Long splenic flexure carcinoma requiring laparoscopic extended left hemicolectomy with CME and transverse-rectal anastomosis: technique for a modified partial Deloyers in 5 steps to achieve enough reach and preserving middle colic vessels.

INTRODUCTION: This How-I-Do-It article presents a modified Deloyers procedure by mean of the case of a 67-year-old female with adenocarcinoma extending for a long segment and involving the splenic flexure and proximal descending colon who underwent a laparoscopic left extended hemicolectomy (LELC) with derotation of the right colon and primary colorectal anastomosis. BACKGROUND: While laparoscopic extended right colectomy is a well-established procedure, LELC is rarely used (mainly for distal transverse or proximal descending colon carcinomas extending to the area of the splenic flexure). LELC presents several technical challenges which are demonstrated in this How-I-Do-It article. TECHNIQUE AND METHODS: Firstly, the steps needed to mobilize the left colon and procure a safe approach to the splenic flexure are described, especially when a tumor is closely related to it. This is achieved by mobilization and resection of the descending colon, while maintaining a complete mesocolic excision to the level of the duodenojejunal ligament for the inferior mesenteric vein and flush to the aorta for the inferior mesenteric artery. Subsequently, we depict the adjuvant steps required to enable a primary anastomosis by trying to mobilize the transverse colon and release as much of the mesocolic attachments at the splenic flexure area. Finally, we present the rare instance when a laparoscopic derotation of the ascending colon is required to provide a tension-free anastomosis. The resection is completed by delivery of the fully derotated ascending colon and hepatic flexure through a suprapubic mini-Pfannenstiel incision. The primary colorectal anastomosis is subsequently fashioned in a tension-free way and provides for a quick postoperative recovery of the patient. RESULTS: This modified Deloyers procedure preserves the middle colic since the fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump. Also, by eliminating the need for a mesenteric window and the transposition of the caecum, we allow the small bowel to rest over the anastomosis and the mobilized transverse colon and reduce the possibility of an internal herniation of the small bowel into the mesentery. CONCLUSIONS: Laparoscopic derotation of the right colon and a partial, modified Deloyers procedure preserving the middle colic vessels are feasible techniques in experienced hands to provide primary anastomosis after LELC with improved functional outcome. Nevertheless, it is important to consider anatomical aspects of the left hemicolectomy along with oncological considerations, to provide both a safe oncological resection along with good postoperative bowel function.

[A case-control study of extracorporeal versus intracorporeal anastomosis in patients subjected to right laparoscopic hemicolectomy]. / Estudio de casos y controles entre anastomosis intra y extracorpórea en pacientes intervenidos de hemicolectomía derecha laparoscópica.

INTRODUCTION: There is still insufficient scientific evidence on which is the best technique to perform the anastomosis -intracorporeal (IC) or extracorporeal (EC)- in right laparoscopic hemicolectomy. The objective of the present study is to determine whether there are differences to compare in both techniques. MATERIAL AND METHODS: A study was performed on a prospective patient series subjected to right laparoscopic hemicolectomy in our Hospital. The preoperative and the postoperative variables associated with complications recorded depending on the type of anastomosis. RESULTS: A total of 60 patients were intervened form June 2004 to June 2010 (35 IC; 25 EC). There were no significant differences between both groups as regards baseline preoperative characteristics or associated comorbidities. The median operation time was 212 minutes (142-305 min), with no significant difference between both techniques. The number of lymph nodes removed was higher in the IC group (21 versus 14; p=0.03). The beginning of oral tolerance and the first bowel movement were significantly earlier in the IC group. The complications rate was similar for both groups (14% IC; 16% EC; p=0.89). Three patients in the IC group had anastomosis dehiscence. The mortality rate was 2.8% (one patient in each group). CONCLUSION: Intracorporeal versus extracorporeal anastomosis in right laparoscopic hemicolectomy can obtain a higher number of resected lymph nodes and an earlier oral tolerance and intestinal transit.

A large gastric duplication (choristoma) in an adult mimicking a mucinous cystic tumor of the pancreas.

Gastric duplication represents a very rare entity in the adult population. Most of the symptoms are due to the presence of ectopic gastric mucosa (30-35% of cases), gastrointestinal bleeding or perforation or neoplasm formation. We report a case of gastric duplication in an adult mimicking a mucinous cystic neoplasm of the pancreas.