Comparing 5-Year Survival Rates Before and After Re-stratification of Stage I-III Right-Sided Colon Cancer Patients by Establishing the Presence/Absence of Occult Tumor Cells and Lymph Node Metastases in the Different Levels of Surgical Dissection.

BACKGROUND: To establish the impact of re-stratification on the outcomes of patients (stage I-III right-sided colon cancer) based on the presence/absence of occult tumor cells (OTC) and/or metastatic lymph nodes in the different levels of surgical dissection. METHODS: Consecutive patients were drawn from a multicenter prospective trial. After surgery, the surgical specimen was divided into the D1/D2 and D3 volumes before being further analyzed separately. All lymph nodes were examined with cytokeratin CAM 5.2 immunohistochemically. Lymph nodes containing metastases and OTC (micrometastases; isolated tumor cells) were identified. Re-stratification was as follows: RS1, stages I/II, no OTC in D1/D2 and D3 volumes; RS2, stages I/II, OTC in D1/D2 and/or D3; RS3, stage III, lymph node metastases in D1/D2, with/without OTC in D3; RS4, stage III, lymph node metastases in D3, with/without OTC in D3. RESULTS: Eighty-seven patients (39 men, 68.4 + 9.9 years) were included. The standard stratified (SS) group contained the following: stages I/II (SS1) 57 patients; stage III (SS2) 30 patients. Re-stratified (RS) contained RS1 (38), RS2 (19), RS3 (24), and RS4 (6) patients. Lymph node ratio (OTC) RS2: 0.157 D1/D2; 0.035 D3 and 0.092 complete specimens. Lymph node ratio RS3: 0.113 D1/D2; complete specimen 0.056. Overall survival and disease-free survival were p = 0.875 and p = 0.049 for SS and p = 0.144 and p = 0.001 for RS groups, respectively. CONCLUSION: This re-stratification identifies a patient group with poor prognosis (RS4). Removing this group from SS2 eliminates all the differences in survival between RS2 and RS3 groups. The level of dissection of the affected nodes may have an impact on survival. CLINICAL TRIAL: "Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-Detector Computed Tomography (MDCT) Angiography" registered at http://clinicaltrials.gov/ct2/show/NCT01351714.

Interactions of occult tumor spread and surgical technique on overall and disease-free survival in patients operated for stage I and II right-sided colon cancer.

PURPOSE: To determine if "medial to lateral" (ML) dissection with devascularization first is superior to "lateral to medial" (LM) dissection regarding numbers of lymph node micro metastases (MM) and isolated tumor cells (ITC) as well as 5-year disease-free (5YDFS) and 5-year overall survival (5YOS) in stage I/II right-sided colon cancer. METHODS: Two datasets are used. ML group consists of consecutive stage I/II patients from a prospective trial. LM group is the original dataset from a previous publication. All harvested lymph nodes are examined with monoclonal antibody CAM 5.2 (immunohistochemically). Lymph node harvest and 5YOS/5YDFS were compared between ML/LM groups, stage I/II tumors and MM/ITC presence/absence. RESULTS: 117 patients included ML:51, LM:66. MM/ITC positive in ML 37.3% (19/51), LM 31.8% (21/66) p = 0.54. The 5YDFS for patients in ML 70.6% and LM 69.7%, p = 0.99, 5YOS: 74.5% ML and 71.2% LM (p = 0.73). No difference in 5YDFS/5YOS between groups for Stage I/II tumors; however, LM group had an excess of early tumors (16) when compared to ML group, while lymph node harvest was significantly higher in ML group (p < 0.01) 15.1 vs 26.7. 5YDFS and 5YOS stratified by MM/ITC presence/absence was 67.5%/71.4%, p = 0.63, and 75.0%/71.4%, p = 0.72, respectively. Death due to recurrence in MM/ITC positive was significantly higher than MM/ITC negative (p = 0.012). CONCLUSION: Surgical technique does not influence numbers of MM/ITC or 5YDFS/5YOS. Presence of MM/ITC does not affect 5YOS/5YDFS but can be a potential prognostic factor for death due to recurrence. CLINICAL TRIAL: Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-Detector Computed Tomography (MDCT) Angiography" registered at http://clinicaltrials.gov/ct2/show/NCT01351714 .

Navigating the mesentery: Part III. Unusual anatomy of ileocolic vessels.

AIM: The ileocolic vessels are important landmarks in advanced surgery of the midgut. The aim of the present study is to present variations of ileocolic vessels relevant to complete mesocolic excision with D3 lymphadenectomy of the right colon, within their detailed and precise morphometric framework and deriving from a large and consistent series of operated patients. METHODS: An ongoing prospective trial 'Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multidetector Computed Tomography Angiography' was reviewed. The imaging datasets underwent manual segmentation and 3D reconstruction, and the results were validated at surgery. A total of 356 patients were included in the study. RESULTS: A cross-section of the series revealed five cases (1.4%) with variation of ileocolic vessels relevant to complete mesocolic excision or D3 extended mesenterectomy. There were two cases with absence of a true classical ileocolic artery, two cases with absence of a true classical ileocolic vein, and one case of precocious bifurcation of the ileocolic artery, left to the superior mesenteric vein. The entire D3 area in all the cases was thoroughly documented and analysed from the morphometric point of view (calibres, lengths of vessels, crossing patterns). CONCLUSION: The preoperative visualization of a patient's individual 3D anatomy is a powerful tool in identifying the variations whose negligence could have dire consequences in complete mesocolic excision of the right colon.

Navigating the mesentery: part II. Vascular abnormalities and a review of the literature.

AIM: Vascular abnormalities present advantages and/or disadvantages for the patient undergoing surgery. The aims of this study were to define, classify and demonstrate the courses, and to assess the clinical value, of arterial and venous abnormalities in the central mesentery. METHOD: We conducted a review of the anatomy of 340 patients planned for enrolment in the 'Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic MDCT Angiography' trial, 312 of whom were submitted to surgery. Vascular abnormalities were analysed in context with surgical notes and images. A meta-analysis of the literature was performed. RESULTS: Arterial Abnormalities were found in 28 (8.2%) of the 340 patients and were classified into the following three groups based on anticipated surgical difficulty: group 1, accessory or replaced arteries to solid organs [14 (4.1%)]; group 2, arterial shunts [11 (3.2%)] between the coeliac trunk and the superior mesenteric artery, which resulted in bleeding in three patients; and group 3, common stem abnormalities [3 (0.9%)]. Two groups of superior mesenteric vein abnormalities were noted. The first included morphological abnormalities in a single vein [4 (1.2%)]: aneurysm [1 (0.3%)]; and ring variants of principal tributaries [3 (0.9%)]. The second included double superior mesenteric vein trunks [31 (9.1%)]: genuine bifid [10 (2.9%)]; and pseudo bifid [21 (6.2%)]. The meta-analysis revealed 26 articles, including 10 series of anatomical dissections or angiographies [1970 cases with 205 (10.4%) arterial abnormalities] and 16 case reports, none of which described a clinical or surgical setting. CONCLUSION: Vascular abnormalities occur frequently. Arterial abnormalities are a hazard when inadvertent injury occurs during surgery. Preoperative knowledge of a bifid superior mesenteric vein is useful.

Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy.

BACKGROUND: The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: "Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography" in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed. METHODS: Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews. RESULTS: Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p = 0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p = 0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores. CONCLUSIONS: Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery.

Navigating the mesentery: a comparative pre- and per-operative visualization of the vascular anatomy.

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.

3D for D3: role of imaging for right colectomy in a case with congenital superior mesenteric vein aneurysm and co-existing anomalous irrigation.

BACKGROUND: The D3 right colectomy for cancer requires dissection in the vicinity of the superior mesenteric vessels, which requires preoperative 3D imaging in these patients. CASE REPORT: We present a patient with a caecum adenocarcinoma cancer which underwent D3 resection of the right colon, preceded by pre-operative MDCT with 2D multiplanar reconstruction and 3D volume rendering. RESULTS: The dataset analysis revealed a rare congenital aneurysm of the superior mesenteric vein below the spleno-mesenteric confluence and a co-existing anomalous irrigation in the form of an ileo-mesenteric trunk. The surgical procedure was carried out as planned and the patient presents no signs of recurrence of the disease one year after the intervention. CONCLUSIONS: The case presented - with a rare and complicated vascular situs - illustrates particularly well that multimodal post-processing of the CT dataset for volume rendering allows proper assessment of the arrangement of pertinent blood vessels, and, consequently in the planning, setup and accomplishing the delicate operation, avoiding the surgical pitfalls and iatrogenic injuries.

Gastric varices without portal hypertension: role of left inferior vena cava?

A variant vascular anatomy was detected during regular analysis of multidetector computed tomography angiography of the abdomen in a 70 year-old female patient, referred to the department of surgery for laparoscopic right colectomy for colon cancer. The anomalous vessel was located left to the aorta, and was consistent with a persistent left inferior vena cava. It was connected by two retroaortic rootlets to the dorsal surface of the regular right inferior vena cava and had four notable tributaries - an anastomosis with the iliolumbar trunk, ovarian vein, renal vein and the inferior phrenic vein. In the upper abdomen, the left inferior vena cava took a tortuous course, passing at first between the spleen and the diaphragm, then curving below the inferior splenic border and terminating in an irregular network in the posterior region of gastric fundus and cardia, close to the splenic hilum, without supradiaphragmatic continuation. Despite this extraordinary termination, there were no signs of portal hypertension or data on previous occurrence of this condition.

3D relations between right colon arteries and the superior mesenteric vein: a preliminary study with multidetector computed tomography.

BACKGROUND: 3-D relations between the ileocolic (ICA), right colic artery (RCA) with the superior mesenteric vein (SMV) have been described in cadavers. However, no data exists on preoperative evaluation of these relations. AIM: To define the length of crossing and 3-D position of the ICA and RCA to the SMV in patients undergoing multidetector computerized tomography (MDCT) angiography. METHODS: MDCT angiographies were analyzed with the aid of Osirix v.3.0.2. image processing application. All the datasets included arterial and venous phase, undergoing multimodal visualization: 2D multiplanar reconstruction with maximum intensity projection and 3D Volume rendering. The anatomical relations were analyzed in various planes (orthogonal and oblique), depending upon their particular course. When a clear spatial reference was achieved, the distance of the colic artery from their origin on the aorta to the right border of the SMV was measured, and its position noted. RESULTS: 50 MDCT were analyzed (29 male). RCA occurred in 27 patients (54.0%), 25 (92.6%) passed anterior to the SMV. Length of crossing was 22.7±8.1 (8.3-41.3) mm. The ICA occurred in 48 (96%) passing under the SMV in 38 (79.2%). Length of crossing 15.4±5.8 (14.0-26.6) mm. CONCLUSIONS: RCA occurs in 54% patients, passes over the SMV in 92.6% specimens and leaves a 22.7 mm stump. ICA passes under the SMV in most cases, leaving a 15.4 mm stump. These data could be of crucial importance to the surgeon facing laparoscopic right colectomy for cancer.

Vascular relationships in right colectomy for cancer: clinical implications.

AIMS: The study aim was to provide data on pattern and length of crossing of the ileocolic artery (ICA) and right colic artery (RCA) with the superior mesenteric vein (SMV). METHODS: Specimens from 30 fresh human cadavers underwent corrosion casting. Methylacrylate was injected into the SMV and superior mesenteric artery (SMA). Length of crossing was measured with a scaleable ruler and copper wire. Values are mean (SD; range). RESULTS: ICA was present in all specimens and crossed posterior to the SMV in 19 (63.33%) of 30 specimens. Length of crossing was 17.01 (7.84; 7.09-42.89) mm. RCA was present in 19 (63.33%) of 30 specimens. RCA crossed anterior to SMV in 16 (84.21%) of 19 specimens. Length of crossing was 20.63 (8.09; 6.3-35.7) mm. CONCLUSIONS: ICA was always present, crossed posterior to SMV in 60% of specimens with a crossing length of 17 mm. RCA was present in 63% of specimens, crossed anterior to the SMV in 84% of specimens with a crossing length of 20 mm. Clinical implications include arterial length left behind with main nodes, arterial bleeding and safety of laparoscopic access.

[Cystic artery anatomy characteristics in minimally invasive surgical procedures].

UNLABELLED: Large patient series undergoing laparoscopic cholecystectomy fail to show anatomic variations which lead to intraoperative bleeding. METHOD: Cadaver material was used and corrosion casting and postmortem arteriography were employed. RESULTS: Three types of cystic artery were devised according to the results. Type 1 normal anatomy. Type 2 more than one artery in Calots triangle and Type 3 no artery in Calots triangle. DISCUSSION: only 40% of the second cystic artery is present in Calots triangle. The short second cystic artery is characteristic and its most often origin is from a segmental branch of the right hepatic artery. When there is no artery in Calots triangle its origin unusual, and the artery is either on the postero-lateral side of the cystic duct or it approaches the gallbladder through hepatic tissue. The specifics of MIS approach make changes in the way we understand the anatomic variations of the cystic artery. The classification is a result of practical experience and anatomical investigations.

The basis for splenic segmental dearterialization: a post-mortem study.

The anatomical features of splenic segmental vessels in 102 human spleen autopsy specimens were analyzed. Methods applied were corrosion casting and post-mortem arteriography. The superior terminal splenic branch divided extracapsularly into 2.8+/-0.9 (range 2-5) and the inferior terminal splenic branch into 2.3+/-0.75 (range 2-5) branches per sample. The extracapsular lengths of the segmental branches ranged from 4.0 to 16.7 mm and the calibers from 0.4 to 2.2 mm. Superior polar arteries occurred in 31.3% and inferior polar arteries in 20.6% of cases. Their average extracapsular lengths were 39 mm and 31 mm, respectively. In conclusion, segmental splenic arteries have an extrasplenic origin and course, with an average length and caliber that allow surgical access and ligation, in order to achieve segmental dearterialization for hemostasis purposes and splenic preservation.

Venous anatomy of the right colon: three-dimensional topographic mapping of the gastrocolic trunk of Henle.

BACKGROUND: The gastrocolic trunk of Henle has not been described in detail in context with right hemicolectomy. The aim of this study was to define the caliber, length and three-dimensional position of the gastrocolic trunk of Henle (GTH). METHODS: We studied 10 fresh (<24 h) cadavers. A corrosion cast method was employed. Cold polymerized methylacrylate was injected into the superior mesenteric vein (SMV) and artery. GTH diameter, length and point of confluence with the SMV were assessed. RESULTS: The GTH was present in all specimens originating from the confluence of the right gastroepiploic and superior-anterior pancreaticoduodenal veins. The GTH joined the SMV at an average distance of 2.2 cm (range, 1.6-3.2 cm) from the inferior pancreatic border and it coursed towards the right side in a ventral-cranial direction. The mean caliber and length of the GTH were 5.2 mm (range, 4.8-5.8 mm) and 16.1 mm (range, 10.1-20.7 mm), respectively. CONCLUSIONS: The GTH is a short, medium-sized vessel of potential clinical significance with a consistent ventral-cranial direction.

Rectal cancer. Is the surgeon the variable in the outcome?

Four factors influence the outcome of rectal surgery: tumour biology, stage of lesion, type of surgery performed and the performing surgeon himself. Tumour biology and tumour stage depend on each other and are not influenced on by the surgeon, while he seems to have a great influence on the latter two factors. This influence mainly consists of the following: training, volume, individual skill and experience.

[Meta-analysis on minimally invasive surgical therapy of sigmoid diverticulitis]. / Meta-analiza o minimalno invazivnoj hirurskoj terapiji divertikulitisa sigmoidnog kolona.

UNLABELLED: The bowel diverticulitis is a complication of diverticulosis, occuring in 35% patients in 20 years after diagnosis. The study purpose was analysis of the results published in world literature. METHOD: Double blind electronic search of several databases using key words: diverticulitis, laparoscopy. RESULTS: 11 studies with 415 patients that satisfy the criteria were selected. AGE: 62.7 + 14.2. Hinchey stadiums: I, IIa i IIb of these 44% I and 28% IIa i Iib each. Operative time: 197.4 +/- 49.6 min. Conversions: 11.7 +/- 10.1 (0 - 38.9%). Protective stoma: 5.5%. Bowel sounds: 2.3 - 3.2 postoperative day. Oral feeding: 2.6-5 postoperative day. Hospitalization: 6.1 2.1 dana. Anastomotic dehiscence: 2.8%, wound infection: 7.3%, iatrogen rectum perforation with stapler: 3.3%, bleeding: 3.5%, ileus: 4.4%, reoperation rate: 4.7%. CONCLUSION: Sigmoid resection with or without a protective "loop" ileostomy is technically feasable by minimally invasive surgical technique, with an acceptable ratio of benefits and complications.

Anatomical rationale for spleen salvage by lobe/segment dearterialization in inferior pole spleen injury during left hemicolectomy: a post-mortem study.

The aim of this study was to determine the rationale for spleen salvage by lobe/segment dearterialization without resection for inferior pole injury during left hemicolectomy. One hundred and two consecutive human cadavers were dissected. Corrosion case and post-mortem arteriography with computerized planimetry were employed. Lobe/segment size, artery diameter and length and anastomoses between arteries were measured. The mean inferior terminal splenic artery had a significantly smaller diameter than the superior (2.8 vs. 3.4 mm, p<0.01). An inferior polar artery was found in 22.5% of the specimens (mean diameter, 1.9 mm; mean length, 33 mm). The inferior lobe and inferior polar segment comprised 41.3% and 12.6% of the spleen, respectively. Anastomoses were detected in 34 of 102 spleens (3% extraparenchymal, 88% intraparenchymal, 9% combined). The mean diameter and length of intrasplenic anastomoses were 0.3 mm and 20 mm, respectively. In conclusion, there was a positive correlation between diameters of lobar/segmental arteries and vascular zones ( p<0.05). The rationale for splenic lobe/segment dearterialization without resection is found in the presence of intrasplenic anastomoses.