levels with a postoperative computed tomography angiography (CT-angiography) in patients operated for rectal cancer. Methods Patients operated for rectal cancer at two Swedish university hospitals were prospectively included between December 2016 and December 2019. At the 1-year postoperative follow-up, an additional CT-angiography was performed and independently examined by two radiologists. The radiological assessment of the ligation level was compared to registry data, using different measures of agreement. Results A total of 94 patients were included, 55 (59%) were men and 39 (41%) women. All patients underwent abdominal resection: conventional or robot-assisted laparoscopic surgery, n=56 (60%), or open resection, n=38 (40%). The ligation level as assessed on CT-angiography was high in 29 (31%) patients and low in 65 (69%). The registered level of ligation of the IMA and the radiological assessment of the CT-angiographies were consistent in 77/94 cases, demonstrating an 82% agreement and a sensitivity and specificity of 86% and 72%, respectively. The estimated Kappa value was 0.58, reaching 0.64 after prevalence bias adjustment. Conclusion This study showed that CT-angiography can be used to evaluate the reliability of the registered ligation level in the Swedish Colorectal Cancer Registry. The demonstrated agreement between the registry and postoperative CT-angiography was moderate to good. This discrepancy impacts registry-based research using IMA ligation data and may ultimately influence surgical practice. Trial registration Clinical Trials identifier NCT03875612 Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02222-5.
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Affiliation(s)
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Karl Sörelius
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Petter Legrell
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden. .,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
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17
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Zhao X, Ma J, Fu Z, Hong H, Zhang L, Xue P, Cai Z, He Z, Zang L, Zheng M. Prognostic value of apical lymph node metastasis at the inferior mesenteric artery in sigmoid and rectal cancer patients who undergo laparoscopic surgery. J Surg Oncol 2021; 123 Suppl 1:S88-S94. [PMID: 33650692 DOI: 10.1002/jso.26346] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Evidence supporting the importance of apical lymph nodes (LNs) and the potential long-term impact of LN metastases at the inferior mesenteric artery (IMA) lymphectomy remains limited. This study aimed to evaluate the prognostic value of LNs at the IMA (IMA-LN) in sigmoid and rectal cancer patients undergoing laparoscopic surgery. METHODS We retrospectively evaluated 265 consecutive patients who underwent laparoscopic sigmoid or rectal cancer surgery between August 2016 and May 2020. They were divided into two groups according to the pathological results of the IMA LNs: IMA-LN negative (n = 248) and IMA-LN positive (n = 17). RESULTS The IMA-LN negative group had significantly better overall survival (OS) (p = .020) and disease-free survival (DFS) (p = .000) than did the IMA-LN positive group. IMA-LN metastasis was associated with worse OS and DFS regardless of the pN stage. Patients with IMA-LN metastasis had a higher risk of postoperative recurrence, especially liver (p = .000) and lung (p = .025) metastasis, than did those without metastasis. However, there was no significant difference in the local recurrence rate between the two groups. CONCLUSIONS IMA-LN metastasis is an independent risk factor for poor prognosis in sigmoid and rectal cancer. Dissecting and evaluating IMA-LN separately is a more accurate and practical method for predicting prognosis.
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Affiliation(s)
- Xuan Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junjun Ma
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhanwei Fu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hiju Hong
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Luyang Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pei Xue
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenghao Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zirui He
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lu Zang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minhua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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18
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Feng W, Zong Y, Zhao J, Li W, Miao Y, Xu Z, Xu Z, Sun J, Zheng M, Lu A. High versus low ligation of the inferior mesenteric artery during laparoscopic rectal cancer surgery: A prospective study of surgical and oncological outcomes. J Surg Oncol 2021; 123 Suppl 1:S76-S80. [PMID: 33651908 DOI: 10.1002/jso.26362] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES There is controversy regarding whether the inferior mesenteric artery (IMA) should be ligated at its origin from the aorta (high ligation, HL) or below the branch of the left colic artery (low ligation, LL) during surgery for rectal cancer. METHODS This prospective study randomized 95 patients with histologically proven rectal cancer (clinical stages I-III based on the 8th American Joint Committee on Cancer guidelines) to undergo HL (n = 47) or LL with lymph node dissection at the root of the IMA (n = 48). RESULTS Only two intraoperative adverse events were observed (two HL patients experienced anastomotic ischemia and underwent extended bowel excision and splenic flexure mobilization). The LL group had a significantly shorter time to first flatus (p < .0001). No significant differences were observed in operative time (p = .14), intraoperative blood loss (p = .21), distance from the upper margin (p = .77), distance from the lower margin (p = .35), harvested lymph nodes (p = .33), or anastomotic leakage (p = .44), 2-year overall survival (p = .97), or 2-year disease-free survival (p = .42). CONCLUSION During laparoscopic low anterior resection, a combination of LL at the IMA and vascular root lymph node dissection may help protect the blood supply of the anastomosis, reduce postoperative complications, and enhance recovery, without compromising radical excision.
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Affiliation(s)
- Wenqing Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Yaping Zong
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Jingkun Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Wenchang Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Yiming Miao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Zifeng Xu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Zhuoqing Xu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Jing Sun
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Minhua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Aiguo Lu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Shanghai, China
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19
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Kong M, Chen H, Xin Y, Jiang Y, Han Y, Sheng H. High ligation of the inferior mesenteric artery and anastomotic leakage in anterior resection for rectal cancer: a systematic review and meta-analysis of randomized controlled trial studies. Colorectal Dis 2021; 23:614-624. [PMID: 33131205 DOI: 10.1111/codi.15419] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/06/2020] [Accepted: 10/27/2020] [Indexed: 02/08/2023]
Abstract
AIM Surgeons have concerns whether high ligation (HL) of the inferior mesenteric artery (IMA) increases the incidence of anastomotic leakage (AL). This meta-analysis aimed to evaluate the influence of HL of the IMA on AL compared with low ligation (LL). METHODS PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases were searched. Randomized controlled trial studies that compared HL with LL of the IMA in anterior resection for rectal cancer and reported AL outcomes were eligible for inclusion. The odds ratios and mean differences were analysed by a random-effects model. Trial sequential analysis was performed to minimize the risk of random errors. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence for outcomes. RESULTS Of the 531 records screened, five randomized controlled trials with 779 patients were selected for analysis. The pooled incidence of AL was 12.1% (95% Cl 7.77-18.26) in the HL group and 9.7% (95% Cl 5.79-15.82) in the LL group (OR 1.20, 95% CI 0.77-1.87, P = 0.42). In trial sequential analysis, the cumulative Z-score curve exceeded the futility boundary, although the required information size of 1060 had not been reached. The quality of evidence was judged to be high according to the GRADE approach. CONCLUSIONS This meta-analysis shows that HL of the IMA does not increase the incidence of AL in anterior resection for rectal cancer.
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Affiliation(s)
- Meng Kong
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Hongyuan Chen
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yingying Xin
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yugang Jiang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yue Han
- Department of Gastrointestinal Surgery, Shandong Provincial Third Hospital, Shandong University, Jinan, Shandong, China
| | - Hongguang Sheng
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
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Zhang C, Li A, Luo T, Li Y, Li F, Li J. Evaluation of characteristics of left-sided colorectal perfusion in elderly patients by angiography. World J Gastroenterol 2020; 26:3484-3494. [PMID: 32655271 PMCID: PMC7327791 DOI: 10.3748/wjg.v26.i24.3484] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Handling of the inferior mesenteric artery (IMA) and maintaining anastomotic perfusion are important in radical resection of left-sided colorectal cancer. However, the branching of this artery and the drainage patterns of this vein vary among individuals, and the characteristics and perfusion region of this artery in elderly patients remain unclear.
AIM To evaluate the characteristics and perfusion region of the IMA in elderly patients using angiography.
METHODS We enrolled 154 patients (> 65 years old) who underwent digital subtraction angiography of the IMA. The characteristics, bifurcation, and distribution of the IMA and termination of the anastomotic perfusion of the left colon and rectum were examined using digital subtraction angiography. Collateral arterial arches and the IMA hemoperfusion region were also recorded. Perfusion regions were cross-referenced with clinical and anatomical features by the univariate analysis.
RESULTS Of 154 patients, 25 (16.2%) had IMA lesions. The left colic artery arose independently from the IMA in 44.2% of patients, shared a trunk with the sigmoid artery in 35.1%, shared an opening with the sigmoid and superior rectal arteries in 16.9%, and was absent in 5.1%. The IMA perfusion region stopped at the splenic flexure in 50 (32.5%) patients. The collateral circulation existed in the colonic perfusion region, including the marginal artery (Drummond’s artery), the ascending branch of the left colonic artery to supply the transverse colon, and the arc of Riolan with a frequency of 100%, 22.7%, and 1.9%, respectively. The IMA perfusion region was independently associated with the comorbidity of atherosclerosis, IMA atherosclerotic lesion, branching pattern, collateral circulation, and marginal artery integrity.
CONCLUSION The IMA and its branches are prone to arteriosclerosis, and IMA perfusion may be interrupted at the splenic flexure in elderly patients. The applicability and precision of preoperative angiography for evaluating the IMA branching and perfusion patterns could facilitate geriatric laparoscopic left-sided colorectal cancer surgery with suspicion of poor IMA perfusion.
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Affiliation(s)
- Chao Zhang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- Gastroenteropancreatic Center, National Clinical Research Center for Geriatric Diseases, Beijing 100053, China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- Gastroenteropancreatic Center, National Clinical Research Center for Geriatric Diseases, Beijing 100053, China
| | - Tao Luo
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- Gastroenteropancreatic Center, National Clinical Research Center for Geriatric Diseases, Beijing 100053, China
| | - Yu Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- Gastroenteropancreatic Center, National Clinical Research Center for Geriatric Diseases, Beijing 100053, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- Gastroenteropancreatic Center, National Clinical Research Center for Geriatric Diseases, Beijing 100053, China
| | - Jia Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- Gastroenteropancreatic Center, National Clinical Research Center for Geriatric Diseases, Beijing 100053, China
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A three-dimensional computed tomography angiography study of the anatomy of the accessory middle colic artery and implications for colorectal cancer surgery. Surg Radiol Anat 2020; 42:1509-1515. [PMID: 32500228 PMCID: PMC7644475 DOI: 10.1007/s00276-020-02511-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
Abstract
Purpose In the present study, we focused on the accessory middle colic artery and aimed to increase the safety and curative value of colorectal cancer surgery by investigating the artery course and branching patterns. Methods We included 143 cases (mean age, 70.4 ± 11.2 years; 86 males) that had undergone surgery for neoplastic large intestinal lesions at the First Department of Surgery at Yamagata University Hospital between August 2015 and July 2018. We constructed three-dimensional (3D) computed tomography (CT) angiograms and fused them with reconstructions of the large intestines. We investigated the prevalence of the accessory middle colic artery, the variability of its origin, and the prevalence and anatomy of the arteries accompanying the inferior mesenteric vein at the same level as the origin of the inferior mesenteric artery. Results Accessory middle colic artery was observed in 48.9% (70/143) cases. This arose from the superior mesenteric artery in 47, from the inferior mesenteric artery in 21, and from the celiac artery in two cases. In 78.2% (112/143) cases, an artery accompanying the inferior mesenteric vein was present at the same level as the origin of the inferior mesenteric artery; this artery was the left colic artery in 92, the accessory middle colic artery in 11, and it divided and became the left colic artery and the accessory middle colic artery in 10 cases. Conclusion 3D CT angiograms are useful for preoperative evaluation. Accessory middle colic arteries exist and were observed in 14.9% of cases.
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Yoo RN, Cho HM, Kye BH, Kim HJ, Shin S, Kim G. Rapid transit in the left-sided colon is related to poor defecatory function at early period after stoma closure. Sci Rep 2020; 10:3739. [PMID: 32111913 PMCID: PMC7048930 DOI: 10.1038/s41598-020-60808-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/17/2020] [Indexed: 01/04/2023] Open
Abstract
Sphincter-saving surgery (SSS) is the gold standard for rectal cancer surgery but results in a wide spectrum of bowel dysfunction. This study investigated the impact of colonic dysmotility on the incontinent form of bowel dysfunction. Bowel function of patients who received SSS with loop ileostomy for treating rectal cancer was reviewed retrospectively from June 2013 two August 2015 at a single hospital. Immediately after closure of a diverting stoma, patients were tested for the colonic transit time (CTT) using radiopaque markers. Bowel dysfunction at 6 and 12 months after SSS was measured as the severity of fecal incontinence according to the Cleveland Clinic Incontinence Score (CCIS) and the use of an anti-diarrheal drug. A short CTT for the left colonic segment was significantly associated with the high CCIS and use of an antidiarrheal agent at 6 months after sphincter preservation. However, the CTT didn't correlate with the CCIS at 12 months after SSS. Rather, age and surgical method demonstrated a significant association. Colonic dysmotility after SSS appears to intensify fecal incontinence for a relatively short period. Its impact abates within a year.
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Affiliation(s)
- Ri Na Yoo
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea.
| | - Hyeon-Min Cho
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
| | - Bong-Hyeon Kye
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea.
| | - Hyung Jin Kim
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
| | - Sukhyun Shin
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
| | - Gun Kim
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
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Park SS, Park B, Park EY, Park SC, Kim MJ, Sohn DK, Oh JH. Outcomes of high versus low ligation of the inferior mesenteric artery with lymph node dissection for distal sigmoid colon or rectal cancer. Surg Today 2020; 50:560-568. [DOI: 10.1007/s00595-019-01942-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/06/2019] [Indexed: 02/06/2023]
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Cui Y, Sun S, Li Z, Wang W. Safety, Survival, and Efficacy of Preserving Left Colonic Artery in Rectal Cancer Surgery: A Meta-Analysis and Review. J Laparoendosc Adv Surg Tech A 2019; 29:1405-1413. [PMID: 31436498 DOI: 10.1089/lap.2019.0406] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- YongHe Cui
- Department of Emergency (Acute Abdomen) Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - ShaoMing Sun
- Department of Emergency (Acute Abdomen) Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Zhanwu Li
- Department of Emergency (Acute Abdomen) Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - WenJun Wang
- Department of Emergency (Acute Abdomen) Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
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AlSuhaimi MA, Yang SY, Kang JH, AlSabilah JF, Hur H, Kim NK. Operative safety and oncologic outcomes in rectal cancer based on the level of inferior mesenteric artery ligation: a stratified analysis of a large Korean cohort. Ann Surg Treat Res 2019; 97:254-260. [PMID: 31742210 PMCID: PMC6848010 DOI: 10.4174/astr.2019.97.5.254] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/24/2019] [Accepted: 10/08/2019] [Indexed: 12/22/2022] Open
Abstract
Purpose To compare high and low inferior mesenteric artery (IMA) ligation in a large number of patients, and investigate the short-term and long-term outcomes. Methods This retrospective study compared outcomes between high IMA ligation and low IMA ligation with dissection of lymph nodes (LNs) around the IMA origin. A total of 1,213 patients underwent elective low anterior resection with double-stapling anastomosis for stage I-III rectal cancer located ≥6 cm from the anal verge (835 patients underwent IMA ligation at the IMA origin; 378 patients underwent IMA ligation directly distal to the root of the left colic artery along with dissection of LNs around the IMA origin). Results There was no difference in anastomotic leakage rate between groups. The 2 groups did not significantly differ in intraoperative blood loss, perioperative complications, total number of harvested LNs, and metastatic IMA LNs. However, more metastatic LNs were harvested in the high-tie than in the low-tie group (1.3 ± 2.9 vs. 0.8 ± 1.9, P = 0.002), and the incidence of positive pathologic nodal status was higher in the high-tie group (37.9% vs. 28.6%, P = 0.001). The 5-year local recurrence-free and metastasis-free survival rates were similar between groups, as were the 5-year overall and cancer-specific survival rates. Conclusion Low IMA ligation with dissection of LNs around the IMA origin showed no differences in anastomotic leakage rate compared with high IMA ligation, without affecting oncologic outcomes. High IMA ligation did not seem to increase the number of total harvested LNs, whereas the ratio of metastatic apical LNs were similar between groups.
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Affiliation(s)
| | - Seung Yoon Yang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jamal F AlSabilah
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Hur
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Darwich I, Rustanto D, Friedberg R, Willeke F. Spectrophotometric assessment of bowel perfusion during low anterior resection: a prospective study. Updates Surg 2019; 71:677-686. [PMID: 31606856 PMCID: PMC6892764 DOI: 10.1007/s13304-019-00682-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/25/2019] [Indexed: 12/16/2022]
Abstract
Good perfusion of the bowel and a tension-free anastomosis are the two main prerequisites for an uneventful anastomotic healing in rectal surgery. This prospective cohort study investigates the noninvasive intraoperative spectrophotometric assessment of the bowel perfusion using a device called “Oxygen to See” (O2C®). Forty patients, planned for low anterior resection, were prospectively enrolled in this study to undergo an intraoperative spectrophotometric assessment of the bowel. Three different O2C® parameters were collected from the colonic and the rectal stumps before fashioning the anastomosis: SO2 (capillary venous oxygen saturation), rHb (relative hemoglobin amount), and flow (blood flow velocity). Bowel perfusion was also assessed with the cold-steel-test (CST), which involves severing the colic marginal artery of Drummond at the tip of the colon stump. The data collected from the spectrophotometric measurement and the CST were analyzed for correlation of both methods with respect to each other and to the outcome of the anastomosis. Nine patients were excluded due to different reasons, thus leaving 31 patients for statistical analysis. Three flow parameters collected at the colonic stump significantly predicted an anastomotic leak (p: 0.0057; p: 0.0250; p: 0.0404). One rHb parameter collected at the rectal stump correlated weakly with the anastomotic outcome (p: 0.0768). The CST did not correlate significantly with anastomotic leak (p: 0.1195), but showed significant correlations to some rHb values. Intraoperative noninvasive spectrophotometric measurement is feasible and could be a useful method in assessing bowel perfusion before fashioning a colorectal anastomosis.
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Affiliation(s)
- Ibrahim Darwich
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany.
| | - Darmadi Rustanto
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
| | - Ronald Friedberg
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
| | - Frank Willeke
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
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Tiselius C, Kindler C, Rosenblad A, Smedh K. Localization of mesenteric lymph node metastases in relation to the level of arterial ligation in rectal cancer surgery. Eur J Surg Oncol 2019; 45:989-994. [DOI: 10.1016/j.ejso.2019.01.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/25/2019] [Indexed: 01/13/2023] Open
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Level of inferior mesenteric artery ligation in low rectal cancer surgery: high tie preferred over low tie. Tech Coloproctol 2019; 23:267-271. [DOI: 10.1007/s10151-019-01931-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 01/21/2019] [Indexed: 12/17/2022]
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En-Bloc Excision of the High-ligated Inferior Mesenteric Vein Pedicle With the Specimen in Patients Undergoing Minimally Invasive and Open Sphincter Saving Rectal Resections for Cancer. Surg Laparosc Endosc Percutan Tech 2019; 29:13-17. [DOI: 10.1097/sle.0000000000000615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Yang X, Ma P, Zhang X, Wei M, He Y, Gu C, Deng X, Wang Z. Preservation versus non-preservation of left colic artery in colorectal cancer surgery: An updated systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e13720. [PMID: 30702552 PMCID: PMC6380791 DOI: 10.1097/md.0000000000013720] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND It remains unclear whether or not preservation of the left colic artery (LCA) for colorectal cancer surgery. The objective of this updated systematic review and meta-analysis is to evaluate the current scientific evidence of LCA non-preservation versus LCA preservation in colorectal cancer surgery. METHODS A systematic search was conducted in the Medline, Embase, PubMed, Cochrane Library, ClinicalTrials, Web of Science, China National Knowledge Infrastructure and Chinese BioMedical Literature Database, and reference without limits. Quality of studies was evaluated by using the Newcastle-Ottawa scale and the Cochrane Collaboration's tool for assessing the risk of bias. Effective sizes were pooled under a random- or fixed-effects model. The funnel plot was used to assess the publication bias. The outcomes of interest were oncologic consideration including the number of apical lymph nodes, overall recurrence, 5-years overall survival, and 5-years disease-free survival (DFS); safety consideration including overall 30-day postoperative morbidity and overall 30-day postoperative mortality; anatomic consideration including anastomotic circulation, anastomotic leakage, urogenital, and defaecatory dysfunction. RESULTS Twenty-four studies including 4 randomized controlled trials (RCTs) and 20 cohort studies with a total of 8456 patients (4058 patients underwent LCA non-preservation surgery vs 4398 patients underwent LCA preservation surgery) were enrolled in this meta-analysis. The preservation of LCA was associated with significantly less anastomotic leakage (odds ratio 1.23, 95% confidence interval 1.02-1.48, P = .03). In term of sexual dysfunction, urinary retention, the number of apical lymph nodes, and long-term oncologic outcomes, there were no significant differences between the LCA non-preservation and LCA preservation group. It was hard to draw definitive conclusions on other outcomes including operation time, blood loss, the first postoperative exhaust time, and perioperative morbidity and mortality for insufficient data and highly significant heterogeneity among studies. CONCLUSIONS The pooled data provided evidence to support the LCA preservation preferred over LCA non-preservation in anastomotic leakage. Future more large-volume, well-designed RCTs with extensive follow-up are needed to draw a definitive conclusion on this dilemma.
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Affiliation(s)
- Xuyang Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Pingfan Ma
- State Key Laboratory of Biotherapy and Collaborative Innovation Center of Biotherapy, Sichuan University,Chengdu, China
| | - Xubing Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Mingtian Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Yazhou He
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Chaoyang Gu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Xiangbing Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
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A randomized clinical trial comparing the initial vascular approach to the inferior mesenteric vein versus the inferior mesenteric artery in laparoscopic surgery of rectal cancer and sigmoid colon cancer. Surg Endosc 2018; 33:1310-1318. [PMID: 30377755 DOI: 10.1007/s00464-018-6551-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The inferior mesenteric artery approach with a selective lateral splenic flexure mobilization is the most widely used initial step in laparoscopic rectal and left colon surgery. Surgery started through the inferior mesenteric vein (IMV) with systematic medial mobilization (MM) has some theoretical advantages that have never been analyzed in a clinical trial. The aim of this study was to compare the two techniques with regards to surgical technique variables (conversion, surgical time, bleeding, morbidity, and mortality) and pathological outcomes. METHODS A single-blinded, randomized, controlled trial of patients operated electively by laparoscopic with curative intention for rectal or sigmoid cancer was performed at a single, specialized colorectal surgery department from April 2016 to October 2017. RESULTS 49 patients were included in each group. There were no statistical differences in patient demographics between the two approaches. Pathological outcomes did not differ between the two groups. Intra-operative characteristics showed a higher conversion rate in patients in which the inferior mesenteric artery was dissected first (p = 0.031). The artery approach also increased intra-operative bleeding (p = 0.049), but there were no differences regarding operative time. On multivariate analysis, the artery approach was associated with a higher risk of conversion (OR 8.68; p = 0.050). Post-operatory complications did not differ between artery and vein dissection. CONCLUSIONS In our study, the initial approach by the IMV with a systematic MM of the splenic flexure has allowed us to reduce the conversion rate without increasing complications or the surgical time. No differences were observed in the pathological results. Both approaches seem to be safe and effective and well-trained laparoscopic surgeons should have the two techniques available to them for use as needed.
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Iversen H, Ahlberg M, Lindqvist M, Buchli C. Changes in Clinical Practice Reduce the Rate of Anastomotic Leakage After Colorectal Resections. World J Surg 2018; 42:2234-2241. [PMID: 29282510 PMCID: PMC5990567 DOI: 10.1007/s00268-017-4423-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Anastomotic leakage is a serious clinical problem after colorectal resections and is associated with a significantly increased length of stay, morbidity and mortality. The aim of the present study was to evaluate the effect of changes in clinical practice on anastomotic leakage rate after colorectal resections. Methods Retrospective cohort study based on prospectively collected data. All 894 patients with primary anastomosis after colorectal resection at a tertiary referral center between 2006 and 2013 were analyzed. Changes in clinical practice aiming at reducing the rate of anastomotic leakages were introduced in January 2010 and were characterized by exclusion of perioperative nonsteroidal anti-inflammatory drugs, introduction of intra-operative goal-directed fluid therapy and avoidance of primary anastomoses in emergency resections. The study population was divided into two groups, one treated before and one after the introduction of changes in clinical practice. Groups were compared regarding patient characteristics and incidence of anastomotic leakage. Results The cumulative incidence of anastomotic leakage after colorectal resections decreased from 10.0% (41 of 409) to 4.5% (22 of 485) after changing clinical practice, relative risk 0.45 (95% CI 0.27–0.75, p = 0.002). The adjusted odds ratio was 0.45 (0.26–0.78, p = 0.004). A separate analysis showed a decrease after colon resections from 9.1% (23 of 252) to 4.5% (14 of 310), relative risk 0.49 (0.26–0.94, p = 0.039), and from 11.5% (18 of 157) to 4.6% (8 of 175) after rectal resections, relative risk 0.40 (0.18–0.89, p = 0.024). Conclusion Implementing a structured change of clinical practice can significantly reduce the anastomotic leakage rate after colorectal resections. Trial registration Clinical trial registration number: ACTRN12617001497392.
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Affiliation(s)
- Henrik Iversen
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Solna, P9:03, 17176, Stockholm, Sweden.
| | - Madelene Ahlberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Solna, P9:03, 17176, Stockholm, Sweden
| | - Marja Lindqvist
- Department of Physiology and Pharmacology, Karolinska Institutet and Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Buchli
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Solna, P9:03, 17176, Stockholm, Sweden
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Zarokosta M, Piperos T, Chrysikos D, Nikou E, Flessas I, Skarpas G, Papapanagiotou I, Tsiaoussis I, Noussios G, Mariolis-Sapsakos T. Anatomic variation of the relation between the inferior mesenteric artery and the bifurcation point of abdominal aorta during lower anterior resection: A rare case report. Int J Surg Case Rep 2018; 51:385-387. [PMID: 30268066 PMCID: PMC6170327 DOI: 10.1016/j.ijscr.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/28/2018] [Accepted: 09/05/2018] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Identification and ligation of the inferior mesenteric artery (IMA) is a crucial surgical step when performing lower anterior resection (LAR) for rectal cancer. Anatomic variations of the relation between the IMA and the bifurcation point of abdominal aorta (AA) encumber surgical maneuvers and are of great clinical importance. PRESENTATION OF CASE An unusual anatomic variation of the relation between IMA and the bifurcation point of AA was unexpectedly detected during LAR to a 69-year-old Caucasian female patient. The operation was uneventful. A meticulous review of the recent literature was conducted as well. DISCUSSION Variations of the mesenteric vascular supply are mainly identified incidentally, during the operation. In particular, variations of IMA are extremely uncommon in the literature. However, such kind of congenital variations, are not as rare as considered and their presence encumbers surgical maneuvers and increases the potentiality of intraoperative injury and hemorrhage. CONCLUSION Surgeons' deep knowledge and unceasing awareness concerning probable anatomic variations of the relation between the IMA and AA, combined with detailed exposure of the operative field and of the relationship between these adjacent arteries constitute the cornerstone of a safe operation.
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Affiliation(s)
- Maria Zarokosta
- University Department of Surgery, General and Oncologic Hospital of Kifissia "Agii Anargiri'', Athens, Greece & Anatomy and Histology Laboratory, School of Nursing, University of Athens, Greece.
| | - Theodoros Piperos
- University Department of Surgery, General and Oncologic Hospital of Kifissia "Agii Anargiri'', Athens, Greece & Anatomy and Histology Laboratory, School of Nursing, University of Athens, Greece.
| | - Dimosthenis Chrysikos
- University Department of Surgery, General and Oncologic Hospital of Kifissia "Agii Anargiri'', Athens, Greece & Anatomy and Histology Laboratory, School of Nursing, University of Athens, Greece
| | - Eythumios Nikou
- University Department of Surgery, General and Oncologic Hospital of Kifissia "Agii Anargiri'', Athens, Greece & Anatomy and Histology Laboratory, School of Nursing, University of Athens, Greece
| | - Ioannis Flessas
- University Department of Surgery, General and Oncologic Hospital of Kifissia "Agii Anargiri'', Athens, Greece & Anatomy and Histology Laboratory, School of Nursing, University of Athens, Greece
| | - George Skarpas
- University Department of Surgery, General and Oncologic Hospital of Kifissia "Agii Anargiri'', Athens, Greece & Anatomy and Histology Laboratory, School of Nursing, University of Athens, Greece
| | - Ioannis Papapanagiotou
- University Department of Surgery, General and Oncologic Hospital of Kifissia "Agii Anargiri'', Athens, Greece & Anatomy and Histology Laboratory, School of Nursing, University of Athens, Greece
| | - Ioannis Tsiaoussis
- Anatomy Laboratory, Faculty of Medicine, University of Crete, Crete, Greece
| | - George Noussios
- Department of Physical Education and Sports Sciences, "Aristotles", University of Thessaloniki, Serres, Greece
| | - Theodoros Mariolis-Sapsakos
- University Department of Surgery, General and Oncologic Hospital of Kifissia "Agii Anargiri'', Athens, Greece & Anatomy and Histology Laboratory, School of Nursing, University of Athens, Greece
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Wang KX, Cheng ZQ, Liu Z, Wang XY, Bi DS. Vascular anatomy of inferior mesenteric artery in laparoscopic radical resection with the preservation of left colic artery for rectal cancer. World J Gastroenterol 2018; 24:3671-3676. [PMID: 30166862 PMCID: PMC6113723 DOI: 10.3748/wjg.v24.i32.3671] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/17/2018] [Accepted: 07/21/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Ke-Xin Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Zhi-Qiang Cheng
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Zhi Liu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Xiao-Yang Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Dong-Song Bi
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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Fujii S, Ishibe A, Ota M, Watanabe K, Watanabe J, Kunisaki C, Endo I. Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer. BJS Open 2018; 2:195-202. [PMID: 30079388 PMCID: PMC6069351 DOI: 10.1002/bjs5.71] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 03/16/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The optimal level for inferior mesenteric artery ligation during anterior resection for rectal cancer is controversial. The aim of this randomized trial was to clarify whether the inferior mesenteric artery should be tied at the origin (high tie) or distal to the left colic artery (low tie). METHODS Patients were allocated randomly to undergo either high- or low-tie ligation and were stratified by surgical approach (open or laparoscopic). The primary outcome was the incidence of anastomotic leakage. Secondary outcomes were duration of surgery, blood loss and 5-year overall survival. RESULTS Some 331 patients entered the trial between June 2006 and September 2012. The trial was stopped prematurely as recruitment was slow. Seven patients were excluded after randomization but before operation because of procedural changes. High tie and low tie were performed in 164 and 160 patients respectively. The incidence of anastomotic leakage was not significantly different (17·7 versus 16·3 per cent respectively; P = 0·731). The incidence of severe complications requiring intervention was 2·4 versus 5·0 per cent for high and low tie respectively (P = 0·222). In multivariable analysis, risk factors for anastomotic leakage included male sex (odds ratio 4·36, 95 per cent c.i. 1·56 to 12·18) and distance of the tumour from the anal verge (odds ratio 0·99, 0·98 to 1·00). At 5 years there were no significant differences in overall (87·2 versus 89·4 per cent respectively; P = 0·386) and disease-free (76·3 versus 77·6 per cent; P = 0·765) survival. CONCLUSION The level of ligation of the inferior mesenteric artery does not significantly influence the rate of anastomotic leakage. Registration number: NCT01861678 ( https://clinicaltrials.gov).
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Affiliation(s)
- S. Fujii
- Department of Gastroenterological Surgery, Ichikawa HospitalInternational University of Health and WelfareChibaJapan
- Department of Surgery, Gastroenterological CentreYokohama City UniversityYokohamaJapan
| | - A. Ishibe
- Department of Surgery, Gastroenterological CentreYokohama City UniversityYokohamaJapan
| | - M. Ota
- Department of Surgery, Gastroenterological CentreYokohama City UniversityYokohamaJapan
| | - K. Watanabe
- Department of Gastroenterological Surgery, Graduate School of MedicineYokohama City UniversityYokohamaJapan
| | - J. Watanabe
- Department of Gastroenterological Surgery, Graduate School of MedicineYokohama City UniversityYokohamaJapan
| | - C. Kunisaki
- Department of Surgery, Gastroenterological CentreYokohama City UniversityYokohamaJapan
| | - I. Endo
- Department of Gastroenterological Surgery, Graduate School of MedicineYokohama City UniversityYokohamaJapan
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Fujii S, Ishibe A, Ota M, Suwa H, Watanabe J, Kunisaki C, Endo I. Short-term and long-term results of a randomized study comparing high tie and low tie inferior mesenteric artery ligation in laparoscopic rectal anterior resection: subanalysis of the HTLT (High tie vs. low tie) study. Surg Endosc 2018; 33:1100-1110. [DOI: 10.1007/s00464-018-6363-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/10/2018] [Indexed: 12/11/2022]
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Yamamoto M, Egi H, Kochi M, Mukai S, Ohdan H. Left colic artery-preserving D3 lymphadenectomy using near-infrared spectroscopy was effective for double advanced cancers of the transverse colon and rectum: A case report. Int J Surg Case Rep 2018; 49:131-135. [PMID: 30005365 PMCID: PMC6037831 DOI: 10.1016/j.ijscr.2018.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/04/2018] [Accepted: 06/20/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Exact assessment of intestinal viability is necessary, since the risk of anastomotic complications increases due to the reduction in anastomotic blood supply. Near-infrared spectroscopy is useful in assessing blood flow because it allows real-time monitoring and quantifying of tissue oxygen saturation. Herein, we report a case in which two intestinal resections were performed safely by using near-infrared spectroscopy to evaluate the blood flow at the anastomotic sites. PRESENTATION OF CASE A 67-year-old man was diagnosed with multiple cancers of the transverse colon and rectum. Laparoscopic transverse colon resection and low anterior resection were performed along with left colic artery-preserving lymphadenectomy, including tissues around the origin of the inferior mesenteric artery. After mesenteric dissection, the tissue oxygen saturation of the proximal side and distal side stumps were 93% and 87%, respectively. The tissue oxygen saturation of the anastomotic proximal side after mesenteric dissection was 76%, thus confirming sufficient blood flow. DISCUSSION Performance of transverse colon resection and low anterior resection for multiple cancers of the transverse colon and rectum resulted in blockage of the blood flow to the descending colon; therefore, it was necessary to preserve the blood flow to the descending colon by preserving the left colic artery. Near-infrared spectroscopy was used to evaluate blood flow to the anastomotic sites, in order to perform the surgery safely. CONCLUSION Near-infrared spectroscopy is a safe, simple and low-cost method for assessing blood flow intraoperatively in conjunction with left colic artery-preserving surgery.
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Affiliation(s)
- Masateru Yamamoto
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Hiroyuki Egi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Masatoshi Kochi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Shoichiro Mukai
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
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Expression of guanylyl cyclase C in tissue samples and the circulation of rectal cancer patients. Oncotarget 2018; 8:38841-38849. [PMID: 28418917 PMCID: PMC5503576 DOI: 10.18632/oncotarget.16406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 02/17/2017] [Indexed: 01/09/2023] Open
Abstract
Guanylyl cyclase C (GCC) is a transmembrane surface receptor restricted to intestinal epithelial cells, from the duodenum to the rectum. We compared GCC expression in tumors and normal rectal tissues, and investigated the relation between GCC expression and metastasis and long-term survival of rectal cancer patients. Based on the UICC classification, 42 rectal cancer patients in this study were classified as stage I, 48 patients as stage II, and 90 patients as stage III. Overexpression of GCC was observed in 80 rectal tumors as compared to matched normal tissues, where no strong staining of GCC was observed. An association between GCC mRNA in the circulation and tumor emboli in vessels, CK20 mRNA, distant organ metastasis, and survival status was observed in 100 rectal cancer patients. Univariate Cox regression analysis indicated that tumor emboli in vessels, lymph node metastasis, mesenteric root lymph node metastasis and GCC mRNA correlated with 5-year disease-free survival (DFS); while lymph node metastasis, GCC mRNA, and CK20 mRNA strongly correlated with 5-year overall survival (OS). In a multivariate Cox regression model, GCC mRNA level and mesenteric root lymph node metastasis associated with DFS, while GCC mRNA levels associated with OS. Quantification of GCC expression in circulation is a valuable biomarker for assessing tumor burden and predicting outcome in rectal cancer patients.
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Yang Y, Wang G, He J, Zhang J, Xi J, Wang F. High tie versus low tie of the inferior mesenteric artery in colorectal cancer: A meta-analysis. Int J Surg 2018; 52:20-24. [PMID: 29432970 DOI: 10.1016/j.ijsu.2017.12.030] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/14/2017] [Accepted: 12/24/2017] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Yafan Yang
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Guiying Wang
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, China.
| | - Jingli He
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Jianfeng Zhang
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Jinchuan Xi
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Feifei Wang
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, China
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Lee KH, Kim JS, Kim JY. Feasibility and oncologic safety of low ligation of inferior mesenteric artery with D3 dissection in cT3N0M0 sigmoid colon cancer. Ann Surg Treat Res 2018; 94:209-215. [PMID: 29629356 PMCID: PMC5880979 DOI: 10.4174/astr.2018.94.4.209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/10/2017] [Accepted: 08/03/2017] [Indexed: 12/17/2022] Open
Abstract
Purpose There is no standard consensus for the ligation level of the inferior mesenteric artery during radical resection of sigmoid colon cancer. Especially, there is little research about low ligation combined with D3 dissection. The study was performed to compare feasibility and oncologic safety between low ligation with D3 dissection to high ligation in intermediately advanced sigmoid colon cancer. Methods From January 2008 to December 2013, 134 patients who underwent radical surgery for cT3N0M0 sigmoid colon cancer were evaluated retrospectively. Clinicopathologic factors and oncologic outcomes of high ligation (HL, n = 51) and low ligation (LL, n = 83) groups were compared. Results The mean operative time was significantly shorter in LL, and there was no difference in complications, distal margin or number of retrieved lymph node. The tumor size was significantly larger in HL, but there was no difference in number of metastatic lymph node, pT or pN stage. There was no difference in overall survival, disease-free survival, or local and systemic recurrence. Conclusion In cT3N0M0 sigmoid colon cancers, we suggest that low ligation with D3 dissection can be performed with feasibility and oncological safety.
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Affiliation(s)
- Kyung Ha Lee
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Ji Yeon Kim
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
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Fan YC, Ning FL, Zhang CD, Dai DQ. Preservation versus non-preservation of left colic artery in sigmoid and rectal cancer surgery: A meta-analysis. Int J Surg 2018; 52:269-277. [PMID: 29501795 DOI: 10.1016/j.ijsu.2018.02.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/29/2018] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to conduct a meta-analysis comparing the oncological, intraoperative and safety outcomes in sigmoid and rectal cancer surgery with and without preservation of the left colic artery (LCA). METHOD We searched Medline, Embase, China National Knowledge Infrastructure (CNKI), and PubMed databases for relevant articles published between 1962 and 2017. Randomized and non-randomized clinical trials were identified and included in the study. End-points evaluated included 5-year mortality, number of patients with retrieved positive metastatic lymph nodes (LN) at the root of inferior mesenteric artery (IMA), number of retrieved LNs, morbidity, mortality, recurrence, bowel obstruction, intraoperative blood loss, anastomotic leakage, operation time, surgical site infection and postoperative bleed. Meta-analysis was conducted using RevMan 5.3 software. The odds ratio (OR) with 95% confidence intervals (CI) was used to analyze dichotomous data. RESULTS Seventeen studies including 6247 patients were identified for the meta-analysis. Meta-analysis revealed that preserving the LCA was associated with reduced anastomotic leakage rate (OR, 0.78; 95% CI, 0.62-0.98; P = 0.03). There were no significant differences between the two groups with respect to the 5-year mortality, number of retrieved LNs, number of patients with retrieved positive metastatic LNs at the root of IMA, morbidity, mortality, recurrence, bowel obstruction, intraoperative blood loss, operation time, surgical site infection and postoperative bleed. CONCLUSION In comparison with ligating the left colic artery, preserving the left colic artery seems to achieve comparable success with acceptable safety outcomes and we suggest to preserve the LCA in the sigmoid and rectal cancer surgeries. However, more multicenter randomized controlled trials are required to further evaluate the efficacy and safety of preserving the left colic artery in surgeries.
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Affiliation(s)
- Yu-Chen Fan
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Fei-Long Ning
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China; Department of General Surgery, Xuzhou Hospital of Traditional Chinese Medicine, Xuzhou, Jiangsu, China
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Dong-Qiu Dai
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China; Cancer Center, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.
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Tulina IA, Zhurkovsky VI, Bredikhin MI, Tsugulya PB, Tsarkov PV. [Selective approach for splenic flexure mobilization in total mesorectal excision followed by low colorectal anastomoses]. Khirurgiia (Mosk) 2018:41-46. [PMID: 29992925 DOI: 10.17116/hirurgia2018741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
AIM To evaluate the results of selective approach for splenic flexure mobilization (SFM) after total mesorectal excision with low colorectal anastomoses. MATERIAL AND METHODS Clinical data were obtained from the multicenter RCT database comparing ileostomy and colostomy in patients with rectal cancer who underwent total mesorectal excision from 2012 to 2017. Our clinic policy is performing paraaortic lymph node dissection with 'low' inferior mesenteric artery ligation, left colic artery preservation and use of sigmoid colon for colorectal anastomosis. SFM was used only in cases of inability to apply above-mentioned procedure (selective approach for SFM). RESULTS SFM was performed in 15 (13%) out of 115 patients. The most frequent reasons for SFM were sigmoid colon diverticulosis, impaired blood supply or inadequate length of sigmoid colon. There were no differences in intraoperative and postoperative complications between TME without SFM and TME with SFM. CONCLUSION Selective SFM in TME followed by advanced paraaortic lymph node dissection and left colic artery preservation is safe and may be considered as a viable option to routine SFM in rectal cancer surgery.
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Affiliation(s)
- I A Tulina
- Chair of Surgery of the Faculty of Medicine and Prevention of Sechenov First Moscow State Medical University, Moscow, Russia
| | - V I Zhurkovsky
- Chair of Surgery of the Faculty of Medicine and Prevention of Sechenov First Moscow State Medical University, Moscow, Russia
| | - M I Bredikhin
- Chair of Surgery of the Faculty of Medicine and Prevention of Sechenov First Moscow State Medical University, Moscow, Russia
| | - P B Tsugulya
- Chair of Surgery of the Faculty of Medicine and Prevention of Sechenov First Moscow State Medical University, Moscow, Russia
| | - P V Tsarkov
- Chair of Surgery of the Faculty of Medicine and Prevention of Sechenov First Moscow State Medical University, Moscow, Russia
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Kverneng Hultberg D, Afshar AA, Rutegård J, Lange M, Haapamäki MM, Matthiessen P, Rutegård M. Level of vascular tie and its effect on functional outcome 2 years after anterior resection for rectal cancer. Colorectal Dis 2017; 19:987-995. [PMID: 28544473 DOI: 10.1111/codi.13745] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/12/2017] [Indexed: 02/08/2023]
Abstract
AIM Previous research indicates that high tie of the inferior mesenteric artery during anterior resection for rectal cancer might be associated with an increased risk of postoperative functional disturbances. The goal of this population-based retrospective cohort study was to further investigate that association. METHOD Patients who underwent anterior resection for rectal cancer from April 2011 to September 2012 were identified through the Swedish Colorectal Cancer Registry. Bowel and urogenital function were assessed by a postal questionnaire 2 years after surgery. Information on the level of mesenteric tie and clinical variables was retrieved from the registry. The outcome was defined as any defaecatory, urinary or sexual dysfunction as reported by the patient. The association between high tie and the outcome was evaluated with multivariable logistic and linear regression with adjustment for confounders, such as sex, body mass index, comorbidity and preoperative radiation. RESULTS With a response rate of 86%, 805 patients were included in the study. Of these, 46% were operated with high tie. After adjustment for confounders, high tie did not affect the risk of faecal incontinence (OR 0.85; 95% CI 0.59-1.22), urinary incontinence (OR 0.94; 95% CI 0.63-1.41) or various aspects of sexual dysfunction (erectile dysfunction, anejaculation, dyspareunia and coital vaginal dryness). However, an association between high tie and defaecation at night was detected (OR 1.44; 95% CI 1.02-2.03). CONCLUSION This study does not support that the level of vascular tie influences the risk of major defaecatory, urinary or sexual disturbances 2 years after anterior resection for rectal cancer.
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Affiliation(s)
- D Kverneng Hultberg
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - A A Afshar
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M Lange
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - M M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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刘 云, 张 磊, 黄 箕, 易 金, 方 传, 夏 来, 刘 红, 易 建. [Enhanced recovery after preserving the left colonic artery during laparoscopic anterior resection for rectal cancer]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:1261-1264. [PMID: 28951373 PMCID: PMC6765479 DOI: 10.3969/j.issn.1673-4254.2017.09.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate the postoperative outcomes of preserving the left colonic artery during laparoscopic anterior resection for rectal cancer. METHODS The clinicopathologic data of 91 rectal cancer patients (pathologic Stage II) undergoing laparoscopic anterior resection was retrospectively analyzed. During the surgeries, the left colonic artery was preserved in 40 patients (preserved group) and ligated in 51 patients (unpreserved group). The operating time, intraoperative blood loss, time to first flatus and defecation, duration of postoperative abdominal distension and pain, number of retrieved lymph nodes, ileum fistulation and anatomical leakage rate were compared between the two groups. RESULTS The surgeries were completed in all the 91 patients laparoscopically without conversion. There was no intraoperative complications including rectal perforation, injury to vessel or ureter in either group. The operating time, blood loss and number of retrieved lymph nodes were similar between the groups (P>0.05). Three patients in preserved group and 5 in ligation group received preventive ileum fistulation due to low rectal cancer. Anatomical leakage occurred in three patients of unpreserved group. The average duration of postoperative abdominal distension and pain was 2.14∓0.35 days in preserved group and 3.15∓0.42 days in ligation group. The time to first flatus and defecation was 37.15∓12.62 h and 3.16∓0.52 days in preserved group and 62.25∓11.75 h and 4.25∓0.75 days in ligation group. Postoperative hospital stay was 4.54∓0.42 days in preserved group and 6.23∓0.51 days in ligation group. Total hospitalization cost in the two groups was 34 525.32∓1206.36 Yuan and 41 215∓1051.32 Yuan, respectively. Significant differences were found the in duration of postoperative abdominal distension and pain, postoperative hospital stay, and total cost between the two groups (P<0.05). CONCLUSION During laparoscopic anterior resection for rectal cancer, preserving the left colonic artery effectively ensures the blood supply to the anastomosis and the remaining descending colon to promote the recovery of the patients after surgery.
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Affiliation(s)
- 云庚 刘
- 江西省赣州市人民医院普外一科,江西 赣州 341000Department of General Surgery, Ganzou People's Hospital, Jiangxi 341000, China
| | - 磊 张
- 江西省赣州市人民医院普外一科,江西 赣州 341000Department of General Surgery, Ganzou People's Hospital, Jiangxi 341000, China
| | - 箕然 黄
- 江西省上犹县人民医院普外科,江西 赣州 341200Department of General Surgery, Shangyu People's Hospital, Jiangxi 341200, China
| | - 金容 易
- 江西省赣州市人民医院普外一科,江西 赣州 341000Department of General Surgery, Ganzou People's Hospital, Jiangxi 341000, China
| | - 传发 方
- 江西省赣州市人民医院普外一科,江西 赣州 341000Department of General Surgery, Ganzou People's Hospital, Jiangxi 341000, China
| | - 来阳 夏
- 江西省赣州市人民医院普外一科,江西 赣州 341000Department of General Surgery, Ganzou People's Hospital, Jiangxi 341000, China
| | - 红权 刘
- 江西省赣州市人民医院普外一科,江西 赣州 341000Department of General Surgery, Ganzou People's Hospital, Jiangxi 341000, China
| | - 建中 易
- 江西省赣州市人民医院普外一科,江西 赣州 341000Department of General Surgery, Ganzou People's Hospital, Jiangxi 341000, China
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Matsuda K, Yokoyama S, Hotta T, Takifuji K, Watanabe T, Tamura K, Mitani Y, Iwamoto H, Mizumoto Y, Yamaue H. Oncological Outcomes following Rectal Cancer Surgery with High or Low Ligation of the Inferior Mesenteric Artery. Gastrointest Tumors 2017; 4:45-52. [PMID: 29071264 DOI: 10.1159/000477805] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/24/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The level of inferior mesenteric artery (IMA) ligation for anterior resection of rectal cancer has several considerations concerning oncological outcomes. The primary endpoint of this randomized controlled trial (RCT) was to assess bowel function between high and low ligation. This study was intended to clarify oncological outcome as the secondary endpoint. OBJECTIVE The aim of this study was to assess in a prospective RCT whether the ligation level of the IMA in rectal cancer influences oncological outcomes. METHODS Between February 2008 and December 2011, 100 patients who underwent anterior resection for rectal cancer were randomized to perform either high or low ligation of the IMA. Oncological outcomes was the secondary endpoint of this RCT, whereas assessing bowel function was the primary endpoint. This RCT was registered at clinicaltrials.gov (NCT00701012). RESULTS There were no differences between the groups in terms of clinical data except for tumor stage. There were more advanced-stage patients in the high ligation group (p = 0.046). There were no lymph node (LN) metastases in the root of the IMA in the high ligation group. The average number of harvested LNs for the high and low ligation groups was 16.7 and 14.9, respectively. There was no difference in disease-free survival (DFS), site of first recurrence, and overall survival (OS). When patients were in stage III, there was also no difference in DFS and OS. CONCLUSIONS The ligation level of the IMA in rectal cancer may not influence oncological outcomes. However, further large-scale RCTs are needed to conclude this issue.
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Affiliation(s)
- Kenji Matsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shozo Yokoyama
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Tsukasa Hotta
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Katsunari Takifuji
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Watanabe
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Koichi Tamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasuyuki Mitani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiromitsu Iwamoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuki Mizumoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
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Fukuoka A, Sasaki T, Tsukikawa S, Miyajima N, Ostubo T. Evaluating distribution of the left branch of the middle colic artery and the left colic artery by CT angiography and colonography to classify blood supply to the splenic flexure. Asian J Endosc Surg 2017; 10:148-153. [PMID: 28008722 DOI: 10.1111/ases.12349] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 09/30/2016] [Accepted: 10/16/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION CT angiography has gained widespread acceptance for preoperative evaluation of blood supply in patients with colorectal cancer. However, there have been few reports that pertain to the splenic flexure, for which surgery is technically difficult. We used preoperative CT angiography and CT colonography to evaluate blood supply to the splenic flexure. METHODS We defined the splenic flexure as the junction of the distal third of the transverse colon and the proximal third of the descending colon. We reviewed 191 cases and considered the descending colon as divided into the proximal third and the distal two-thirds; we then determined which part of the descending colon the left colic artery (LCA) entered. We also considered the transverse colon as divided into the proximal two-thirds and the distal third, and evaluated which part of the transverse colon the left branch of the middle colic artery entered. RESULT We classified blood supply to the splenic flexure into six types, described by the feeder vessels: type 1, the LCA (39.7%); type 2, the left branch of the middle colic artery (17.8%); type 3, the LCA and the left branch of the middle colic artery (9.9%); type 4, the accessory left colic artery (4.1%); type 5, the LCA and the accessory left colic artery (2.6%); and type 6, the marginal artery (25.6%). CONCLUSION We classified blood supply to the splenic flexure into more complex types than previous reports had. Because we dissect the lymph nodes according to the type of blood supply, knowing the type before splenic flexure surgery is crucial.
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Affiliation(s)
- Asako Fukuoka
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.,Department of Gastroenterological Surgery, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Takahiro Sasaki
- Department of Gastroenterological Surgery, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Satoshi Tsukikawa
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Nobuyoshi Miyajima
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takehito Ostubo
- Department of Gastroenterological Surgery, St. Marianna University Toyoko Hospital, Kawasaki, Japan
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Inferior Mesenteric Artery Lymph Node Metastasis Is an Independent Prognostic Factor for Stage III Sigmoid Colon and Rectal Cancer. Int Surg 2017. [DOI: 10.9738/intsurg-d-16-00108.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
It is unclear whether the number or distribution of lymph node metastases can provide a more accurate prognosis. The aim of this study was to evaluate the prognostic impact of inferior mesenteric artery (IMA) lymph node metastasis (LNM) in sigmoid colon and rectal cancer. We included 188 patients who underwent curative resection for stage III sigmoid colon and rectal cancer between January 2001 and December 2012. Patients were divided into 2 groups based on the presence of IMA-LNM (LNM-positive versus LNM-negative group). Clinicopathologic characteristics, 3-year recurrence-free survival and 5-year overall survival rates, and recurrence patterns were compared between the 2 groups. Of 188 patients, 9 patients (4.79%) were in the LNM-positive group. After curative resection, 3-year recurrence-free survival and 5-year overall survival rates were significantly lower in the LNM-positive group compared to the LNM-negative group (44.44% versus 69.98%, P = 0.016 for 3-year recurrence-free survival and 48.61% versus 81.73%, P = 0.018 for 5-year overall survival). Multivariate analysis revealed that the presence of IMA-LNM (P = 0.04), not the number of LNMs (P = 0.153), was an independent prognostic factor for recurrence-free survival. The para-aortic LNM rate was significantly higher in the LNM-positive group (P = 0.0078). IMA-LNM is an independent predictor of survival for stage III sigmoid colon and rectal cancer patients. Evaluation of IMA-LNM enables accurate estimation of patient prognosis and enhances appropriate postoperative therapy.
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Goh N, Fong SS, How KY, Wong KY, Loong TH, Tay GT. Apical lymph node dissection of the inferior mesenteric artery. Colorectal Dis 2016; 18:O206-9. [PMID: 26880360 DOI: 10.1111/codi.13299] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 12/22/2015] [Indexed: 12/10/2022]
Abstract
AIM It is controversial whether a high or low ligation of the inferior mesenteric artery (IMA) is superior. The former allows an extended lymph node clearance whereas the latter preserves the distal vascular supply via the left colic artery (LCA). Apical lymph node dissection of the IMA (ALMA) harvests nodal tissue along the IMA proximal to the LCA whilst performing a low ligation. This anatomically replicates the oncological benefit of high ligation and the vascular preservation of low ligation. Our study evaluates the nodal yield of ALMA and the short-term outcome of this technique. METHOD We retrospectively studied 19 patients with sigmoid or rectal cancer who underwent curative surgical resection with ALMA. All ALMAs were performed with a standard technique previously described (Kobayashi et al., Surg Endosc 2005, 20:563-9; Sekimoto et al. Surg Endosc 2010, 25:861-6) . The lymph node yield from the dissection (the ALMA specimen) was compared with the total lymph node yield. Data on the LCA anatomy, time required to perform ALMA, complications and postoperative recovery were evaluated. RESULTS ALMA was successful in 18 patients. Median postoperative hospitalization was 5 (2-26) days without ALMA-related morbidity or mortality. The median lymph node yield was 20 (9-41) and a median of 14.3 (0-80)% were harvested with ALMA. Two patients not having neoadjuvant chemoradiotherapy had fewer than 12 lymph nodes, excluding nodes harvested from ALMA. The average time required for ALMA was 18 min. CONCLUSION ALMA is a safe and feasible technique, allowing extended lymphadenectomy without sacrificing the LCA. In this small group of patients none were upstaged due to cancerous involvement of the proximal nodes.
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Affiliation(s)
- N Goh
- National University of Singapore, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - S S Fong
- General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - K Y How
- General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - K Y Wong
- General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - T H Loong
- General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - G T Tay
- General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Reddy SHS, Gupta V, Yadav TD, Singh G, Sahni D. Lengthening of left colon after rectal resection: What all is adequate? A prospective cohort study. Int J Surg 2016; 31:27-32. [PMID: 27233374 DOI: 10.1016/j.ijsu.2016.05.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 05/15/2016] [Accepted: 05/20/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Adequate mobilization of colon is essential to achieve tension free anastomosis after sphinchter saving surgeries. METHODS 26 patients undergoing of recto-sigmoid resection underwent low tie of inferior mesenteric artery (IMA), splenic flexure mobilization and descending branch of left colic artery (LCA) ligation in that order. One point at proximal 1/3rd of sigmoid colon (point of partial sigmoid resection) and another at descending-sigmoid colon junction (point of total sigmoid resection) were used for measurements and the distance was measured from pubic symphysis. Mobilization was considered adequate if colon could reach 2 cm beyond the upper border of pubic symphysis. RESULTS The length gained after each maneuver was 4.2 + 3.6 cm (low tie), 5.8 + 3.7 cm (splenic flexure mobilization) and 4.7 + 4.2 cm (descending branch of LCA ligation). Mobilization was adequate in 19% and 0% (low tie), 56% and 20% (low tie with splenic flexure mobilization) and 100% and 86% (all three manoeuvres) with partial and complete sigmoid resection respectively. In 13 patients undergoing low anterior resection, adequate mobilization for anastomosis was attainable in 15.3% and 0% (low tie), 50% and 0% (low tie with splenic flexure mobilization) and 100% and 83.3% (all three manoeuvres) with partial and complete sigmoid resection respectively. 15.3% had anastomotic leak, however none of the patients undergoing descending branch of LCA ligation had anastomotic insufficiency. CONCLUSIONS Low tie of IMA, with splenic flexure mobilization as required results in sufficient mobilization only in 50% patients with partial sigmoid resection. Ligation of descending branch of LCA is feasible, safe and enables a tension free anastomosis and is especially beneficial when sigmoid colon is resected completely.
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Affiliation(s)
- Shruthi H S Reddy
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Thakur D Yadav
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gurpreet Singh
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Daisy Sahni
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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