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Cazelles A, Cadi M, Cossé C, Labiad C, Lecot F, Al Jaafari B, Mariani A, Karoui M, Manceau G. Preoperative angio-CT colonography improves the quality of lymph node dissection during minimally invasive right hemicolectomy: a propensity score-matched study. Surg Endosc 2025; 39:3247-3258. [PMID: 40229597 DOI: 10.1007/s00464-025-11649-w] [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: 10/11/2024] [Accepted: 03/02/2025] [Indexed: 04/16/2025]
Abstract
BACKGROUND Minimally invasive right hemicolectomy for cancer with complete mesocolic excision is a difficult procedure to perform. The aim of this single-center prospective study was to evaluate whether preoperative angio-CT colonography (A-CTC) improved the quality of lymph node dissection during this surgery. METHODS All patients undergoing elective minimally invasive right hemicolectomy for colon adenocarcinoma with complete mesocolic excision between 01/2020 and 12/2023 have been prospectively included. The primary endpoint was the number of lymph nodes examined in the surgical specimen, including the total number of lymph nodes and the percentage of patients with at least 12 lymph nodes examined. Secondary endpoints included operating time, intraoperative complications, overall postoperative morbidity, and length of hospital stay. A propensity score was constructed with groups matched 3:1 using nearest neighbor matching based on the propensity score. RESULTS Of the 161 patients included, 44 had A-CTC (27%) and 117 had conventional CT scans. After propensity score matching, patients in the A-CTC group had significantly more lymph nodes on the surgical specimen (24 vs. 20, p = 0.006) and a better quality of lymph node dissection (≥ 12 examined lymph nodes: 100% vs. 87%, p < 0.001). Median operative times were similar between the two groups (184 vs. 180 min, p = 0.07), but two patients (2%) in the conventional CT group experienced an intraoperative bleeding complication. Postoperative morbidity and length of hospital stay were comparable. CONCLUSIONS Preoperative 3D reconstruction of vascular anatomy with A-CTC is useful and improves the quality of lymph node dissection during minimally invasive right hemicolectomy for cancer.
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Affiliation(s)
- Antoine Cazelles
- Department of Digestive and Oncological Surgery, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France
| | - Mehdi Cadi
- Department of Radiology, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France
| | - Cyril Cossé
- Department of Anesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France
| | - Camélia Labiad
- Department of Digestive and Oncological Surgery, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France
| | - Frederik Lecot
- Department of Digestive and Oncological Surgery, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France
| | - Badr Al Jaafari
- Department of Digestive and Oncological Surgery, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France
| | - Antoine Mariani
- Department of Digestive and Oncological Surgery, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France
| | - Mehdi Karoui
- Department of Digestive and Oncological Surgery, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France
| | - Gilles Manceau
- Department of Digestive and Oncological Surgery, Assistance Publique Hôpitaux de Paris, Georges Pompidou University Hospital, Paris Cité University, Paris, France.
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Chaouch MA, Hussain MI, Gouader A, Krimi B, Mazzotta A, Da Costa AC, Seiller I, Guibal A, Rehim MA, Diana M, Marescaux J, Khan J, Fattal W, Oweira H. Preoperative CT-Scan Angiography Reconstruction Before Right Colectomy with Complete Mesocolon Excision: A Systematic Review and Meta-analysis. J Gastrointest Cancer 2024; 56:37. [PMID: 39739073 DOI: 10.1007/s12029-024-01162-z] [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] [Accepted: 12/22/2024] [Indexed: 01/02/2025]
Abstract
BACKGROUND Complete mesocolon excision (CME) and central vascular ligation for right colonic cancers have been developed to improve oncological outcomes. However, it has been linked with a higher risk of morbidity and technical difficulties in operating near major vessels. This study investigated the impact of preoperative surgical planning utilizing CT reconstruction on surgical outcomes in right colectomy with CME. METHODS This systematic review and meta-analysis followed PRISMA and AMSTAR 2 guidelines. The analysis included clinical trials and observational studies comparing outcomes after preoperative CT scan reconstruction (navigation group) vs. no preoperative CT reconstruction (control group). RESULTS Four eligible studies (published between 2013 and 2023) were included, comprising 420 patients (203 in the navigation group and 217 in the control group). Preoperative navigation was associated with significantly lower blood loss (SMD = - 77.50; 95% CI [- 126.77, - 28.22], p = 0.002), shorter operative time (SMD = - 24.44; 95% CI [- 33.33, - 15.55], p < 0.00001), and a higher number of harvested lymph nodes (SMD = 1.39; 95% CI [0.58, 2.20], p = 0.0007). There was no statistically significant difference between the two groups in terms of overall morbidity (OR = 0.82; 95% CI [0.28, 2.40], p = 0.71), intraoperative complications (OR = 1.39; 95% CI [0.37, 5.26], p = 0.63), anastomotic leak (OR = 1.10; 95% CI [0.16, 7.63], p = 0.92), or hospital stay (SMD = - 0.06; 95% CI [- 0.48, 0.37], p = 0.80). CONCLUSION Preoperative navigation using CT reconstruction could help better delineate the complex vascular anatomy of the right colon. It may reduce operative time and increase the yield of harvested lymph nodes.
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Affiliation(s)
- Mohamed Ali Chaouch
- Department of visceral and digestive surgery, Monastir University Hospital, Monastir, Tunisia.
| | - Mohammad Iqbal Hussain
- Department of Robotic Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Amine Gouader
- Department of Surgery, Perpignan Hospital Center, Perpignan, France
| | - Bassem Krimi
- Department of Surgery, Perpignan Hospital Center, Perpignan, France
| | - Alessandro Mazzotta
- Department of Surgery, M. G., Vannini Hospital, Istituto Figlie Di San Camillo, Rome, Italy
| | | | - Ian Seiller
- Department of Radiology, Perpignan Hospital, Perpignan, France
| | - Aymeric Guibal
- Department of Radiology, Perpignan Hospital, Perpignan, France
| | | | - Michele Diana
- Research Institute against Digestive Cancer (IRCAD), Place de l'Hôpital, Strasbourg, France
- ICube Lab, University of Strasbourg, Strasbourg, France
- Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Jacques Marescaux
- Research Institute against Digestive Cancer (IRCAD), Place de l'Hôpital, Strasbourg, France
| | - Jim Khan
- Department of Robotic Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Wahid Fattal
- Department of Surgery, Universitäts medizin Mannheim, Heidelberg University, Mannheim, Germany
| | - Hani Oweira
- Department of Surgery, Universitäts medizin Mannheim, Heidelberg University, Mannheim, Germany
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Zhao B, Ding Y, Hu X, Guo P, Yu B. Assessing anatomical variations of the superior mesenteric artery via three-dimensional CT angiography and laparoscopic right hemicolectomy: a retrospective observational study. ANZ J Surg 2024; 94:2251-2257. [PMID: 39373124 DOI: 10.1111/ans.19254] [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: 03/05/2023] [Revised: 07/08/2024] [Accepted: 09/23/2024] [Indexed: 10/08/2024]
Abstract
OBJECTIVE This study aimed to analyse the anatomical relationships and differences between the superior mesenteric vessels and their branches by reviewing a laparoscopic right hemicolectomy surgery video and comparing it with preoperative three-dimensional computed tomography (3D-CT) angiography and to verify the accuracy of 3D-CT vascular reconstruction techniques. METHODS Surgical videos and preoperative imaging data of 52 patients undergoing laparoscopic right hemicolectomy were analysed to observe and summarize the probability of occurrence and adjacency of superior mesenteric vascular branches, and the lengths of specific sites of their branches were measured using the above two methods. RESULTS Preoperative CT images and surgical video showed that the ileocolic artery (ICA) was present in 98.1% (51/52) and the ileocolic vein (ICV) was present in 100% (52/52), and ICA was present in 13.7% (7/51) of the ICV directly anteriorly, 13.7% (7/51) anteriorly superiorly, 3.9% (2/51) anteriorly inferiorly, 11.8% (6/51) directly posteriorly, 37.2% (19/51) post superiorly, and 19.7% (10/51) posteriorly inferiorly. In the surgical video, the probability of presence of the right colic artery (RCA) was 21.2% (11/52). On CT images, the RCA was present in 10 patients. The length of the origin of the middle colic artery (MCA) from its bifurcations was 2.33 ± 0.87 cm measured intraoperatively using a sterile isometric filament, and the length measured using 3D-CT vascular reconstruction was 2.36 ± 0.91 cm; the difference was not statistically significant (P = 0.348). The length of the MCA and ICA initiation points was 3.22 ± 0.75 cm measured intraoperatively using sterile isometric filaments and 3.36 ± 0.72 cm measured using 3D-CT vascular reconstruction, which was a statistically significant difference (P < 0.001). CONCLUSIONS 3D-CT vascular reconstruction can accurately predict the vessels related to right hemicolectomy in most cases. It is an important method for preoperative prediction of superior mesenteric vessels, which can guide surgeons in the intraoperative vessel identification.
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Affiliation(s)
- Botian Zhao
- Radiotherapy Department, The Fourth Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Yuanyi Ding
- The Second Department of Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Xuhua Hu
- The Second Department of Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Peiyuan Guo
- The Second Department of Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Bin Yu
- The Second Department of Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
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Ogi Y, Egi H, Ishimaru K, Koga S, Yoshida M, Kikuchi S, Akita S, Sugishita H, Matsumoto H, Shimokawa T, Takeuchi A, Watanabe Y. Cadaveric and CT angiography study of vessels around the transverse colon mesentery. World J Surg Oncol 2023; 21:36. [PMID: 36747176 PMCID: PMC9901106 DOI: 10.1186/s12957-023-02919-9] [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: 10/17/2022] [Accepted: 01/30/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Laparoscopic and robotic surgery for transverse colon cancer are difficult due to complex fusion of the foregut and midgut and variation of the vessels of the transverse colon. Although the vessels of the right colon have been investigated, middle colic artery (MCA) variation and the relationship with vessels around the transvers colon are unknown. We investigated variation of the MCA using computed tomography angiography (CTA) and cadaver specimen and the relationship between the superior mesenteric vein (SMV) and MCA using CTA. The classification of vessels around the transverse colon may lead to safer and reliable surgery. METHODS This study included 505 consecutive patients who underwent CTA in our institution from 2014 to 2020 and 44 cadaver specimens. Vascular anatomical classifications and relationships were analyzed using CT images. RESULTS The MCA was defined as the arteries arising from the superior mesenteric artery (SMA) that flowed into the transverse colon at the distal ends. The classifications were as follows: type I, branching right and left from common trunk; type II, the right and left branches bifurcated separately from the SMA; and type III, the MCA branched from a vessel other than the SMA. Type II was subclassified into two subtypes, type IIa with one left branch and type IIb with two or more left branches from SMA. In the CTA and cadaver studies, respectively, the classifications were as follows: type I, n = 290 and n = 31; type IIa, n = 211 and n = 13; type IIb, n = 3 and n = 0; and type III, n = 1 and n = 0. We classified the relationship between the MCA and left side of the SMV into three types: type A, a common trunk runs along the left edge of the SMV (n = 173; 59.7%); type B, a right branch of the MCA runs along the left edge of the SMV (n = 116; 40.0%); and type C, the MCA runs dorsal of the SMV (n = 1; 0.3%). CONCLUSIONS This study revealed that The MCA branching classifications and relationship between the SMV and MCA. Preoperative CT angiography may be able to reliably identify vessel variation, which may be useful in clinical practice.
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Affiliation(s)
- Yusuke Ogi
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
| | - Hiroyuki Egi
- Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime, 454 Shitsukawa791-0295, Japan.
| | - Kei Ishimaru
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
| | - Shigehiro Koga
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
| | - Motohira Yoshida
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
| | - Satoshi Kikuchi
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
| | - Satoshi Akita
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
| | - Hiroki Sugishita
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
| | - Hironori Matsumoto
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
| | - Tetsuya Shimokawa
- grid.255464.40000 0001 1011 3808Division of Developmental Biology and Functional Genomics, Graduate School of Medicine, Ehime University, 454 Shitsukawa, Toon City, Ehime 795-0295 Japan
| | - Akihide Takeuchi
- grid.255464.40000 0001 1011 3808Division of Developmental Biology and Functional Genomics, Graduate School of Medicine, Ehime University, 454 Shitsukawa, Toon City, Ehime 795-0295 Japan
| | - Yuji Watanabe
- grid.452478.80000 0004 0621 7227Division of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Toon City, Ehime 454 Shitsukawa791-0295 Japan
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Romano G, Di Buono G, Galia M, Agnello F, Anania G, Guerrieri M, Milone M, Silecchia G, Buscemi S, Agrusa A. Role of preoperative CT angiography with multimodality imaging reconstruction to perform laparoscopic Complete Mesocolic Excision (CME) and Central Vascular Ligation (CVL) in right-sided colon cancer: Is it really useful? A prospective clinical study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:209-216. [PMID: 36002353 DOI: 10.1016/j.ejso.2022.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/01/2022] [Accepted: 08/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The concept of complete mesocolic excision (CME) and central vascular ligation (CVL) in right colonic resections appears to improve the oncological outcomes. The highest rate of complications reported in the literature in patients undergoing CME is related to difficult surgical manuevers and intraoperative bleeding due to the central vascular dissection. METHODS We used preoperative findings obtained with the CT angiography, multiplanar reformation (MPR), maximum intesity projection (MIP) and 3D volume rendering (VR) technique to verify if this preoperative radiological assessment had significant benefits regarding the difficulty of dissection of the embryological planes, the identification of vascular structures and central lymph nodes with reduction in mean operative time, intraoperative complications and better short-term outcomes versus standard contrast enhanced CT scan. We also have administered a questionnaire to investigate the subjective responses on the degree of difficulty of the surgical procedure both by the surgical team expert in CME and by a group of young surgeons. RESULTS Statistical analysis showed that overall operative time was significant shorter in patients underwent to radiological assessment (224,5 min; range 160-300 versus 252,6 min; range 200-340; p-value 0.023) with a significant lower rate of intraoperative complication (2.7% versus 4.2%; p-value 0.043). No differences were reported with respect to blood loss, conversion rate, anastomotic leakage or other surgical results. Analysis of the questionnaire underlined a progressive awareness of the correspondence between the radiological imaging and the surgical field. CONCLUSION The possibility of identifying the characteristics and course of the vascular structures along the axis of the superior mesenteric vessels certainly increases the surgeon's knowledge of the operating field, making him more confident with surgical maneuvers and significantly reducing the duration of the operating time and intraoperative complications.
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Affiliation(s)
- Giorgio Romano
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Giuseppe Di Buono
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy.
| | - Massimo Galia
- Department of Radiology, University of Palermo, Palermo, Italy
| | | | - Gabriele Anania
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Mario Guerrieri
- Department of General Surgery, Università Politecnica delle Marche, Ancona, Italy
| | - Marco Milone
- Department of Surgical Specialties, University "Federico II" of Naples, Naples, Italy
| | - Gianfranco Silecchia
- Division of General Surgery & Bariatric Center of Excellence IFSO EC, Department of Medico-Surgical Sciences and Biothecnologies, Sapienza University of Rome, Latina, Italy
| | - Salvatore Buscemi
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Antonino Agrusa
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
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Uludag SS, Kurt SA, Sanli DET, Sanli AN, Tutar O, Zengin AK, Ozcelik MF. Evaluating Portal Vein and Right Colon Venous Vascular Anatomy and Its Variations via Multidetector CT in Healthy Individuals. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03583-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Du K, Ren J, Zheng G, Li S, Chen L, Hou W, Duan W, Huang D, Zhang H, Feng F, Zheng J. Variation of the ileocolic artery and superior mesenteric artery in a patient with right-sided colon cancer with Lynch syndrome: a case report. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:939. [PMID: 36172100 PMCID: PMC9511195 DOI: 10.21037/atm-22-3012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
Background Complete mesangectomy and central vascular detachment are the core elements of laparoscopic right hemicolectomy. Failure to identify vascular variations in patients undergoing laparoscopic right hemicolectomy can result in unwanted bleeding, a prolonged surgical time, transfer to open surgery, and an elevated risk of postoperative complications. In this case report, we describe a new vascular variation that has not yet been reported in the literature. Parallelly vascular variation and the management of vessels in key areas are essential for successful surgery. Case Description The patient was a 32-year-old female who was referred to the department of gastrointestinal surgery of our hospital due to intermittent abdominal pain accompanied by changes in stool habits for 3 months. She had not experienced other symptoms. Physical examination revealed mild tenderness in the right lower abdomen. Subsequently, she underwent laparoscopic radical right hemicolectomy for ascending colon cancer under general anesthesia in our hospital. Preoperative abdominal contrast-enhanced computed tomography (CT) and intraoperative photos confirmed that there were two ileocolic arteries derived from the superior mesenteric artery (SMA). On the other side, the SMA and superior mesenteric vein (SMV) were found to be accompanied like "X"-shaped variant. The final surgical pathological diagnosis was pT3N1aM0 adenocarcinoma of the ascending colon. Given the patient's family history of colon and uterine cancer combined with the results of immunohistochemical staining and next-generation sequencing, we concluded that she had Lynch syndrome (LS). Conclusions This report describes the first case of simultaneous variation of the ileocolic artery (ICA) and SMA in a female patient with colon cancer. This type of vascular variation should be fully recognized by surgeons in order to avoid unnecessary intraoperative bleeding.
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Affiliation(s)
- Kunli Du
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Jiahui Ren
- Department of Anus and Intestine Surgery, Xi'an Mayinglong Anorectal Hospital, Xi'an, China
| | - Gaozan Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Shisen Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Ling Chen
- Department of Pathology, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Wei Hou
- Department of Radiology, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | | | | | | | - Fan Feng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Jianyong Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
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Luo W, Cai Z, Li F, Lu T, Xu Z, Jia Y, Zhang B. Laparoscopic Complete Mesocolic Excision with Central Vascular Ligation (CME + CVL) for Right-Sided Colon Cancer: A New "Superior Mesenteric Artery First" Approach. Ann Surg Oncol 2022; 29:5066-5073. [PMID: 35441309 DOI: 10.1245/s10434-022-11773-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/04/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE It remains a technical challenge to perform "superior mesenteric artery (SMA) first" approach for laparoscopic right hemicolectomy with complete mesocolon excision (CME) as the vascular anatomy of the right colon varies a lot, which may cause difficulty in early location of SMA and the risk of vascular damage during central vascular ligation (CVL). The purpose of this study was to describe a new "SMA first" approach for laparoscopic CME with CVL in right hemicolectomy with Treitz's ligament and ileocolic vascular pedicle as the anatomical landmarks for early identification of and exposure of SMA. METHODS This procedure was performed on 21 patients with right colon cancer between March 2020 and August 2021. To start, the transverse mesocolon was retracted to expose the ligament of Treitz, and the pedicle of ileocolic vessels was anteriorly grasped. Next, the peritoneum near the right border of the ligament of Treitz was divided along the left side of SMA until the peritoneum below the ileocolic vessels. Next, the mesenteric lymphatic adipose tissue outside of the sheath of SMA was dissected from medial to lateral. Then, laparoscopic right hemicolectomy with complete mesocolic excision (CME) was performed. Patients' preoperative baseline characteristics and intraoperative and postoperative complications were examined. RESULTS The median operative time was 180 min, and the median intraoperative blood loss was 50 ml (interquartile range 40-90). Chylous leakage occurred in four patients, and all the patients resolved with percutaneous drainage. The total harvested lymph nodes was 21.0 (range 16-27). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 10.0 days. No severe postoperative complications, such as abdominal infection, anastomotic leakage, or bleeding, were observed. CONCLUSIONS This new "SMA first" approach is safe and technically feasible for laparoscopic CME with CVL in right hemicolectomy.
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Affiliation(s)
- Wenjun Luo
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, Sichuan, China.
| | - Zhaolun Cai
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Fugen Li
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, Sichuan, China
| | - Tingting Lu
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, Sichuan, China
| | - Zhengwen Xu
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, Sichuan, China
| | - Yingdong Jia
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, Sichuan, China
| | - Bo Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Manabe T, Takii Y, Oyanagi H, Nogami H, Maruyama S. Is the ileocolic artery crossing pattern related to oncological outcomes of right-sided colon cancer? Surg Endosc 2022; 36:7210-7218. [DOI: 10.1007/s00464-022-09078-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 01/25/2022] [Indexed: 11/24/2022]
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Zou J, Jiang X, Cao W, Kong D, Cai J, Zhu D, Meng X, Ke J. Terminal Reaches of the Branches from Middle Colic Artery and Their Correlation with Right Colic Artery. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03289-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cirocchi R, Randolph J, Davies RJ, Cheruiyot I, Gioia S, Henry BM, Carlini L, Donini A, Anania G. A systematic review and meta-analysis of variants of the branches of the superior mesenteric artery: the Achilles heel of right hemicolectomy with complete mesocolic excision? Colorectal Dis 2021; 23:2834-2845. [PMID: 34358401 DOI: 10.1111/codi.15861] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/29/2021] [Accepted: 07/27/2021] [Indexed: 12/18/2022]
Abstract
AIM Dissection with subsequent ligation and resection of arteries at their origin (central vascular ligation) is essential for adequate oncological resection during right hemicolectomy with complete mesocolic excision. This technique is technically demanding due to the highly variable arterial pattern of the right colon. Therefore, this study aims to provide a comprehensive evidence-based assessment of the arterial vascular anatomy of the right colon. METHODS A thorough systematic literature search through September 2020 was conducted on the electronic databases PubMed, Scopus and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using MetaXl software. RESULTS A total of 41 studies (n = 4691 patients) were included. The ileocolic artery (ICA), right colic artery (RCA) and middle colic artery (MCA) were present in 99.7% (95% CI 99.4%-99.8%), 72.6% (95% CI 61.3%-82.5%) and 96.9% (95% CI 94.2%-98.8%) respectively of patients. Supernumerary RCA and MCA were observed in 3.2% and 11.4% respectively of all cases. The RCA shared a common trunk with the ICA and MCA in 13.2% and 17.7% respectively of patients. A retro-superior mesenteric vein course of the ICA and RCA was observed in 55.1% and 11.4% respectively of all cases. CONCLUSION The vascular anatomy of the right colon displays several notable variations, namely the absence of some branches (RCA absent in 27.4% of cases), supernumerary branches, common trunks, and retro-superior mesenteric vein courses. These variations should be taken into consideration during right hemicolectomy with complete mesocolic excision to ensure adequate oncological resection while minimizing intra-operative complications.
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Affiliation(s)
- Roberto Cirocchi
- Department of Surgical Science, University of Perugia, Piazza dell' Universitá, Perugia, Italy
| | - Justus Randolph
- Georgia Baptist College of Nursing, Mercer University, Atlanta, Georgia, USA
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Isaac Cheruiyot
- Department of Human Anatomy, University of Nairobi, Nairobi, Kenya.,International Evidence-Based Anatomy Working Group, Krakow, Poland
| | - Sara Gioia
- School of Medicine, Perugia, 3 Section of Legal Medicine, Hospital of Terni, University of Perugia, Terni, Italy
| | | | - Luigi Carlini
- School of Medicine, Perugia, 3 Section of Legal Medicine, Hospital of Terni, University of Perugia, Terni, Italy
| | - Annibale Donini
- Department of Surgical Science, University of Perugia, Piazza dell' Universitá, Perugia, Italy
| | - Gabriele Anania
- Department of Medical Science, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
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12
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Vogelsang RP, Gögenur M, Dencker D, Bjørn Bennedsen AL, Levin Pedersen D, Gögenur I. Routine CT evaluation of central vascular ligation in patients undergoing complete mesocolic excision for sigmoid colon cancer. Colorectal Dis 2021; 23:2030-2040. [PMID: 33974325 DOI: 10.1111/codi.15723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/23/2021] [Accepted: 05/04/2021] [Indexed: 02/08/2023]
Abstract
AIM Objective and reproducible quality measures of complete mesocolic excision (CME) for colon cancer are not currently available. This study aimed to measure the inferior mesenteric stump length following CME for sigmoid colon cancer and explore surgical, pathological and oncological outcomes in patients with a stump length of <10 mm vs. ≥10 mm. METHOD This was a single-centre, retrospective cohort study including patients undergoing minimally invasive surgery for sigmoid colon cancer between May 2013 and May 2015. Follow-up CT scans were reviewed, and a vascular stump cut-off of <10 mm for adequate central ligation of the inferior mesenteric artery was applied. Differences in perioperative, histopathological and oncological outcome parameters (overall, disease-free and recurrence-free survival) were explored between <10 mm vs. ≥10 mm groups. RESULTS A total of 127 patients (43% female) with a median age of 68 years were included. The median follow-up time was 68 months. CT measurements showed good interrater agreement (90% absolute agreement) and reliability among raters (kappa = 0.77, 95% CI 0.53-1.00, p < 0.001). A stump length ≥10 mm was associated with longer operating time (150 vs. 180 min, p = 0.021), intramesocolic resection (p = 0.008), and a shorter distance from the bowel wall to vascular tie (120 vs. 102 mm, p = 0.005). CONCLUSION An arterial stump length ≥10 mm in sigmoid resection for colon cancer was associated with key clinical quality measures. Measurement of arterial stump length using routine follow-up CT may serve as a quality indicator of vascular ligation in CME surgery.
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Affiliation(s)
| | - Mikail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - Ditte Dencker
- Department of Radiology, Zealand University Hospital, Koege, Denmark.,Department of Diagnostic Radiology, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Koege, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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13
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Obara N, Yamaguchi S, Okada Y. A Study of the Right Colonic Vascular Anatomy: Correlations between Veins and Arteries. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:306-312. [PMID: 34395944 PMCID: PMC8321591 DOI: 10.23922/jarc.2021-002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/13/2021] [Indexed: 01/04/2023]
Abstract
Objectives Few studies have examined the correlations between the arteries and veins of the right colon. In this study, we aimed to use high-resolution CT scans to understand the vascular anatomy of Henle's gastrocolic trunk and review the terminology describing the arteries and veins of the right colon. Methods This retrospective study has examined patients who underwent laparoscopic colectomy for right colon cancer in a single institution in Japan. Scans from consecutive patients who underwent surgery between October 2017 and March 2020 (n = 165) were examined. Preoperative CT images were used to create multiplanar reformation images and volume rendering images. Results Among the 139 patients with Henle's gastrocolic trunk (GCT) present, arteries accompanying the accessory right colic vein (ARCV) were most common on the right branch of the middle colic artery (MCA) (71.2%), followed by the right colic artery (RCA) (19.4%); meanwhile, 9.4% of the patients had no accompanying arteries. Of patients with no accompanying arteries to the ARCV, RCA was present in 15.4%. Among the 26 patients with no GCT, the right colic vein (RCV) existed in 15 patients, with the artery accompanying the RCV most commonly being the right branch of the MCA (66.6%), followed by the RCA (33.3%). Conclusions Irrespective of the presence of GCT, approximately 70% of the arteries accompanying the drainage vein from the right colon were the right branch of the MCA. We suggest that vascular branch formation be considered preoperatively in surgical management for right colon cancer.
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Affiliation(s)
- Nao Obara
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Shigeki Yamaguchi
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Yoshitaka Okada
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Hidaka, Japan
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14
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Yu H, Zhuang Y, Jian J, Yang C. Predictive value of computed tomography with coronal reconstruction in right hemicolectomy with complete mesocolic excision for right colon cancers: a retrospective study. World J Surg Oncol 2021; 19:189. [PMID: 34183028 PMCID: PMC8240319 DOI: 10.1186/s12957-021-02307-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/17/2021] [Indexed: 12/16/2022] Open
Abstract
Background Understanding the vascular anatomy is critical for performing central vascular ligation (CVL) in right hemicolectomy with complete mesocolic excision (CME). This study aimed to investigate the predictive value of multi-slice spiral computed tomography (MSCT) with coronal reconstruction in right hemicolectomy with CME. Methods This is a retrospective descriptive study. Eighty patients with right colon cancer who underwent right hemicolectomy from December 2015 to January 2020 were included. The intraoperative reports (including imaging data) and MSCT images with coronal reconstruction were analysed and compared. The detection rates of the ileocolic vein (ICV) and ileocolic artery (ICA) roots and the accuracy in predicting their anatomical relationship were analysed. The detection rate and accuracy in predicting the location of the gastrocolic trunk of Henle (GTH), middle colic artery (MCA) and middle colic vein (MCV) were analysed. The distance from the ICV root to the GTH root (ICV-GTH distance) was measured and analysed. The maximum distance from the left side of the superior mesenteric artery (SMA) to the right side of the superior mesenteric vein (SMV), named the ‘lsSMA-rsSMV distance’, was also measured and analysed. Results In seventy-four (92.5%) patients, both the ICV and ICA roots were located; their anatomical relationship was determined by MSCT, and the accuracy of the prediction was 97.2% (72/74). The GTH was located by MSCT in 75 (93.7%) patients, and the accuracy of the prediction was 97.33% (73/75). The MCA was located by MSCT in 47 (58.75%) patients, and the accuracy was 78.72% (37/47). The MCV was located by MSCT in 51 (63.75%) patients, and the accuracy of the prediction was 84.31% (43/51). The ICV-GTH distance was measured in 73 (91.2%) patients, and the mean distance was 4.28 ± 2.5 cm. The lsSMA-rsSMV distance was measured in 76 (95%) patients, and the mean distance was 2.21 ± 0.6 cm. Conclusions With its satisfactory accuracy in predicting and visualising the information of key anatomical sites, MSCT with coronary reconstruction has some predictive value in CME with CVL in right hemicolectomy.
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Affiliation(s)
- Hui Yu
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, 420 Fuma Street, Jinan, Fuzhou, Fujian, 350014, P.R. China.
| | - Yong Zhuang
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, 420 Fuma Street, Jinan, Fuzhou, Fujian, 350014, P.R. China
| | - Jinliang Jian
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, 420 Fuma Street, Jinan, Fuzhou, Fujian, 350014, P.R. China
| | - Chunkang Yang
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, 420 Fuma Street, Jinan, Fuzhou, Fujian, 350014, P.R. China
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15
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Figueiredo CP, Perez MO, Sales LP, Caparbo VDF, Pereira RMR. Evaluation of bone erosion in rheumatoid arthritis patients by high-resolution peripheral quantitative computed tomography scans: Comparison between two semi-automated programs in a three-dimensional setting. Int J Rheum Dis 2021; 24:948-953. [PMID: 34151526 DOI: 10.1111/1756-185x.14157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/07/2021] [Accepted: 05/20/2021] [Indexed: 01/01/2023]
Abstract
AIM The aim of this study was to compare OsiriX software with the previous published Medical Image Analysis Framework (MIAF) method to assess the volume of erosion in patients with rheumatoid arthritis (RA). METHODS Forty RA patients underwent high-resolution peripheral quantitative computed tomography scans of the second and third metacarpophalangeal joints, and thirty-four patients with any bone erosion were enrolled. Two techniques were applied to erosion evaluation: (a) semi-automated MIAF software, and (b) semi-automated segmentation by free open-source Digital Imaging and Communications in Medicine viewer, OsiriX software. MIAF has been published before, but this is the first time that OsiriX has been used in this way in rheumatology. Bland & Altman plots described agreement between methods. RESULTS Forty-eight erosions from 34 patients were analyzed. Mean age was 40.74 ± 5.32 years and mean disease duration was 10.68 ± 4.96 years. Both methods demonstrated a strong correlation regarding erosion volume (r = 0.96, P < 0.001). Median (interquartile range) of erosion volume was 12.14 (4.5-36.07) when MIAF was considered, and 11.80 (3.45-29.42) when the OsiriX tool was used (P = 0.139). MIAF and OsiriX showed good agreement when the Bland & Altman plot was performed. Evaluation by MIAF took 22.69 ± 6.71 minutes, whereas OsiriX took only 2.62 ± 1.09 minutes (P < 0.001). CONCLUSION The three-dimensional segmentation of bone erosions can be done by both MIAF and OsiriX software with good agreement. However, because OsiriX is a widespread tool and faster, its method seems to be more feasible for evaluating peripheral bone damage, especially bone erosions.
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Affiliation(s)
- Camille Pinto Figueiredo
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mariana Ortega Perez
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Lucas Peixoto Sales
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Valeria de Falco Caparbo
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rosa Maria Rodrigues Pereira
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP Universidade de Sao Paulo, Sao Paulo, Brazil
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16
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Chen Y, Bian L, Zhou H, Wu D, Xu J, Gu C, Fan X, Liu Z, Zou J, Xia J, Xu Z. Usefulness of three-dimensional printing of superior mesenteric vessels in right hemicolon cancer surgery. Sci Rep 2020; 10:11660. [PMID: 32669641 PMCID: PMC7363793 DOI: 10.1038/s41598-020-68578-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/17/2020] [Indexed: 11/30/2022] Open
Abstract
The anatomy of the superior mesenteric vessels is complex, yet important, for right-sided colorectal surgery. The usefulness of three-dimensional (3D) printing of these vessels in right hemicolon cancer surgery has rarely been reported. In this prospective clinical study, 61 patients who received laparoscopic surgery for right hemicolon cancer were preoperatively randomized into 3 groups: 3D-printing (20 patients), 3D-image (19 patients), and control (22 patients) groups. Surgery duration, bleeding volume, and number of lymph node dissections were designed to be the primary end points, whereas postoperative complications, post-operative flatus recovery time, duration of hospitalization, patient satisfaction, and medical expenses were designed to be secondary end points. To reduce the influence of including different surgeons in the study, the surgical team was divided into 2 groups based on surgical experience. The duration of surgery for the 3D-printing and 3D-image groups was significantly reduced (138.4 ± 19.5 and 154.7 ± 25.9 min vs. 177.6 ± 24.4 min, P = 0.000 and P = 0.006), while the number of lymph node dissections for the these 2 groups was significantly increased (19.1 ± 3.8 and 17.6 ± 3.9 vs. 15.8 ± 3.0, P = 0.001 and P = 0.024) compared to the control group. Meanwhile, the bleeding volume for the 3D-printing group was significantly reduced compared to the control group (75.8 ± 30.4 mL vs. 120.9 ± 39.1 mL, P = 0.000). Moreover, patients in the 3D-printing group reported increased satisfaction in terms of effective communication compared to those in the 3D-image and control groups. Medical expenses decreased by 6.74% after the use of 3D-printing technology. Our results show that 3D-printing technology could reduce the duration of surgery and total bleeding volume and increase the number of lymph node dissections. 3D-printing technology may be more helpful for novice surgeons. Trial registration: Chinese Clinical Trial Registry, ChiCTR1800017161. Registered on 15 July 2018.
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Affiliation(s)
- Yigang Chen
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, 68 Zhongshan Road, Wuxi, 214002, Jiangsu, People's Republic of China
| | - Linjie Bian
- Department of Radiology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, 214002, People's Republic of China
| | - Hong Zhou
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, 68 Zhongshan Road, Wuxi, 214002, Jiangsu, People's Republic of China
| | - Danping Wu
- Department of Radiology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, 214002, People's Republic of China
| | - Jie Xu
- Operating Room, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, 214002, People's Republic of China
| | - Chen Gu
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, 68 Zhongshan Road, Wuxi, 214002, Jiangsu, People's Republic of China
| | - Xinqi Fan
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, 68 Zhongshan Road, Wuxi, 214002, Jiangsu, People's Republic of China
| | - Zhequn Liu
- Harbin JunYang Technology Co., Ltd, Harbin, 150000, People's Republic of China
| | - Junyi Zou
- Operating Room, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, 214002, People's Republic of China
| | - Jiazeng Xia
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, 68 Zhongshan Road, Wuxi, 214002, Jiangsu, People's Republic of China.
| | - Zekuan Xu
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, 140 Hanzhong Road, Nanjing, 210029, People's Republic of China.
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17
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Propensity-score-matched analysis of short- and long-term outcomes in patients with an ileocolic artery crossing anterior vs posterior to the superior mesenteric vein during curative resection for right-sided colon cancer. Surg Endosc 2020; 34:5384-5392. [PMID: 31993811 DOI: 10.1007/s00464-019-07333-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/24/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Colorectal cancer is one of the most common malignant diseases worldwide. However, laparoscopic lymph node dissection is technically demanding and time-consuming in right-sided colon cancer surgery because of variable vessel anatomy. We evaluated whether the ileocolic artery (ICA) crossing anterior to the superior mesenteric vein (SMV) was associated with better intraoperative parameters and survival compared with the ICA crossing posterior to the SMV, following laparoscopic curative resection for right-sided colon cancer. METHODS This was a propensity-score-matched retrospective study including data for 540 patients with right-sided colon cancer undergoing laparoscopic curative resection (299 with the ICA crossing anterior to the SMV (group A) and 241 with the ICA crossing posterior to the SMV (group B). We compared propensity-matched scores between the two groups to evaluate surgical and oncological outcomes. RESULTS We found no significant difference in 5-year overall survival rates between groups for any disease stage (0-III). However, 5-year disease-free survival (DFS) rates did differ significantly between groups (p = 0.011), especially in patients with stage III disease (p = 0.013). We then performed univariate and multivariate analyses to determine the associations between DFS and ICA location and tumor-node-metastasis (UICC) stage. ICA location and UICC stage had a poor association with DFS on univariate analysis: ICA hazard ratio (HR) 2.52, CI 1.19-5.78, p = 0.014 vs HR 3.18, CI 1.08-9.46, p = 0.03, and on multivariate analysis: HR 2.48, CI 1.17-5.69, p = 0.016 vs HR 3.86, CI 1.90-7.96, p = 0.0002. CONCLUSION Our results showed that an ICA crossing posterior to the SMV was associated with worse DFS compared with an ICA crossing anterior to the SMV. We recommend careful laparoscopic technique in patients with an ICA crossing posterior to the SMV, during lymph node resection in right-sided colon cancer surgery.
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18
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Semi-automated vs. manual 3D reconstruction of central mesenteric vascular models: the surgeon’s verdict. Surg Endosc 2019; 34:4890-4900. [DOI: 10.1007/s00464-019-07275-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022]
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Bruzzi M, M'harzi L, Poghosyan T, Ben Abdallah I, Papadimitriou A, Ragot E, El Batti S, Balaya V, Taieb J, Chevallier JM, Douard R. Arterial vascularization of the right colon with implications for surgery. Surg Radiol Anat 2019; 42:429-435. [PMID: 31637473 DOI: 10.1007/s00276-019-02359-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/04/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE During right-sided colectomies, surgeons encounter major anatomical variations at the level of the right colon, leading to morbidity. Due to the confusion surrounding the colonic arterial vessels emerging from the superior mesenteric artery (SMA) to vascularize the right part of the colon, this review aimed to describe the arterial vessels found in the mesocolic structures of the ascending colon, the hepatic flexure and the right transverse colon. METHODS A review of the literature was performed using the MEDLINE database. Only human studies were included. All dissection, angiographic, arterial cast and corrosion studies were analyzed. RESULTS This review demonstrates that the right colon, the hepatic flexure and the right transverse colon are vascularized by three significant arteries emerging from the SMA and forming one peripheral paracolic arc: (1) the ileocolic artery (ICA), the most constant vessel (99.8%) with low variability; (2) the right colic artery (RCA), the most inconstant vessel (2/3 of cases) with high variability in its origin; and (3) the middle colic artery (MCA), a constant vessel (95%) with variation in its origin and its number. The marginal artery is almost constant (100%) and represents the only peripheral arterial arc at the level of the right side of the colon. CONCLUSIONS Three arteries emerging from the superior mesenteric artery exist: the ICA, the RCA and the MCA. The ICA and the MCA are the most constant. Knowledge of this vascular anatomy is essential for performing right-sided colectomies.
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Affiliation(s)
- Matthieu Bruzzi
- General and Digestive Surgery Unit, Georges Pompidou AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France. .,Paris Descartes Faculty of Medicine, Paris, France. .,INSERM 970, Équipe 2, PARCC, HEGP, Paris, France. .,Service de Chirurgie générale et digestive, Hôpital européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France.
| | - Leila M'harzi
- General and Digestive Surgery Unit, Georges Pompidou AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France.,Paris Descartes Faculty of Medicine, Paris, France.,INSERM 970, Équipe 2, PARCC, HEGP, Paris, France
| | - Tigran Poghosyan
- General and Digestive Surgery Unit, Georges Pompidou AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France.,Paris Descartes Faculty of Medicine, Paris, France.,INSERM 970, Équipe 2, PARCC, HEGP, Paris, France
| | | | - Argyri Papadimitriou
- General and Digestive Surgery Unit, Georges Pompidou AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France
| | - Emilia Ragot
- General and Digestive Surgery Unit, Georges Pompidou AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France
| | | | | | - Julien Taieb
- Paris Descartes Faculty of Medicine, Paris, France.,Digestive Oncology Unit, Georges Pompidou AP-HP University Hospital, Paris, France
| | - Jean-Marc Chevallier
- General and Digestive Surgery Unit, Georges Pompidou AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France.,Paris Descartes Faculty of Medicine, Paris, France
| | - Richard Douard
- General and Digestive Surgery Unit, Georges Pompidou AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France.,Paris Descartes Faculty of Medicine, Paris, France
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Livadaru C, Morarasu S, Frunza TC, Ghitun FA, Paiu-Spiridon EF, Sava F, Terinte C, Ferariu D, Lunca S, Dimofte GM. Post-operative computed tomography scan – reliable tool for quality assessment of complete mesocolic excision. World J Gastrointest Oncol 2019; 11:208-226. [PMID: 30918594 PMCID: PMC6425332 DOI: 10.4251/wjgo.v11.i3.208] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/06/2018] [Accepted: 01/10/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Quality control in colon cancer surgery is an ongoing debate ever since standardization proved to be highly efficient in improving survival in rectal cancer. Complete mesocolic excision (CME) is widely acclaimed as the new gold-standard in colon cancer resections, thus it is imperative to establish quality criteria of CME in order to make it easily understood and verified by surgeons worldwide. One simple and reproducible tool could be the measurement of arterial stumps postoperatively and a straightforward way to test its reliability is to test it in a comparative study between CME and non-CME surgery.
AIM To validate arterial stump measurement as a surgical quality tool by comparing CME with conventional radical colectomies.
METHODS This was a retrospective study, carried out on a prospective database. We collected data from two groups of patients, divided according to standard CME with D2 central vascular ligation (group A) and non-standardized surgery (group B). The two groups were compared with regard to the arterial stump length after right- and left-sided colectomies for colon cancer. The actual stump lengths of the ileocolic artery (ICA) and inferior mesenteric artery (IMA) were compared with their theoretical best D2 position of predicted ligation levels (D2PLLs) for calculating the potential for improvement. Measurements on follow-up computed tomography scans were carried out by three observers. Pathological data were recorded (specimen length, lymph node yield) and correlated with stump length.
RESULTS We analysed 58 colectomies. The stump lengths (mean ± SD) in group A were 16.97 ± 4.77 mm for ICA and 31.70 ± 15.71 mm for IMA, whereas group B had 49.93 ± 20.29 mm for ICA and 67.24 ± 28.71 mm for IMA. Shorter lengths were obtained in group A, by a mean difference of 35.66 mm (χ2 = 27.38, P < 0.001), which was significant for all types of colectomies. Except for a 5.85 ± 4.71 mm difference for right colectomies, all the ligations from group A significantly reached their potential height (0.26 ± 12.18 mm from D2PLL; χ2 = 0.005, P = 0.944). Apart from three left colectomies, group B failed to reach D2PLL, by a mean difference of 32.14 ± 26.15 mm (χ2 = 21.77, P < 0.001). The calculated improvement potentials were significantly shorter in group A than in group B, by a mean of 31.88 mm (χ2= 22.13, P < 0.001). The large spread of results in group B showed that there is significant variability (P = 0.004) when compared to standard surgery. Significant correlations were found between stump length, specimen length and number of lymph nodes (P = 0.018 and P = 0.008 respectively). No statistical difference was found between observers’ measurements (P = 0.866).
CONCLUSION Arterial stump monitoring is a significant step in defining surgical quality, as longer stumps contain residual mesocolic tissue and correlate with major prognostic factors.
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Affiliation(s)
- Cristian Livadaru
- ”Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Stefan Morarasu
- 2nd Clinic of Surgical Oncology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Tudor Cristian Frunza
- 2nd Clinic of Surgical Oncology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Florina A Ghitun
- ”Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Elena Florina Paiu-Spiridon
- Department of Radiology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Florina Sava
- Department of Radiology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Cristina Terinte
- Department of Pathology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Dan Ferariu
- Department of Pathology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Sorinel Lunca
- 2nd Clinic of Surgical Oncology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
| | - Gabriel Mihail Dimofte
- 2nd Clinic of Surgical Oncology, Regional Oncology Institute, “Grigore T Popa” University of Medicine and Pharmacy, Iasi 700115, Romania
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Wu C, Ye K, Wu Y, Chen Q, Xu J, Lin J, Kang W. Variations in right colic vascular anatomy observed during laparoscopic right colectomy. World J Surg Oncol 2019; 17:16. [PMID: 30636641 PMCID: PMC6330569 DOI: 10.1186/s12957-019-1561-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/03/2019] [Indexed: 01/04/2023] Open
Abstract
Background This study aimed to analyze right colonic vascular variability. Methods The study included 60 consecutive patients who underwent laparoscopic radical right colectomy and D3 lymph node dissection for malignant colonic cancer on the ileocecal valve, ascending colon or hepatic flexure (March 2013 to October 2016). The videos of the 60 surgical procedures were collected. Variations of right colonic vascular anatomy were retrospectively analyzed based on 60 high-resolution surgical videos of laparoscopic surgery. Results The superior mesenteric artery and vein were present in all cases; 95.0% (57/60) had the superior mesenteric artery on the left side of the superior mesenteric vein. The ileocolic artery and vein occurred in 96.7% (58/60) and 100% (60/60) of cases, respectively; 50.0% (29/58) had the ileocolic artery passing the superior mesenteric vein anteriorly. Thirty-three (55.0%) cases had a right colic artery, and 2 (3.33%) had a double right colic artery; 90.9% (30/36) had the right colic vein passing anterior to the superior mesenteric artery. Fifty-six (93.3%) cases had a right colic vein; 7 (12.5%) had a right colic vein accompanied by a right colic artery, 66.1% (37/56) had the right colic vein draining into the gastrocolic trunk of Henle, 23.2% (13/56) had the right colic vein directly draining into superior mesenteric vein, and 10.7% (6/56) had one right colic vein draining into the superior mesenteric vein and the other into the gastrocolic trunk of Henle. Fifty-three (88.3%) cases had a gastrocolic trunk of Henle: a gastrocolic trunk in 35.8% (19/53), a gastropancreatic trunk in 9.4% (5/53), and a gastropancreaticocolic trunk in 54.7% (29/53). The frequencies of middle colic artery and vein were respectively 100% (60/60) and 93.3% (56/60). Conclusions Right colonic vascular variations were classified in Chinese patients. Notable findings included a superior mesenteric artery positioned to the right of the superior mesenteric vein and variation in middle colic artery length. This knowledge may be helpful to colorectal surgeons and could potentially help to improve safety by reducing vascular complications during minimally invasive procedures.
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Affiliation(s)
- Chuying Wu
- Department of Tumor Surgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
| | - Kai Ye
- Department of Tumor Surgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China.
| | - Yiyang Wu
- Department of Tumor Surgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
| | - Qiwei Chen
- Department of Tumor Surgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
| | - Jianhua Xu
- Department of Tumor Surgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
| | - Jianan Lin
- Department of Tumor Surgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
| | - Wengui Kang
- Department of Tumor Surgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
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22
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Ueki T, Nagai S, Manabe T, Koba R, Nagayoshi K, Nakamura M, Tanaka M. Vascular anatomy of the transverse mesocolon and bidirectional laparoscopic D3 lymph node dissection for patients with advanced transverse colon cancer. Surg Endosc 2018; 33:2257-2266. [PMID: 30334162 DOI: 10.1007/s00464-018-6516-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 10/11/2018] [Indexed: 12/18/2022]
Abstract
Laparoscopic D3 lymph node dissection for transverse colon cancer is technically demanding because of complicated anatomy. Here, we reviewed the vascular structure of the transverse mesocolon, explored the extent of the base of the transverse mesocolon, and evaluated the feasibility and oncological safety of D3 lymph node dissection. We retrospectively reviewed the clinical records of 42 patients with advanced transverse colon cancer who underwent curative surgery and D3 dissection at Kyushu University Hospital between January 2008 and December 2015. We examined the venous and arterial anatomy of the transverse mesocolon of each resection and compared surgical outcomes between patients who underwent laparoscopic D3 (Lap D3) and open D3 (Open D3) dissection. Patients included two with Stage I, 18 with Stage II, 20 with Stage III, and two with Stage IVA. Thirty-six (85.7%) and six (14.3%) patients underwent Lap D3 or Open D3, respectively. The tumor sizes of the Open D3 and Lap D3 groups were 7.8 and 3.7 cm, respectively (P < 0.001). The Lap D3 group had significantly less blood loss (26 mL vs 272 mL, P = 0.002). The other outcomes of the two groups were not significantly different, including 3-year overall survival (87.7% vs 83.3%, P = 0.385). We observed four patterns of the middle colic artery (MCA) arising from the superior mesenteric artery (SMA), and the frequency of occurrence of a single MCA was 64.3%. The right-middle colic vein (MCV) was present in 92.9% of resections and served as a tributary of the gastrocolic trunk, and 90.5% of the left MCVs drained into the superior mesenteric vein (SMV). The root of the transverse mesocolon was broadly attached to the head of the pancreas and to the surfaces of the SMV and SMA. Laparoscopic D3 lymph node dissection may be tolerated by patients with advanced transverse colon cancer.
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Affiliation(s)
- Takashi Ueki
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
- Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka, 810-8539, Japan.
| | - Shuntato Nagai
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tatsuya Manabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryo Koba
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masao Tanaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Gaupset R, Nesgaard JM, Kazaryan AM, Stimec BV, Edwin B, Ignjatovic D. Introducing Anatomically Correct CT-Guided Laparoscopic Right Colectomy with D3 Anterior Posterior Extended Mesenterectomy: Initial Experience and Technical Pitfalls. J Laparoendosc Adv Surg Tech A 2018; 28:1174-1182. [DOI: 10.1089/lap.2018.0059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Robin Gaupset
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| | | | - Airazat M. Kazaryan
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
- Intervention Centre, Oslo University Hospital—Rikshospitalet, Oslo, Norway
- Department of Surgery, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia
- Department of Faculty Surgery N 2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
| | - Bojan V. Stimec
- Anatomy Sector, Department of Cell Physiology and Metabolism, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bjørn Edwin
- Intervention Centre, Oslo University Hospital—Rikshospitalet, Oslo, Norway
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hepatopancreatobiliary Surgery, Oslo University Hospital—Rikshospitalet, Oslo, Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
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Feasibility of a unidirectionally progressive, pancreas-oriented procedure for laparoscopic D3 right hemicolectomy. Langenbecks Arch Surg 2018; 403:761-768. [PMID: 30215157 DOI: 10.1007/s00423-018-1703-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 08/05/2018] [Indexed: 12/20/2022]
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Maeda Y, Shinohara T, Futakawa N, Minagawa N, Sunahara M, Koyama R, Nagatsu A, Hamada T. The Oncologic Outcomes of Inferior Mesenteric Artery-Preserving Laparoscopic Lymph Node Dissection for Upper-Rectal or Sigmoid Colon Cancer. J Laparoendosc Adv Surg Tech A 2018; 28:1352-1358. [PMID: 30192168 DOI: 10.1089/lap.2018.0201] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The standard procedure of lymph node (LN) dissection for rectal or sigmoid colon cancer remains controversial. Many laparoscopic surgeons cut the inferior mesenteric artery (IMA) at the root; however, this may cause bowel ischemia around the site of anastomosis. We performed D3 or D2 LN dissection with the preservation of the IMA. The aim of this study was to evaluate the oncologic outcomes of IMA-preserving LN dissection. PATIENTS AND METHODS We retrospectively analyzed 142 consecutive patients with upper-rectal or sigmoid colon cancer who underwent laparoscopic LN dissection with the preservation of the IMA. The number of LNs dissected and the overall and disease-free survival rates were retrospectively evaluated. RESULTS Laparoscopic D3 (n = 92) or D2 (n = 50) LN dissection were performed with the preservation of the IMA. The left colic artery was preserved in all cases, the superior rectal artery was also preserved in 30 cases. The mean number of LNs dissected was 19.6 in the D3 group and 12.9 in the D2 group. The median operative time was 230 minutes, and the median volume of blood loss was 17 mL. There was no treatment-related mortality. The estimated 5-year disease-free survival rates of the stage I, II, and III patients were 93%, 83%, and 74%, respectively. No patients developed LN recurrence. CONCLUSIONS Laparoscopic surgery with IMA-preserving LN dissection is an oncologically acceptable treatment strategy in patients with upper-rectal or sigmoid colon cancer.
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Affiliation(s)
- Yoshiaki Maeda
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center , Sapporo, Japan
| | - Toshiki Shinohara
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center , Sapporo, Japan
| | - Noriaki Futakawa
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center , Sapporo, Japan
| | - Nozomi Minagawa
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center , Sapporo, Japan
| | - Masao Sunahara
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center , Sapporo, Japan
| | - Ryota Koyama
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center , Sapporo, Japan
| | - Akihisa Nagatsu
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center , Sapporo, Japan
| | - Tomonori Hamada
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center , Sapporo, Japan
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Variations of Gastrocolic Trunk of Henle and Its Significance in Gastrocolic Surgery. Gastroenterol Res Pract 2018; 2018:3573680. [PMID: 29977286 PMCID: PMC6011069 DOI: 10.1155/2018/3573680] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/02/2018] [Indexed: 12/22/2022] Open
Abstract
Due to the increasing incidence of gastrointestinal (GI) tumors, more and more importance is attached to radical resection and patients' survival, which requires adequate extent of resection and radical lymph node dissection. Blood vessels around the gastrointestinal tract, as anatomical landmarks for tumor resection and lymph node dissection, play a key role in the successful surgery and curative treatment of gastrointestinal tumors. In the isolation of subpyloric area or hepatic flexure of the colon for gastrectomy or right hemicolectomy, lymph node dissection and ligation are often performed at the head of the pancreas and superior mesenteric vein, during which even a minor inadvertent error may lead to unwanted bleeding. Among these blood vessels, the venous system composed of Henle's trunk and its tributaries is the most complex, which has a direct influence on the outcome and postoperative recovery of the patients. There are many variations of Henle's trunk, with complicated courses and various locations, attracting more and more researchers to study it and tried to analyze the influence of its variations on gastrointestinal surgeries. We characterized various variants and tributaries of Henle's trunk using autopsy, vascular casting, 3D CT reconstruction, intraoperative anatomy, and Hisense CAS system and summarized and analyzed the tributaries of Henle's trunk, to determine its influence on GI surgeries.
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Hamabe A, Park S, Morita S, Tanida T, Tomimaru Y, Imamura H, Dono K. Analysis of the Vascular Interrelationships Among the First Jejunal Vein, the Superior Mesenteric Artery, and the Middle Colic Artery. Ann Surg Oncol 2018; 25:1661-1667. [PMID: 29616421 DOI: 10.1245/s10434-018-6456-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND The technical difficulty of laparoscopic surgery for transverse colon cancer is partly due to the vascular variability around the middle colic vessels. Although individual variations in the arteries or veins in this area were previously investigated, the vascular interrelationships between these vessels remain unknown. This study was designed to investigate the vascular interrelationships between the arteries and veins around the middle colic vessels and to provide practically useful classifications. METHODS This study included 105 consecutive patients who underwent colorectal surgery for colorectal tumors in our institution in 2016. Patients with a history of colectomy were excluded. Vascular anatomical classifications were analyzed by evaluating thin-slice images of preoperative contrast-enhanced computed tomography. RESULTS Vascular anatomical patterns were classified according to whether the first jejunal vein ran behind (type A) or in front (type B) of the superior mesenteric artery. Type B was subclassified into two subtypes, depending on whether the middle colic artery originated cephalad (type B1) or caudad (type B2) to the first jejunal vein. We identified 83 (79.0%) cases of type A, 11 (10.5%) of type B1, and 11 (10.5%) of type B2. In 17 cases, the middle colic vein drained into the inferior mesenteric vein, and all of these were type A (P = 0.0202). Furthermore, in eight cases, the middle colic vein drained into the first jejunal vein, and all of these were type B (P < 0.0001). CONCLUSIONS This study elucidated the vascular interrelationships around the middle colic vessels. Our findings provided important knowledge for laparoscopic surgery in treating transverse colon cancer.
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Affiliation(s)
- Atsushi Hamabe
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan.
| | - SungAe Park
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Shunji Morita
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Tsukasa Tanida
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yoshito Tomimaru
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hiroshi Imamura
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Keizo Dono
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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28
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Negoi I, Beuran M, Hostiuc S, Negoi RI, Inoue Y. Surgical Anatomy of the Superior Mesenteric Vessels Related to Colon and Pancreatic Surgery: A Systematic Review and Meta-Analysis. Sci Rep 2018; 8:4184. [PMID: 29520096 PMCID: PMC5843657 DOI: 10.1038/s41598-018-22641-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 02/27/2018] [Indexed: 12/16/2022] Open
Abstract
The surgeon dissecting the base of the mesenterium, around the superior mesenteric vein (SMV) and artery, is facing a complex tridimensional vascular anatomy and should be aware of the anatomical variants in this area. The aim of this systematic review is to propose a standardized terminology of the superior mesenteric vessels, with impact in colon and pancreatic resections. We conducted a systematic search in PubMed/MEDLINE and Google Scholar databases up to March 2017. Forty-five studies, involving a total of 6090 specimens were included in the present meta-analysis. The pooled prevalence of the ileocolic, right colic and middle colic arteries was 99.8%, 60.1%, and 94.6%, respectively. The superior right colic vein and Henle trunk were present in 73.9%, and 89.7% of specimens, respectively. In conclusion, the infra-pancreatic anatomy of the superior mesenteric vessels is widely variable. We propose the term Henle trunk to be used for any venous confluence between gastric, pancreatic and colic veins, which drains between the inferior border of the pancreas and up to 20 mm downward on the right-anterior aspect of the SMV. The term gastrocolic trunk should not be synonymous, but a subgroup of the Henle trunk, together with to gastropancreatocolic, gastropancreatic, or colopancreatic trunk.
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Affiliation(s)
- Ionut Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania.
- Department of General Surgery, Emergency Hospital of Bucharest, Bucharest, Romania.
| | - Mircea Beuran
- Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania
- Department of General Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Sorin Hostiuc
- Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania
- Department of Legal Medicine and Bioethics, National Institute of Legal Medicine Mina Minovici, Bucharest, Romania
| | | | - Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Munkedal DLE, Rosenkilde M, Nielsen DT, Sommer T, West NP, Laurberg S. Radiological and pathological evaluation of the level of arterial division after colon cancer surgery. Colorectal Dis 2017; 19:O238-O245. [PMID: 28590033 DOI: 10.1111/codi.13756] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/05/2017] [Indexed: 01/08/2023]
Abstract
AIM In aiming to cure patients with colorectal cancer surgery, the surgeon must carefully dissect the mesocolon and mesorectum and divide the vascular pedicle near to its origin so as to include all local lymph nodes. This has been termed complete mesocolic excision. The distance from the distal vascular tie to the bowel wall in the fixed specimen is an indication as to the quality of surgery but this does not assess the length of the residual vascular pedicle and, by implication, residual lymph nodes. The aim of this study was to establish if our surgeons were carrying out complete mesocolic excision by assessing the length of the proximal arterial pedicle and relating this to arterial length in the fixed specimen. METHOD This was a single centre prospective study of patients undergoing elective surgery for locally advanced colorectal cancer. An abdominal and pelvic CT scan was performed 2 days postoperatively and a radiologist blinded to the operative procedure measured the length of the residual arterial stump. Similarly, the length of the vessel in the fixed resected specimen and lymph node yield were also recorded. RESULTS Fifty-two patients were recruited. The mean length of the residual arterial stump was 38 mm (95% CI: 33-43), which was significantly longer than the < 10 mm recommended in guidelines (P < 0.0001). The mean length was 31 mm (95% CI: 25-37) and 49 mm (95% CI: 40-57) for left and right sided resections respectively. There was no correlation between the residual arterial stump and the pathology. CONCLUSIONS The residual arterial length was greater than suggested by guidelines and may indicate that our surgery is less radical than we planned. Caution should be taken when using pathological measurements of vascular ligation as it may not reflect the height of the pedicle division.
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Affiliation(s)
- D L E Munkedal
- Department of Surgery, THG, Aarhus University Hospital, Aarhus C, Denmark
| | - M Rosenkilde
- Department of Radiology, THG, Aarhus University Hospital, Aarhus C, Denmark
| | - D T Nielsen
- Department of Radiology, NBG, Aarhus University Hospital, Aarhus C, Denmark
| | - T Sommer
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | - N P West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St James's University Hospital, Leeds, UK
| | - S Laurberg
- Department of Surgery, THG, Aarhus University Hospital, Aarhus C, Denmark
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The impact of three-dimensional reconstruction on laparoscopic-assisted surgery for right-sided colon cancer. Wideochir Inne Tech Maloinwazyjne 2017; 12:251-256. [PMID: 29062445 PMCID: PMC5649492 DOI: 10.5114/wiitm.2017.67996] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/07/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction During laparoscopic-assisted colorectal surgery (LACS) for right-sided colon cancer patients, we performed three-dimensional (3D) surgical simulation to investigate vascular anatomy, including the ileocolic artery (ICA), right colic artery (RCA) and superior mesenteric vein (SMV). Aim We also used 3D imaging to examine the shortest distance from the root of the ileocolic vein (ICV) to the gastrocolic trunk (GCT). Material and methods We analyzed 46 right-sided colon cancer patients who underwent 3D-simulated LACS. We also examined a control group of 20 right-sided colon cancer patients who underwent LACS without 3D imaging. Patients who received such assessments were classified into the following two groups based on the vessel arrangement patterns of the ICA and SMV: the type A group, in which the ICA crosses anterior to the SMV, and the type B group, in which the ICA crosses posterior to the SMV. The shortest length from the root of the ICV to the GCT (D mm) was measured via 3D imaging. Patient characteristics and perioperative outcomes for these three groups were compared. Results The mean D mm for all cases was 29.2 ±5.21 mm. Mean D mm values for the type A and type B groups were 27.8 ±4.21 and 30.5 ±5.53 mm, respectively. Intraoperative blood loss was lower in the type A group (41.8 ±27.5 g) and the type B group (44.5 ±31.6 g) than that in the control group (86.8 ±27.5 g) (p = 0.013). Conclusions 3D imaging was useful for understanding anatomical relationships during LACS.
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Miyamoto R, Tadano S, Sano N, Inagawa S, Yamamoto M. The Impact of Laparoscopic-assisted Colorectal Surgery Using 3-dimensional Reconstruction for Highly Obese Patients With Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2017; 27:175-178. [PMID: 28346287 DOI: 10.1097/sle.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES During laparoscopic-assisted colorectal surgery (LACS), precise recognition of the anatomic variations and relationships among tumor and vessels is required. However, in highly obese patients, it is more difficult to grasp the surgical anatomy due to the presence of dense mesenteric fat tissue. We utilized a 3-dimensional (3D) reconstructed image for preoperative simulation and intraoperative navigation for LACS. In this study, we examined the correlation between patient obesity and 3D-simulated perioperative outcomes. MATERIALS AND METHODS We retrospectively analyzed 124 patients who underwent LACS using 3D surgical simulation at Tsukuba Medical Center Hospital. We sequentially divided our cohort into 2 groups: patients with a low body mass index (BMI<25 kg/m, n=60) and patients with a high BMI (BMI ≥25 kg/m, n=64). Patient characteristics and perioperative outcomes, including conversion rate, postoperative complications, operating time, intraoperative blood loss, and length of postoperative hospital stay, were compared for these 2 groups. RESULTS There were no significant differences in patient background between the 2 groups.We found it more difficult to grasp the surgical anatomy, including vessel arrangement, for high-BMI patients than for low-BMI patients because of the dense mesenteric fat tissue in high-BMI patients. There were no significant differences between the 2 groups with respect to perioperative outcomes. CONCLUSIONS The utilized reconstructed 3D images were useful for understanding anatomic relationships, including vessel arrangement, during LACS, particularly in highly obese patients.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, Ibaraki, Japan
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Abstract
BACKGROUND Knowledge of the normal pattern and variations of the blood supply of the right colon is crucial for better outcomes after colon surgery. OBJECTIVE The purpose of this study was to describe the precise vascular anatomy of the right colon according to surgical perspective. DESIGN Adult fresh cadavers were dissected between January 2013 and October 2015, focusing on the venous and arterial anatomy of the right side of the colon. SETTINGS Macroscopic anatomical dissections were performed on 111 adult fresh cadavers with emphasis on the vascular anatomy of the right colon. The colic tributaries of the superior mesenteric artery and vein were documented in writing. Furthermore, the dissections were recorded with a video camera. RESULTS The incidence of colic arteries arising from the superior mesenteric artery included ileocolic artery, 100%; right colic artery, 33.3%; middle colic artery, 100%; and accessory middle colic artery, 11,7%. All 111 cadavers had a single ileocolic vein, which drained into the superior mesenteric vein in 103 cases (92.8%), into the gastro-pancreatico-colic trunk in 7 cases (6.3%), and into the jejunal trunk in 1 case (0.9%). The drainage site of the ileocolic vein to the superior mesenteric vein varied, and in 9% of cases the ileocolic vein did not accompany the ileocolic artery. The gastro-pancreatico-colic trunk was detected in 87 cases (78.4%); with several forms of the origin of the respective branches, the gastropancreatic trunk was detected in 24 cases (21.6), and the classic gastrocolic trunk of Henle was not detected. Variations were found in the formation and drainage routes of other venous colic tributaries of the superior mesenteric vein. LIMITATIONS This study is limited by its use of cadavers in that it is impossible to trace each vessel to its origin in live surgery. CONCLUSIONS Surgeons must watch, observe, and bear in mind that vascular variations can occur. Awareness of these complex variations may improve the quality of surgery and may prevent devastating complications during right-sided colon resections.
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Intraoperative Archive of Right Colonic Vascular Variability Aids Central Vascular Ligation and Redefines Gastrocolic Trunk of Henle Variants. Dis Colon Rectum 2017; 60:22-29. [PMID: 27926554 DOI: 10.1097/dcr.0000000000000720] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Vascular supply to the right colon has become an issue because of high variability and subsequent impact on minimally invasive surgery. Past cadaveric or radiologic anatomic assessments are noncomprehensive. OBJECTIVE Intraoperative charting of right colonic arteriovenous anatomy was undertaken to determine the incidence and scope of vascular variations. DESIGN Vascular anatomy variations were documented in snapshot images, captured during laparoscopic video recordings or through open surgical digital photography. SETTINGS Data were drawn from consecutive right hemicolectomies, routinely entailing complete mesocolic excision with central vascular ligation. PATIENTS Seventy patients (mean age, 62.7 years; 37 women (52.8%); 33 men (47.2%)), each with surgically treatable right-sided colon cancer, were prospectively studied. RESULTS Both ileocolic and middle colic arteries were regularly identified (100%), with right colic artery present in 41.4% of patients. Ileocolic and middle colic veins consistently drained into the right colon. Although the ileocolic vein always emptied into the superior mesenteric vein, drainage of the middle colic vein was split (superior mesenteric vein, 94.3%; gastrocolic trunk of Henle, 5.3%), as was drainage of the right colic (superior mesenteric vein, 43.3%; gastrocolic trunk of Henle, 56.7%) and accessory middle colic veins (superior mesenteric vein, 54.5%; gastrocolic trunk of Henle, 45.5%), present in 42.9% and 15.7% of patients. Gastrocolic trunk of Henle was found in 88.6% of patients, usually draining into the superior mesenteric vein. No significant sex-related differences were present regarding the incidence and scope of variability displayed by the right colic artery, right colic vein, accessory middle colic vein, or gastrocolic trunk of Henle classification (p > 0.05). LIMITATIONS The inconsistency between cadaver and live surgery anatomy and the low BMI of the Asian population might be drawbacks of our study. CONCLUSIONS Variations in right colonic arteriovenous channels, assessed intraoperatively, corroborate those established by cadaveric and radiologic means, prompting a new gastrocolic trunk of Henle classification.
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Murono K, Kawai K, Ishihara S, Otani K, Yasuda K, Nishikawa T, Tanaka T, Kiyomatsu T, Hata K, Nozawa H, Yamaguchi H, Watanabe T. Evaluation of the vascular anatomy of the right-sided colon using three-dimensional computed tomography angiography: a single-center study of 536 patients and a review of the literature. Int J Colorectal Dis 2016; 31:1633-8. [PMID: 27461539 DOI: 10.1007/s00384-016-2627-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The requisite for a rigorous preoperative understanding of vascular branching continues to grow in parallel with the implementation of laparoscopic surgery. Three-dimensional (3D)-computed tomography (CT) angiography is a less-invasive modality than traditional angiographic examination. Therefore, we aimed to evaluate branching patterns of the superior mesenteric artery (SMA). METHODS In the present study, 536 consecutive patients who underwent preoperative 3D-CT angiography from April 2012 to March 2014 were prospectively enrolled. The branching pattern of the right colic artery (RCA) and the intersectional patterns of the RCA, ileocolic artery (ICA), and superior mesenteric vein (SMV) were evaluated. RESULTS The RCA existed in only 179 cases (33.4 %); the remaining 357 patients (66.6 %) lacked evidence of the RCA. The ICA was detected in all cases. The RCA ran ventral to the SMV in the majority of cases (89.4 %). Conversely, the ICA ran ventral to the SMV in only half of the cases (50.6 %). When the RCA was observed to pass dorsal to the SMV, the ICA also ran dorsal to SMV in all cases. CONCLUSIONS 3D-CT angiography can aid surgeons in identifying and understanding the anatomical vascular variations and intersectional patterns of the RCA, ICA, and SMV. Developing awareness of these variations can aid in the prevention of unexpected vascular injury during laparoscopic right-sided colon surgery.
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Affiliation(s)
- Koji Murono
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kazushige Kawai
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Soichiro Ishihara
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kensuke Otani
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koji Yasuda
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Nishikawa
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Tanaka
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomomichi Kiyomatsu
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Hata
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Nozawa
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hironori Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Watanabe
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Abstract
BACKGROUND The vascular anatomy in the right colon varies; however, related studies are rare, especially on the laparoscopic vascular anatomy of living patients. OBJECTIVE The purpose of this study was to describe vascular variations around the gastrocolic trunk, middle colic vein, and ileocolic vessels in laparoscopic surgery for right-sided colon cancer. DESIGN This is a retrospective descriptive study of patients undergoing laparoscopic colectomy for right colon cancer. SETTINGS The study was conducted at a single tertiary institution in Korea. PATIENTS Consecutive patients with right colon cancer who underwent laparoscopic right colectomy using the cranial-to-caudal approach (N = 116) between January 2014 and April 2015 were included. MAIN OUTCOME MEASURES Three colorectal surgeons took photographs and videos of the vascular anatomy during each laparoscopic right colectomy, and these were analyzed for vascular variations. RESULTS We classified venous variations around the gastrocolic trunk into 2 types (3 subtypes), type 1 (n = 92 (79.3%)), defined as 1 or 2 colic veins draining into the gastrocolic trunk, and type II (n = 24 (20.7%)), defined as having no gastrocolic trunk. We also investigated the tributaries of the superior mesenteric vein. One, 2, and 3 middle colic veins were found in 86 (74.1%), 26 (22.4%), and 4 patients (3.5%). The right colic vein drained directly into the superior mesenteric vein in 22 patients (19.0%). All of the patients had a single ileocolic vein draining into the superior mesenteric vein and a single ileocolic artery from the superior mesenteric artery. The right colic artery from the superior mesenteric artery was present in 38 patients (32.7%). The ileocolic artery passed the superior mesenteric vein anteriorly or posteriorly in 58 patients (50%) each. LIMITATIONS Unlike cadaver or radiological studies, we could not clarify the complete vessel paths. CONCLUSIONS We classified vascular anatomic variations in laparoscopic colectomy for right colon cancer, which could be helpful for colorectal surgeons.
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Alsabilah J, Kim WR, Kim NK. Vascular Structures of the Right Colon: Incidence and Variations with Their Clinical Implications. Scand J Surg 2016; 106:107-115. [PMID: 27215222 DOI: 10.1177/1457496916650999] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS There is a demand for a better understanding of the vascular structures around the right colonic area. Although right hemicolectomy with the recent concept of meticulous lymph node dissection is a standardized procedure for malignant diseases among most surgeons, variations in the actual anatomical vascular are not well understood. The aim of the present review was to present a detailed overview of the vascular variation pertinent to the surgery for right colon cancer. MATERIALS AND METHODS Medical literature was searched for the articles highlighting the vascular variation relevant to the right colon cancer surgery. RESULTS Recently, there have been many detailed studies on applied surgical vascular anatomy based on cadaveric dissections, as well as radiological and intraoperative examinations to overcome misconceptions concerning the arterial supply and venous drainage to the right colon. Ileocolic artery and middle colic artery are consistently present in all patients arising from the superior mesenteric artery. Even though the ileocolic artery passes posterior to the superior mesenteric vein in most of the cases, in some cases courses anterior to the superior mesenteric artery. The right colic artery is inconsistently present ranging from 63% to 10% across different studies. Ileocolic vein and middle colic vein is always present, while the right colic vein is absent in 50% of patients. The gastrocolic trunk of Henle is present in 46%-100% patients across many studies with variation in the tributaries ranging from bipodal to tetrapodal. Commonly, it is found that the right colonic veins, including the right colic vein, middle colic vein, and superior right colic vein, share the confluence forming the gastrocolic trunk of Henle in a highly variable frequency and different forms. CONCLUSION Understanding the incidence and variations of the vascular anatomy of right side colon is of crucial importance. Failure to recognize the variation during surgery can result in troublesome bleeding especially during minimal invasive surgery.
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Affiliation(s)
- J Alsabilah
- Division of Colorectal Surgery, Department of Surgery, College of Medicine, Yonsei University Health System, Seoul, Korea
| | - W R Kim
- Division of Colorectal Surgery, Department of Surgery, College of Medicine, Yonsei University Health System, Seoul, Korea
| | - N K Kim
- Division of Colorectal Surgery, Department of Surgery, College of Medicine, Yonsei University Health System, Seoul, Korea
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Kaye TL, West NP, Jayne DG, Tolan DJM. CT assessment of right colonic arterial anatomy pre and post cancer resection - a potential marker for quality and extent of surgery? Acta Radiol 2016; 57:394-400. [PMID: 25940063 DOI: 10.1177/0284185115583033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/25/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is conflicting opinion as to the optimum extent of resection for right-sided colonic cancer, which is currently graded by pathological analysis of the resected specimen. It is not known if computed tomography (CT) analysis of residual post-resection arterial stump length could be used as an alternative in vivo marker for extent of mesenteric resection. Ileocolic artery stumps have been demonstrated previously on CT after right hemicolectomy, but only in the early postoperative period. PURPOSE To analyze preoperative right colonic arterial anatomy using portal venous colorectal cancer staging CT and subsequently determine if post-resection arterial stumps (a potential in vivo marker of surgical resection) could be consistently identified using routine follow-up CT scans many months after cancer resection. MATERIAL AND METHODS A retrospective analysis of routine staging and follow-up CT scans for 151 patients with right-sided colorectal cancer was performed. Preoperative right colonic arterial anatomy and postoperative arterial stumps were analyzed and measured. RESULTS Preoperative ileocolic (98.8%), middle (94.7%), and right colic artery (23.8%) identification was comparable to catheter angiogram studies. Postoperative ileocolic stumps were consistently demonstrated (88.3%) many months (average, 2 years and 42 days) after resection and were significantly longer than expected for a standard D2 resection (paired t-test, t(127) = -11.45, P ≤ 0.001). CONCLUSION This is the first study to successfully demonstrate ileocolic arterial stumps many months (and years) after cancer resection using routine portal venous CT. Further prospective research should assess whether arterial stumps can be used as an in vivo marker of surgical quality and extent.
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Affiliation(s)
- Tom L Kaye
- Department of Clinical Radiology and Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nick P West
- Department of Clinical Radiology and Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David G Jayne
- Department of Clinical Radiology and Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Damian JM Tolan
- Department of Clinical Radiology and Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Miyamoto R, Nagai K, Kemmochi A, Inagawa S, Yamamoto M. Three-dimensional reconstruction of the vascular arrangement including the inferior mesenteric artery and left colic artery in laparoscope-assisted colorectal surgery. Surg Endosc 2016; 30:4400-4. [PMID: 26850027 DOI: 10.1007/s00464-016-4758-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/11/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND We performed three-dimensional (3D) reconstruction to investigate the vascular anatomy, including the inferior mesenteric artery (IMA), left colic artery (LCA), and inferior mesenteric vein (IMV), for laparoscope-assisted left-side colorectal surgery. Furthermore, we also examined the distances from the root of the IMA to the bifurcation of the LCA and to the IMV using 3D imaging. METHODS We retrospectively analyzed 46 patients who underwent laparoscope-assisted left-side colorectal surgery via 3D surgical reconstruction at Tsukuba Medical Center Hospital. The branching patterns among the IMA, LCA, and sigmoidal colic artery (SCA) in colon cancer could be classified into three groups (types A, B, and C): type A, in which both arteries (LCA and SCA) branch off from the same point of the IMA; type B, in which the common trunk of the LCA and SCA branches off from the IMA; and type C, in which the LCA and SCA branch off separately from the IMA. The shortest length from the root of the IMA to bifurcation of the LCA and SCA branches (D mm) or to the IMV (d mm) was measured by 3D imaging. RESULTS The mean D mm and d mm for all cases were 39.4 ± 11.2 and 27.9 ± 9.21 mm, respectively. The D mm from the IMA root to the LCA or SCA branch in types A, B, and C was 37.8 ± 9.21, 40.5 ± 12.7, and 38.6 ± 10.2 mm, respectively. Similarly, the d mm from the IMA root to the IMV in types A, B, and C was 30.2 ± 11.3, 29.9 ± 7.27, and 25.2 ± 10.3 mm, respectively. CONCLUSION The present 3D reconstruction technique was useful for determining the 3D vascular anatomical pattern including the relative positions of the IMA, SCA, and IMV during laparoscope-assisted left-side colorectal surgery.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan.
| | - Kentaro Nagai
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Akira Kemmochi
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Satoshi Inagawa
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Masayoshi Yamamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
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Nesgaard JM, Stimec BV, Bakka AO, Edwin B, Ignjatovic D. Navigating the mesentery: a comparative pre- and per-operative visualization of the vascular anatomy. Colorectal Dis 2015; 17:810-8. [PMID: 25988347 DOI: 10.1111/codi.13003] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 03/26/2015] [Indexed: 02/08/2023]
Abstract
AIM Awareness of anatomy is critical for performing safe surgery within the root of the mesentery. Our aim was to investigate the anatomical relationship between the superior mesenteric artery (SMA) and vein (SMV) and their branches within a predefined D3 area of the right colon and to compare preoperatively established three-dimensional (3D) mesenteric vessel anatomy from CT with that found at surgery. METHOD Prospective data were collected on 139 patients included in the 'Safe Radical D3 Right Hemicolectomy for Cancer Through Preoperative Biphasic Multi-detector Computed Tomography (MDCT) Angiography' trial. CT data sets were 3D reconstructed before surgery and compared with photographs taken during the operation. RESULTS The ileocolic artery was present and correctly identified in all patients and crossed the SMV anteriorly in 58 (41.7%). Seventeen patients had a right colic artery at surgery and there were three false-negative and one false-positive CT findings, yielding a diagnostic accuracy of 97.1%, sensitivity of 85.7% and specificity of 95.2%. Positive and negative predictive values were 94.7% and 97.5%, respectively. The middle colic artery was absent in one (0.7%) patient and multiple (nine double and one triple) in 10 (7.2%) patients. A mean of 3.8 ± 1.2 jejunal arteries and 2.0 ± 0.8 jejunal veins arose from the SMA and SMV. Jejunal veins crossed the SMA in the D3 area anteriorly in 30.9% of patients. In 26 (18.7%) patients, additional veins drained into the SMV, including pancreaticoduodenal in 16, right colic in six and both in two. The inferior mesenteric vein entered the SMV in 58 (41.7%) patients and crossed the D3 area in three (2.2%). CONCLUSION CT-reconstructed anatomy has high specificity, sensitivity, accuracy and reliability.
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Affiliation(s)
- J M Nesgaard
- Department of Gastrointestinal Surgery, Vestfold Hospital Trust, Tonsberg, Norway
| | - B V Stimec
- Faculty of Medicine, Department of Cellular Physiology and Metabolism, Anatomy Sector, University of Geneva, Geneva, Switzerland
| | - A O Bakka
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - B Edwin
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Interventional Centre, Gastrointestinal and Pediatric Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - D Ignjatovic
- Department of Gastrointestinal Surgery, Vestfold Hospital Trust, Tonsberg, Norway.,Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway
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Flor N, Campari A, Ravelli A, Lombardi MA, Pisani Ceretti A, Maroni N, Opocher E, Cornalba G. Vascular Map Combined with CT Colonography for Evaluating Candidates for Laparoscopic Colorectal Surgery. Korean J Radiol 2015; 16:821-6. [PMID: 26175581 PMCID: PMC4499546 DOI: 10.3348/kjr.2015.16.4.821] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 04/08/2015] [Indexed: 01/23/2023] Open
Abstract
Contrast-enhanced computed tomography colonography (CE-CTC) is a useful guide for the laparoscopic surgeon to avoid incorrectly removing the colonic segment and the failure to diagnose of synchronous colonic and extra-colonic lesions. Lymph node dissection and vessel ligation under a laparoscopic approach can be time-consuming and can damage vessels and organs. Moreover, mesenteric vessels have extreme variations in terms of their courses and numbers. We describe the benefit of using an abdominal vascular map created by CE-CTC in laparoscopic colorectal surgery candidates. We describe patients with different diseases (colorectal cancer, diverticular disease, and inflammatory bowel disease) who underwent CE-CTC just prior to laparoscopic surgery.
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Affiliation(s)
- Nicola Flor
- Unità Operativa di Radiologia Diagnostica e Interventistica, Azienda Ospedaliera San Paolo, Milan 20142, Italy. ; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan 20142, Italy
| | - Alessandro Campari
- Scuola di Specializzazione in Radiodiagnostica, Facoltà di Medicina e Chirurgia, Universitì degli Studi di Milano, Milan 20122, Italy
| | - Anna Ravelli
- Scuola di Specializzazione in Radiodiagnostica, Facoltà di Medicina e Chirurgia, Universitì degli Studi di Milano, Milan 20122, Italy
| | - Maria Antonietta Lombardi
- Scuola di Specializzazione in Radiodiagnostica, Facoltà di Medicina e Chirurgia, Universitì degli Studi di Milano, Milan 20122, Italy
| | | | - Nirvana Maroni
- Unità Operativa di Chirurgia, Azienda Ospedaliera San Paolo, Milan 20142, Italy
| | - Enrico Opocher
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan 20142, Italy. ; Unità Operativa di Chirurgia, Azienda Ospedaliera San Paolo, Milan 20142, Italy
| | - Gianpaolo Cornalba
- Unità Operativa di Radiologia Diagnostica e Interventistica, Azienda Ospedaliera San Paolo, Milan 20142, Italy. ; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan 20142, Italy
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Seishima R, Okabayashi K, Hasegawa H, Tsuruta M, Hoshino H, Yamada T, Kitagawa Y. Computed tomography attenuation values of ascites are helpful to predict perforation site. World J Gastroenterol 2015; 21:1573-1579. [PMID: 25663776 PMCID: PMC4316099 DOI: 10.3748/wjg.v21.i5.1573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/27/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of computed tomography (CT) attenuation values of ascites on gastrointestinal (GI) perforation site prediction.
METHODS: The CT attenuation values of the ascites from 51 patients with GI perforations were measured by volume rendering to calculate the mean values. The effect of the CT attenuation values of the ascites on perforation site prediction and postoperative complications was evaluated.
RESULTS: Of 24 patients with colorectal perforations, the CT attenuation values of ascites were significantly higher than those in patients with perforations at other sites [22.5 Hounsfield units (HU) vs 16.5 HU, respectively, P = 0.006]. Colorectal perforation was significantly associated with postoperative complications (P = 0.038). The prediction rate of colorectal perforation using attenuation values as an auxiliary diagnosis improved by 9.8% compared to that of CT findings alone (92.2% vs 82.4%).
CONCLUSION: The CT attenuation values of ascites could facilitate the prediction of perforation sites and postoperative complications in GI perforations, particularly in cases in which the perforation sites are difficult to predict by CT findings alone.
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Abstract
BACKGROUND The branching of the inferior mesenteric artery and vein varies among individuals. Three-dimensional CT angiography is a less invasive modality than traditional angiographic examination to assess the artery and vein. OBJECTIVE We aimed to demonstrate the clinical applicability of CT angiography by evaluating bifurcations of the inferior mesenteric artery and the positional relationship between the inferior mesenteric artery and vein. DESIGN This was a prospective observational study of patients undergoing preoperative CT angiography. SETTINGS This study was conducted at a single tertiary care institution in Japan. PATIENTS A total of 471 consecutive patients who underwent preoperative CT angiography from April 2012 to December 2013 were prospectively enrolled. MAIN OUTCOME MEASURES The branching pattern of the inferior mesenteric artery, the positional relationship between the inferior mesenteric artery and vein, and the associations between inferior mesenteric artery length and clinical features were evaluated. RESULTS The length of the inferior mesenteric artery varied widely, from 10.1 to 82.2 mm. In 41.2% patients, the left colic artery arose independently from the sigmoid artery, and in 44.7% of the patients, the left colic artery and sigmoid artery had a common trunk, whereas the left colic artery did not exist in 5.1%. The left colic artery was located lateral to the inferior mesenteric vein at the level of the origin of the inferior mesenteric artery in 73.0% of the patients. The incidence of a short inferior mesenteric artery was significantly increased in men with high BMIs (75.0%). LIMITATIONS Three-dimensional reconstruction was performed by the use of a single software, and angiographic examination was not performed. Therefore, accuracy and reliability of the 3-dimensional reconstruction could not be established for each modality. CONCLUSIONS Using 3-dimensional CT angiography, preoperative understanding of the anatomic vascular variations can be easily obtained, which would help surgeons to safely perform laparoscopic surgery in the left-side colon and rectum.
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Miyazawa M, Kawai M, Hirono S, Okada KI, Shimizu A, Kitahata Y, Yamaue H. Preoperative evaluation of the confluent drainage veins to the gastrocolic trunk of Henle: understanding the surgical vascular anatomy during pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:386-91. [PMID: 25565654 DOI: 10.1002/jhbp.205] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 11/26/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND The aim of this study was to classify the variations of the anatomical tributaries of the colic drainage veins into the gastrocolic trunk of Henle detected by three-dimensional multidetector computed tomography to understand the surgical vascular anatomy during pancreaticoduodenectomy. METHODS One hundred and twenty patients who underwent three-dimensional multidetector computed tomography studies before pancreaticoduodenectomy were retrospectively reviewed. RESULTS The gastrocolic trunk of Henle was identified in 100 patients (83.3%) by three-dimensional multidetector computed tomography. The anatomical tributaries of the gastrocolic trunk of Henle described by three-dimensional multidetector computed tomography were classified into four types based on the number of veins (superior right colic vein, right colic vein and middle colic vein) that drained into the gastrocolic trunk of Henle, as follows: Type-0 (no colic drainage veins), -I (one colic drainage vein), -II (two colic drainage veins) and -III (three colic drainage veins). The frequencies of Type-0, Type-I, Type-II and Type-III were 7% (n = 7), 71% (n = 71), 20% (n = 20) and 2% (n = 2), respectively. CONCLUSIONS Three-dimensional multidetector computed tomography can provide clinically useful information about the confluent colic drainage veins to gastrocolic trunk of Henle during pancreaticoduodenectomy.
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Affiliation(s)
- Motoki Miyazawa
- Second Department of Surgery, Wakayama Medical University School of Medicine, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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Søndenaa K, Quirke P, Hohenberger W, Sugihara K, Kobayashi H, Kessler H, Brown G, Tudyka V, D'Hoore A, Kennedy RH, West NP, Kim SH, Heald R, Storli KE, Nesbakken A, Moran B. The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery : proceedings of a consensus conference. Int J Colorectal Dis 2014; 29:419-28. [PMID: 24477788 DOI: 10.1007/s00384-013-1818-2] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors. METHOD There are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354-365, 2009; West et al., J Clin Oncol 28:272-278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction. RESULT The oncological rationale for CME and various technical aspects of the surgical management will be explored. CONCLUSION The consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery.
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Affiliation(s)
- K Søndenaa
- Department of Surgery, Haraldsplass Deaconess Hospital, POB 6165, 5892, Bergen, Norway,
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Weber K, Hohenberger W. Right hemicolectomy with central vascular ligation in colon cancer. Surg Endosc 2012; 26:282. [PMID: 21792711 DOI: 10.1007/s00464-011-1849-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
BACKGROUND Current practice when performing right colectomy for cancer is to divide the feeding vessels for the right colon on the right side of the superior mesenteric vein. OBJECTIVE This study aims to show that arterial stumps can be visualized through an early postoperative CT and analyze their anatomical and surgical characteristics. DESIGN This study presents a retrospective review of prospective data. SETTINGS :The study was conducted at the Department of Surgery, Vestfold Hospital, Tonsberg, Norway. PATIENTS Patients with leakage after a right colectomy for cancer (2003-2011) were identified through a local prospective complication registry (FileMaker Pro 9.0v3 software). INTERVENTIONS Both preoperative and postoperative CTs were retrieved, reanalyzed, and 3-dimensionally reconstructed (Osirix v.3.0.2./Mimics v.13.1.). Patients without postoperative CTs were excluded. MAIN OUTCOME MEASURES The main outcomes measured were length, caliber of presumed and actual arterial stumps, and their position relative to the superior mesenteric vein. RESULTS Eighteen patients, median age 69 (10 men) were included. All patients had postoperative CTs, and 15 patients had preoperative CTs. Median time from operation to postoperative CT was 5 days. The ileocolic artery was found in 14 (11 CT pairs) patients, and the right colic artery was found in 5 (4 pairs) patients. Actual stump lengths were 28.0 mm (SD 9.3) and 37.3 mm (SD 14.9). A significant statistical difference between presumed and actual ileocolic artery stump lengths was found (P = .002). Posterior crossing to the superior mesenteric vein was noticed in 8 of 14 ileocolic arteries and in 3 of 5 right colic arteries. There was no statistical difference in mean caliber for the preoperative and postoperative right colic artery (P = .505) and ileocolic artery (P = .474). LIMITATIONS Difficulties when interpreting the postoperative images, due to intra-abdominal effusion, staples, edema, and altered syntopy of blood vessels, were overcome through comparison with preoperative CTs. CONCLUSION An early postoperative CT can show arterial stumps after right colectomy for cancer. These stumps appear to be significantly longer than presumed; implying a significant improvement potential when specimen size is concerned.
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