Open Right Hemicolectomy:Lateral to Medial or Medial to Lateral Approach?

"Caudal to cranial" versus "medial to lateral" approach in laparoscopic right hemicolectomy with complete mesocolic excision for the treatment of stage II and III colon cancer: perioperative outcomes and 5-year prognosis

The purpose of this study was to compare the "caudal to cranial" (CC) versus "medial to lateral" (ML) approach for laparoscopic right hemicolectomy. Pertinent data from all patients with stage II and III between January 2015 and August 2017 were entered into a retrospective database. A total of 175 patients underwent the ML (N = 109) or CC approach (N = 66). Patient characteristics were equivalent between groups. The CC group showed a shorter surgical time 170.00 (145.00, 210.00) vs. (206.50 (178.75, 226.25) min) than the ML group (p < 0.001). The time to oral intake was shorter in the CC group than in the ML group ((3.00 (1.00, 4.00) vs. 3.00 (2.00, 5.00) days; p = 0.007). For the total harvested lymph nodes, there was no statistical significance between the CC group 16.50 (14.00, 21.25) and the ML group 18.00 (15.00, 22.00) (p = 0.327), and no difference was found in the positive harvested lymph nodes (0 (0, 2.00) vs. 0 (0, 1.50); p = 0.753). Meanwhile, no differences were found in other perioperative or pathological outcomes, including blood loss and complications. For 5-year prognosis, overall survival rates were 75.76% in the CC group and 82.57% in the ML group (HR 0.654, 95% CI 0.336-1.273, p = 0.207); disease-free survival rates were 80.30% in the CC group and 85.32% in the ML group (HR 0.683, 95% CI 0.328-1.422, p = 0.305). Both approaches were safe and feasible and resulted in excellent survival. The CC approach was beneficial in terms of the surgical time and time to oral intake.

Effectiveness of immunization with multi-component bacterial immunomodulator in foals at 35th day of life

The aim of the study was to investigate the mechanisms leading to immunization through the use of a multicomponent bacterial immunomodulator and to find out the relationship between the TLR 4 receptor with selected parameters of innate immunity and to acquire immunity. The study was conducted on 18 Polish Pony Horses foals divided into two study groups: control (n = 9) and experimental (n = 9). Foals from the experimental group received intramuscular duplicate injection of 5 ml of multi-component bacterial immunomodular at 35 and 40 days of age. RNA isolated from venous blood was used to evaluate the expression of TLR4 genes using RT-PCR. Concentration of Il-6, IL-10, IgM and IgG2 was determined by the ELISA method in blood plasma. Immunostimulation had a significant impact on the level of genes expression for TLR4 expression and IL-6 concentration. No effect of stimulation on IgM and IgG2 concentrations was found. The expression of TLR4 genes as well as the levels of interleukins could be modulated by stimulation with a pharmacological agent multi-component bacterial immunomodulator. The experiment demonstrated a strong positive correlation between TLR4 gene expression and IL-6 concentration and between TLR4 gene expression and IgM concentration.

Regenerated Microvascular Networks in Ischemic Skeletal Muscle

Skeletal muscle is the largest organ in humans. The viability and performance of this metabolically demanding organ are exquisitely dependent on the integrity of its microcirculation. The architectural and functional attributes of the skeletal muscle microvasculature are acquired during embryonic and early postnatal development. However, peripheral vascular disease in the adult can damage the distal microvasculature, together with damaging the skeletal myofibers. Importantly, adult skeletal muscle has the capacity to regenerate. Understanding the extent to which the microvascular network also reforms, and acquires structural and functional competence, will thus be critical to regenerative medicine efforts for those with peripheral artery disease (PAD). Herein, we discuss recent advances in studying the regenerating microvasculature in the mouse hindlimb following severe ischemic injury. We highlight new insights arising from real-time imaging of the microcirculation. This includes identifying otherwise hidden flaws in both network microarchitecture and function, deficiencies that could underlie the progressive nature of PAD and its refractoriness to therapy. Recognizing and overcoming these vulnerabilities in regenerative angiogenesis will be important for advancing treatment options for PAD.

Securing the surgical field for mobilization of right-sided colon cancer using the duodenum-first multidirectional approach in laparoscopic surgery

Background

The aim of this study was to compare the short-term outcomes of the duodenum-first multidirectional approach (DMA) in laparoscopic right colectomy with those of the conventional medial approach to assess its safety and feasibility.

Methods

This retrospective study enrolled 120 patients who had laparoscopic surgery for right-sided colon cancer in our institution between April 2013 and December 2019. Fifty-four patients underwent colectomy using the multidirectional approach; among these, 20 underwent the DMA and 34 underwent the caudal-first multidirectional approach (CMA). Sixty-six patients underwent the conventional medial approach. Complications within 30 days of surgery were compared between the groups.

Results

There were 54 patients in the multidirectional group [29 females, median age 72 years (range 36–91 years)] and 66 in the medial group [42 females, median age 72 years (range 41–91 years)]. Total operative time was significantly shorter in multidirectional approach patients than conventional medial approach patients (208 min vs. 271 min; p = 0.01) and significantly shorter in patients who underwent the DMA compared to the CMA (201 min vs. 269 min; p < 0.001). Operative time for the mobilization procedure was also significantly shorter in patients who underwent the DMA (131 min vs. 181 min; p < 0.001). Blood loss and incidence of postoperative complications did not differ. In 77 patients with advanced T3/T4 tumors, the DMA, CMA, and conventional medial approach were performed in 13, 21, and 43 patients, respectively. Total operative time and operative time of the mobilization procedure were significantly shorter in patients undergoing DMA. Blood loss and incidence of postoperative complications did not differ. R0 resection was achieved in all patients with advanced tumors.

Conclusions

The DMA in laparoscopic right colectomy is safe and feasible and can achieve R0 resection with a shorter operative time than the conventional medial approach, even in patients with advanced tumors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-021-02444-5.

LGR4 silence aggravates ischemic injury by modulating mitochondrial function and oxidative stress via ERK signaling pathway in H9c2 cells

It is reported that LGR4 (leucine-rich repeat domain containing G protein-coupled receptor 4) plays a crucial role in the physiological function of many organs. However, few data are available on the function and mechanism of LGR4 in myocardial ischemia-reperfusion (I/R) injury. The aim of this study was to explore the function and mechanism of LGR4 in I/R injury. We incubated H9c2 cells in simulating ischemia buffer and then re-incubated them in normal culture medium to establish a model of I/R injury in vitro. The expression of LGR4 was evaluated by RT-PCR and western blot. Besides, the cell apoptosis was evaluated by flow cytometric analysis and the content of ROS, SOD, MDA, LDH, CK, ATP, cyt c were detected by special commercial kits. The expression of mitochondrial function-related proteins were detected by western blot. Then, the roles of ERK signaling pathway was determined with TBHQ (ERK activator) treatment. Our data have demonstrated that I/R boosted the expression of LGR4 in H9c2 cells. Knockdown of LGR4 increased the apoptosis rate of H9c2 cells and led to excessed oxidant stress and impaired mitochondrial function by increasing the levels of ROS, MDA, LDH, CK and cyt c and inhibiting SOD activity, ATP production. In addition, LGR4 silence inhibited the activation of ERK pathway. And TBHQ partially reversed the effects of LGR4 knockdown on H9c2 cells. To conclude, our study indicated that LGR4 regulated mitochondrial dysfunction and oxidative stress by ERK signaling pathways, which provides a potential cardiac protective target against I/R.

Clinical outcome of laparoscopic vs open right hemicolectomy for colon cancer: A propensity score matching analysis of the Japanese National Clinical Database

AIM

The advantages of laparoscopic right hemicolectomy over open surgery for colon cancer in general clinical practice are debated, as evidenced by the continued use of open surgery in a significant proportion of patients worldwide. This study aimed to assess and compare the clinical outcome of laparoscopic and open right hemicolectomy for colon cancer using data from the Japanese National Clinical Database.

METHODS

A total of 72 299 patients who underwent laparoscopic (n = 46 084) and open (n = 26 215) right hemicolectomy for colon cancer between 2014 and 2018 were enrolled in this retrospective study. Short-term outcome was compared between groups using propensity score matching analysis.

RESULTS

The incidence of overall postoperative morbidity ≥ Clavien-Dindo classification grade 3 was significantly higher in the open surgery group than the laparoscopic group (4.7% vs 3.2%, P < .001). The incidence of most individual morbidities, including surgical site infection, anastomotic leakage, and ileus, was higher in the open surgery group. Short-term outcomes, including intraoperative blood loss, postoperative hospital stay, reoperation rate, 30-day mortality, and in-hospital mortality, were superior in the laparoscopic group, except for operative time. Subgroup analyses showed that the incidence of postoperative morbidity was lower in the laparoscopic group for all prespecified subgroups.

CONCLUSION

Laparoscopic right hemicolectomy has an advantage over open surgery for colon cancer with respect to short-term outcome.

Beyond the NCCN Risk Factors in Colon Cancer: An Evaluation in a Swedish Population-Based Cohort

Background

The purpose of this study was to investigate whether pT3–4 and pN-subclassifications, lymph-node ratio (LNR), tumour deposits, pre- and postoperative carcinoembryonic antigen (CEA), and C-reactive protein (CRP)—all parameters commonly collected in clinical management—add information about recurrence risk against a background of routine clinicopathological parameters as defined by the NCCN.

Methods

The prospective cohort consisted of all 416 patients diagnosed with colon cancer stage I–III in Uppsala County between 2010 and 2015. Cox proportional hazard models were used to calculate hazard ratios for time to recurrence and overall survival. The results were compared with the entire Swedish population concerning parameters recorded in the national quality registry, SCRCR, during the same time period.

Results

The Uppsala cohort was representative of the entire Swedish cohort. In unadjusted analyses, pT3-subclassification, pN-subclassification, LNR, tumour deposits, elevated postoperative CEA, and preoperative CRP correlated with recurrence. After adjusting for T-, N-stage, and NCCN risk factors, pN-subclassification, sidedness, and elevated postoperative CEA levels correlated with recurrence. Survival correlated with parameters associated with recurrence, LNR, and elevated postoperative CRP.

Conclusions

Additional information on recurrence risk is available from several routinely recorded parameters, but most of the risk is predicted by the commonly used clinicopathological parameters.

Electronic supplementary material

The online version of this article (10.1245/s10434-019-08148-3) contains supplementary material, which is available to authorized users.

Method of pedicle division during laparoscopic right hemicolectomy affects lymph node yield and short-term outcomes

BACKGROUND

Several ways of performing laparoscopic right hemicolectomy (RHC) have evolved. The vascular pedicle can be divided into extracorporeal (RHC-EC) or intracorporeal (RHC-IC). It is not known whether vessel ligation during RHC-EC is as central as during RHC-IC. We compare these approaches in terms of pathological and short-term clinical outcomes.

METHODS

Patients undergoing elective laparoscopic RHC in a single centre (July 2013-September 2016) were identified. Data collection included operative details, length of stay, complications, specimen parameters including number and involvement of lymph nodes and recurrence.

RESULTS

One hundred and sixty-nine patients were included (94 RHC-IC, 75 RHC-EC). For caecal and ascending colon cancers, mesocolic width was greater after RHC-IC than RHC-EC (7.9 cm versus 6.6 cm, P < 0.05), as was lymph node yield (19.5 versus 17.3, P < 0.05). There was no significant difference in length of colon resected, distal resection margin, number of positive nodes, proportion of node-positive tumours and R1 rate. Operative duration was higher for RHC-IC (163 min versus 91 min, P < 0.001), as was incidence of ileus (35% versus 15%, P < 0.05). Length of stay also tended to be higher (7.4 days versus 6.0 days, P = 0.19). There was no difference in disease recurrence (follow-up 12 months). Body mass index was positively correlated with lymph node yield for RHC-EC, but not for RHC-IC.

CONCLUSION

Lymph node yield after laparoscopic RHC is adequate, whether the vascular pedicle is taken intracorporeal or extracorporeal, supporting the use of both approaches. RHC-IC yields more lymph nodes and greater mesocolic width, but involves a longer operation and higher incidence of ileus.

Clinical outcome of laparoscopic complete mesocolic excision in the treatment of right colon cancer

Background

This study aimed to investigate the clinical outcome of complete mesocolic excision (CME) with a caudal-to-cranial medial approach in the treatment of right colon cancer.

Methods

The clinical data of 172 patients who underwent laparoscopic CME for right colon cancer and were admitted to the First Affiliated Hospital of Nanjing Medical University from January 2010 to April 2015 were retrospectively analyzed. The 3-year disease-free survival (DFS) and overall survival (OS) in relation to gender, age, history of abdominal surgery, tumor size, complications, and tumor–node–metastasis (TNM) classification were analyzed using the Kaplan–Meier survival curves.

Results

A total of 172 patients with 94 males and 78 females were included. The average surgical time was 113.5 ± 34.4 min, blood loss was 74.2 ± 28.1 mL, and the number of lymph nodes retrieved was 23.3 ± 9.2. No readmission or death occurred within 30 days after surgery. Postoperative complications occurred in 16.3% of the patients, which included wound infection (3 patients), chylous fistula (22 patients), anastomotic leakage (1 patient), anastomotic bleeding (1 patient), and lung infection (1 patient). The 3-year DFS and OS were 81.7 and 89.1%, respectively. The rate of DFS and OS was significantly higher in stages I and II compared with that in stage III (P < 0.05), and in stages IIIA and IIIB compared with that in stage IIIC (P < 0.05).

Conclusions

Laparoscopic CME with a caudal-to-cranial medial approach in the treatment of right colon cancer had good short-term efficacy and satisfactory oncological outcome.