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Objective@#To compare the evaluation effects of abdominal enhanced computed tomography (CT) coronal imaging versus three-dimensional (3D) vascular reconstruction for critical blood vessels in right colon cancer.@*Methods@#The retrospective and descriptive study was conducted. The clinicopathological data of 50 patients with right colon cancer who were admitted to Changhai Hospital Affiliated to Naval Medical University from January to September in 2018 were collected. There were 33 males and 17 females, aged from 33 to 86 years, with an average age of 63 years. All the 50 patients underwent abdominal multi-slice CT examination on the same CT equipment. The CT examination data were analyzed by two-dimensional (2D) coronal imaging and 3D vascular reconstruction. Observation indicators: (1) anatomical type of Henle trunk; (2) the length of Henle trunk and surgical trunk; (3) the positional relationship between ileocolic vein (ICV) and ileocolic artery (ICA). Measurement data with normal distribution were represented as Mean±SD, and count data were represented as absolute numbers. Kappa coefficients were used to measure the consistency between anatomical types of Henle trunk on 2D coronal images and on 3D vascular reconstructed images. Pearson coefficients were used to evaluate the correlation between the length of Henle trunk and surgical trunk on 2D coronal images and on 3D vascular reconstructed images. Bland-Altman method was used to assess the consistency between the length of Henle trunk and surgical trunk on 2D coronal images and on 3D vascular reconstructed images.@*Results@#(1) Anatomical type of Henle trunk: on the 2D coronal images, 43 of 50 patients had the Henle trunk and 7 had no Henle trunk. On the 3D vascular reconstructed images, 44 of 50 patients had the Henle trunk and 6 had no Henle trunk. There were 2, 21, 17, 3 patients classified as type 0, Ⅰ, Ⅱ, Ⅲ of Henle trunk on the 2D coronal images of 43 patients. There were 6, 19, 16, 3 patients classified as type 0, Ⅰ, Ⅱ, Ⅲ of Henle trunk on the 3D vascular reconstructed images of 44 patients. Six patients with no Henle trunk, 2 in type 0, 18 in type Ⅰ, 15 in type Ⅱ, and 3 in type Ⅲ had the same anatomical type of Henle trunk on the 2D and 3D images. The consistency between anatomic types of Henle trunk on 2D coronal images and on 3D vascular reconstructed images was high (κ=0.830, 95% confidence interval: 0.705-0.956, P<0.05). (2) The length of Henle trunk and surgical trunk: on the 2D coronal images, 43 of 50 patients had the length of Henle trunk as (10±5)mm, and 42 of 50 patients had the length of surgical trunk as (34±12)mm. On the 3D vascular reconstructed images, 44 of 50 patients had the length of Henle trunk as (9±5)mm, and 43 of 50 patients had the length of surgical truck as (35±12)mm. The correlation between the length of Henle trunk and surgical trunk on 2D coronal images and on 3D vascular reconstructed images was positive (r=0.872, 0.979, P<0.05). Bland-Altman plot showed a high consistency between the length of Henle trunk and surgical trunk on 2D coronal images and on 3D vascular reconstructed images (P<0.05). (3) The positional relationship between ICV and ICA: on the 2D coronal images, 24 of 50 patients had anterior crossing between ICV and ICA, 26 had posterior crossing between ICV and ICA. On the 3D vascular reconstructed images, 24 of 50 patients had anterior crossing between ICV and ICA, 26 had posterior crossing between ICV and ICA. There was a complete consistency in the positional relationship between ICV and ICA on the 2D coronal images and on 3D vascular reconstructed images.@*Conclusion@#Abdominal enhanced CT coronal imaging and 3D vascular reconstruction have the similar evaluation effects for position of critical blood vessels in right colon cancer, with a good consistency.
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Objective To compare the evaluation effects of abdominal enhanced computed tomography (CT) coronal imaging versus three-dimensional (3D) vascular reconstruction for critical blood vessels in right colon cancer.Methods The retrospective and descriptive study was conducted.The clinicopathological data of 50 patients with right colon cancer who were admitted to Changhai Hospital Affiliated to Naval Medical University from January to September in 2018 were collected.There were 33 males and 17 females,aged from 33 to 86 years,with an average age of 63 years.All the 50 patients underwent abdominal multi-slice CT examination on the same CT equipment.The CT examination data were analyzed by two-dimensional (2D) coronal imaging and 3D vascular reconstruction.Observation indicators:(1) anatomical type of Henle trunk;(2) the length of Henle trunk and surgical trunk;(3) the positional relationship between ileocolic vein (ICV) and ileocolic artery (ICA).Measurement data with normal distribution were represented as Mean±SD,and count data were represented as absolute numbers.Kappa coefficients were used to measure the consistency between anatomical types of Henle trunk on 2D coronal images and on 3D vascular reconstructed images.Pearson coefficients were used to evaluate the correlation between the length of Henle trunk and surgical trunk on 2D coronal images and on 3D vascular reconstructed images.Bland-Ahman method was used to assess the consistency between the length of Henle trunk and surgical trunk on 2D coronal images and on 3D vascular reconstructed images.Results (1) Anatomical type of Henle trunk:on the 2D coronal images,43 of 50 patients had the Henle trunk and 7 had no Henle trunk.On the 3D vascular reconstructed images,44 of 50 patients had the Henle trunk and 6 had no Henle trunk.There were 2,21,17,3 patients classified as type 0,Ⅰ,Ⅱ,Ⅲ of Henle trunk on the 2D coronal images of 43 patients.There were 6,19,16,3 patients classified as type 0,Ⅰ,Ⅱ,Ⅲ of Henle trunk on the 3D vascular reconstructed images of 44 patients.Six patients with no Henle trunk,2 in type 0,18 in type Ⅰ,15 in type Ⅱ,and 3 in type Ⅲ had the same anatomical type of Henle trunk on the 2D and 3D images.The consistency between anatomic types of Henle trunk on 2D coronal images and on 3D vascular reconstructed images was high (κ =0.830,95％ confidence interval:0.705-0.956,P＜0.05).(2) The length of Henle trunk and surgical trunk:on the 2D coronal images,43 of 50 patients had the length of Henle trunk as (10±5)mm,and 42 of 50 patients had the length of surgical trunk as (34± 12)mm.On the 3D vascular reconstructed images,44 of 50 patients had the length of Henle trunk as (9±5)mm,and 43 of 50 patients had the length of surgical truck as (35± 12)mm.The correlation between the length of Henle trunk and surgical trunk on 2D coronal images and on 3D vascular reconstructed images was positive (r=0.872,0.979,P＜0.05).Bland-Altman plot showed a high consistency between the length of Henle trunk and surgical trunk on 2D coronal images and on 3D vascular reconstructed images (P＜0.05).(3) The positional relationship between ICV and ICA:on the 2D coronal images,24 of 50 patients had anterior crossing between ICV and ICA,26 had posterior crossing between ICV and ICA.On the 3D vascular reconstructed images,24 of 50 patients had anterior crossing between ICV and ICA,26 had posterior crossing between ICV and ICA.There was a complete consistency in the positional relationship between ICV and ICA on the 2D coronal images and on 3D vascular reconstructed images.Conclusion Abdominal enhanced CT coronal imaging and 3D vascular reconstruction have the similar evaluation effects for position of critical blood vessels in right colon cancer,with a good consistency.
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Laparoscopic radical colectomies have been more widely used gradually, among which laparoscopic extended right hemicolectomy is considered as the most difficult procedure. The difficulty of extended right hemicolectomy lies in the need to dissect lymph nodes along the superior mesenteric vein (SMV) and disconnect numerous and possible aberrant vessels. To address this problem, we emphasize two points in key vessel assessment: getting familiar with the anatomy along the medial-to-lateral approach and having a good understanding about the preoperative imaging presentations. An accurately preoperative imaging assessment by abdominal enhanced CT can help the surgeon understand the relative position of the key vessels to be dealt with during operation and the situation of the possible aberrant vessels so as to guide the procedure more effectively and facilitate the prevention and management of the intraoperative complications. During operation, the operator should pay special attention to the management of the vessels in the ileocolic vessel region, Henle's trunk and middle colon vessels. The operation highlights of the key vessels are as follows: (1) The ileocolic vessels: identifying the Toldt's gap correctly and opening the vascular sheath of the SMV securely; making sure that the duodenum is well protected. (2) Henle's trunk: dissecting along the surface of the Henle's trunk; preserving the anterior superior pancreaticoduodenal vein (ASPDV) and main trunk of the Henle's trunk; disconnecting the roots of the right colic vein (RCV) and right gastroepiploic vein (RGEV), and then dissecting lymph nodes along the surface of the pancreas. (3) The middle colon vessels: identifying the root of the middle colon vessel along the lower edge of the pancreas; avoiding entering behind the pancreas; mobilizing the transverse mesocolon sufficiently along the surface of the pancreas. Finally, we discuss and analyze the disputes currently existing in laparoscopic extended right hemicolectomy, including dissection of No.6 lymph nodes, naking the SMA and dissecting lymph nodes around the roots of the branches of SMA. This article shares our experience about laparoscopic extended right hemicolectomy, hoping that it could help beginners master the technique more safely and skillfully.
Subject(s)
Humans , Colectomy , Methods , Colon, Transverse , Colonic Neoplasms , General Surgery , Laparoscopy , Mesocolon , General SurgeryABSTRACT
<p><b>OBJECTIVE</b>To investigate the relationship between tumor regression grade (TRG) and lymph node regression grade (LRG) after neoadjuvant chemoradiotherapy (CRT) for rectal cancer and its clinical implication.</p><p><b>METHODS</b>Clinicopathological data of 176 rectal cancer patients undergoing radical excision after neoadjuvant CRT from January 2005 to December 2013 in our department were retrospectively analyzed.</p><p><b>INCLUSION CRITERIA</b>(1) Radiology indicated locally advanced low rectal cancer and patients had strong desire to preserve the sphincter before neoadjuvant CRT; (2) there was no definite metastatic lesion before neoadjuvant CRT; (3) patients received whole course of neoadjuvant CRT (regular radiotherapy plus synchronous fluorouracil-like drugs chemotherapy); (4) patients underwent radical operation after neoadjuvant CRT. Patients with short-course CRT and emergency surgery were excluded. TRG and LRG of postoperative specimens (including tumor and lymph nodes) were carried out based on the percentage of the fibrosis and the cancer residue. No cancer residue was defined as TRG1 and LRG1; rare cancer cell residue as TRG2 and LRG2; fibrosis growth over residual cancer as TRG3 and LRG3; residual cancer growth over fibrosis as TRG4 and LRG4; absence of regressive changes as TRG5 and LRG5; and normal lymph nodes as LRG0. Spearman correlation test was used to assess the correlation between TRG and LRG.</p><p><b>RESULTS</b>Of 176 patients, 111 were men and 65 were women. The mean age was (53.9±13.0) years. The number of patients with stage I(, II(, and III( before operation was 10, 49 and 62 while other 55 patients were unknown. Transabdominal low anterior resection (LAR) was performed in 118 cases and abdominal-perineal resection(APR) in 47 cases following the principle of total mesorectal excision (TME). Postoperative pathology of specimens revealed that the number of patients from TRG1 to TRG5 was 19 (10.8%), 25 (14.2%), 66 (37.5%), 47 (26.7%), 19 (10.8%), and from LRG0 to LRG5 was 35 (19.9%), 68 (38.6%), 10 (5.7%), 14 (8.0%), 15(8.5%), 34 (19.3%), respectively. TRG was correlated to LRG (P=0.005) while the Spearman correlation coefficient was only 0.24. The analysis of subgroup without LRG1 also showed that TRG was correlated to LRG(P=0.0005) and the Spearman correlation coefficient was 0.40.</p><p><b>CONCLUSIONS</b>TRG can not represent LRG. Therefore, both TRG and LRG should be assessed when evaluating the response of rectal cancer to neoadjuvant CRT.</p>
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<p><b>OBJECTIVE</b>To identify the risk factors associated with lymph node metastasis in rectal cancer after neoadjuvant chemoradiotherapy (CRT).</p><p><b>METHODS</b>From January 2005 to December 2013, the clinical data of 178 patients with advanced rectal cancer undergoing radical excision after neoadjuvant CRT in our department were reviewed retrospectively. A total of 11 clinicopathologic factors relating to lymph node metastasis were studied using univariate and multivariate Logistic regression analyses.</p><p><b>RESULTS</b>There were 74(41.6%) cases with lymph node metastasis, while 104 cases without lymph node metastasis. Univariate analysis showed that age(P=0.000 2), post-CRT CEA level(P=0.011 2), ypT stage(P=0.000 0), pathologic type(P=0.004 0), and tumor regression grade(TRG)(P=0.033 8) were significantly associated with lymph node metastasis. Multivariate analysis showed that age(OR=2.385, 95% CI:1.372 ~ 4.147, P=0.002 1), post-CRT CEA level(OR=2.310, 95% CI:1.005 ~ 5.307, P=0.048 6) and ypT stage(OR=2.592, 95% CI:1.236 ~ 5.432, P=0.011 7) were independent risk factors. However, 15.8% of the patients who achieved TRG1 had lymph node metastasis and TRG failed to independently correlate with lymph node metastasis in rectal cancer after neoadjuvant CRT.</p><p><b>CONCLUSIONS</b>There was a higher ratio of lymph node metastasis in rectal cancer patients who were young, CEA≥5 μg/L or deep invasion after neoadjuvant CRT. Therefore, neoadjuvant CRT should be carefully considered in these patients.</p>