Four-directional approach to the meso-transverse attachment combined with preoperative radiological vascular simulation facilitates short-term surgical outcomes in laparoscopic transverse colon cancer surgery

Oncological outcomes of open, laparoscopic and robotic colectomy in patients with transverse colon cancer

BACKGROUND

Literature concerning surgical management of transverse colon cancer is scarce, since many key trials excluded transverse colon cancer. The aim of this study was to evaluate clinical and oncological outcomes comparing open, laparoscopic and robotic transverse colon cancer resection.

METHODS

Consecutive patients who underwent elective surgery for transverse colon cancer between December 2005 and July 2021 were included. Data were kept in a prospective database approved by the institutional ethics committee. Primary outcome was overall and disease-free survival. Secondary outcomes included complications, operative time, length of stay and lymph node harvest. Statistical analysis was corrected for age and tumour localisation.

RESULTS

Two hundred and forty-six (38 robotic, 71 open and 137 laparoscopic resections) were recruited in this study. There were five conversions during laparoscopic procedures. Operative time was significantly shorter in robotic vs laparoscopic procedures (195 vs 238 min, p = 0.005) and length of stay was shorter in robotic vs laparoscopic and open group (7 vs 9 vs 15 days, p < 0.001). There was no difference in overall complications. R0 resections were similar. Lymph node harvest was highest in the robotic group vs. laparoscopic or open (32 vs. 29 vs. 21, p < 0.001). Overall survival was 97%, 85% and 60% (p < 0.001) and disease-free survival was 91%, 78% and 56% (p < 0.001) for the robotic, laparoscopic and open groups, respectively.

CONCLUSIONS

Minimally invasive surgery for transverse colon cancer is safe and offers good clinical and oncological outcomes. Robotic resection is associated with significantly shorter operating times, higher lymph node harvest, lower conversion rate and does not increase morbidity. Differences in disease-free and overall survival should be further explored in randomised controlled trials.

The use of ultrasound in central vascular ligation during laparoscopic right-sided colon cancer surgery: technical notes

BACKGROUND

Complete mesocolic excision (CME) with central vascular ligation (CVL) requires the surgeon to sharply dissect the mesocolon and approach the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) for ligation of the supplying vessels relating to right-sided colon cancer at their origin. Even with preoperative images, it can still be challenging to identify these structures during laparoscopic surgery because of various intraoperative conditions. The aim of this study was to assess the efficacy of intraoperative ultrasound (IOUS) for identification of blood vessels during right-sided colon cancer surgery.

METHODS

We performed IOUS on 19 patients diagnosed with right-sided colon cancer at our institution, in January-October 2020. Preoperatively, a three-dimensional computed tomography (3D-CT) angiogram was obtained for the majority of patients to visualize the SMA, SMV, and their respective branches. The running position of the ileocolic artery (ICA) and right colic artery (RCA) related to the SMV and the presence of the middle colic artery were identified and compared using preoperative 3D-CT, IOUS, and intraoperative findings.

RESULTS

Nineteen patients [seven men and 12 women with a mean age of 73.9 ± 8.4 years (range 58-82 years)] were studied, including some with a body mass index of > 30 kg/m², locally advanced cancer, and severe adhesion. There were IOUSs that detected the SMA, SMV, and their tributaries in all patients. The positional relationships between the SMV and the ICA and RCA revealed by IOUS were consistent with the preoperative and intraoperative findings.

CONCLUSION

IOUS is a safe, feasible, and reproducible technique that can assist in detecting the branching of the SMA and SMV during CME with CVL in laparoscopic right-sided colon cancer surgery, regardless of individual conditions.

Surgical management of adenocarcinoma of the transverse colon: What should be the extent of resection?

Transverse colon, owing its origin to midgut and hindgut and harbouring a flexure at both ends, continues to pose a surgical challenge. When compared to the rest of the colon, transverse colon adenocarcinoma is relatively uncommon. These cancers usually present late and lie in close proximity to the stomach, omentum, and pancreas. Adequate lymphadenectomy entails dissection around and ligation of the middle colic vessels. Hence, resectional surgery for transverse colon carcinoma is considered difficult. This is more so because of the variation of arterial and venous anatomy. From this perspective, the surgeon is tempted to perform a more radical operation like extended right or left hemicolectomy to secure an adequate lymphadenectomy. Such a cancer has also been dealt with a more limited transverse colectomy with colo-colic anastomosis. For all these reasons, patients with transverse colon adenocarcinoma were excluded from randomised trials which compared laparoscopic resection with traditional open operation. Surgical literature is yet to establish a definite operation for transverse colon cancer and the exact procedure is often dictated by surgeon's preference. This is primarily because this is an uncommon cancer. The rapid adoption of laparoscopic operation favoured extended colectomy as transverse colectomy can be difficult by minimally invasive technique. However, in the recent past, cohort studies and meta-analyses have shown equivalent oncological outcome between transverse colectomy and extended colectomy. It is time to resurrect transverse colectomy and consider it equivalent to its radical counterpart for cancers around the mid-transverse colon.

The feasibility and safety of complete laparoscopic extended right hemicolectomy with preservation of the ileocecal junction in right-transverse colon cancer

BACKGROUND

To evaluate the feasibility and safety of a new surgical method, complete laparoscopic extended right hemicolectomy with preservation of the ileocecal junction in right-transverse colon cancer.

METHODS

We retrospectively analyzed and compared the data of consecutive patients with right-transverse colon cancer who underwent complete laparoscopic extended right hemicolectomy with preservation of the ileocecal junction (n = 23) and conventional complete laparoscopic extended right hemicolectomy (n = 34) in our hospital between October 2017 to May 2019, respectively.

RESULTS

The overall operation time of the ileocecal junction-preserved group was significantly shorter than that of the control group (p = 0.048). There was no difference in the number of harvested lymph nodes, metastatic lymph nodes, and rate of metastatic lymph nodes (p > 0.05). The ileocecal junction-preserved group showed shorter time of first flatus, lower frequency of postoperative diarrhea, and shorter duration of postoperative hospitalization. Furthermore, it also showed that the defecation frequency was lower in the ileocecal junction-preserved group than the control group on the 1st, 3rd, and 6th month (p < 0.05), and the number of patients who defecated at night or defecated four times or more a day was less in the ileocecal junction-preserved group than control group on the 1st month (p < 0.05).

CONCLUSION

The complete laparoscopic extended right hemicolectomy with preservation of the ileocecal junction promises as a safe and feasible surgical procedure for right-transverse colon cancer, associated with earlier recovery of bowel function, shorter operation time, and similar pathological outcomes when compared to the conventional laparoscopic procedure.