Laparoscopic right radical hemicolectomy: Central vascular ligation and complete mesocolon excision vs D3 lymphadenectomy - How I do it?

In colon cancer surgery, ensuring the complete removal of the primary tumor and draining lymph nodes is crucial. Lymphatic drainage in the colon follows the vascular supply, typically progressing from pericolic to paraaortic lymph nodes. While NCCN guidelines recommend the removal of 10-12 lymph nodes for adequate oncological resection, achieving complete oncological resection involves more than just meeting these numerical targets. Various techniques have been developed and studied over time to attain optimal oncological outcomes. A key technique central to this goal is identifying the ileocolic vessels at their origin from the superior mesenteric vessels. Complete excision of the visceral and parietal mesocolon ensures the intact removal of the specimen, while D3 lymphadenectomy targets all draining regional lymph nodes. Although these principles emphasize different aspects, they ultimately converge to achieve the same goal of complete oncological resection. This article aims to simplify the surgical steps that align with the principle of central vascular ligation and mesocolon mobilization while ensuring adequate D3 dissection.

Ascending colon cancer metastasized to the right testicle: a case report.

BACKGROUND: Testicular metastasis from malignant solid tumors is extremely rare. It is usually found by chance during autopsy or pathological examination of testicular specimens. Therefore, we consider it necessary to report our patient's case of testicular metastasis from colon cancer. CASE PRESENTATION: We report a 61-year-old Han Chinese male patient who presented to our clinic with progressive painless swelling of the right testicle for 2 years. Positron emission tomography-computed tomography scans showed increased 18F-fluorodeoxyglucose metabolism in the right testicle, possibly owing to distant metastasis. His previous medical history suggested that he had undergone laparoscopic-assisted right hemicolectomy for ascending colon cancer 4 years ago. Considering the ascending colon cancer metastasis to the right testicle, we performed a right radical testicular resection through an inguinal approach. Postoperative histological examination showed intestinal metastatic adenocarcinoma. CONCLUSION: Colon cancer metastasis to the testes is uncommon. The clinical and imaging manifestations of this tumor are nonspecific, so the diagnosis relies on postoperative pathology. If testicular metastasis is found, treatment principles for advanced colon cancer should be followed.

A first report of right-hemicolectomy for ascending colon cancer in Japan with the da Vinci SP surgical robot system.

BACKGROUND: The da Vinci SP robotic surgical system received regulatory approval for use in colorectal cancer surgery in Japan in April 2023. Given the advantages of the precision of a robot and the postoperative cosmesis of single-site surgery, the system is expected to be further utilized for minimally invasive surgeries, in addition to the curative and safety-assured laparoscopic technique. CASE PRESENTATION: A 73-year-old man presented at our hospital with positive fecal occult blood. He was diagnosed with cT2N0M0 (Stage I) ascending colon cancer and underwent a right hemicolectomy, which was performed with the da Vinci SP system. The operation was performed safely, and the patient was discharged without complications. Pathology findings showed that complete mesocolic excision was achieved. CONCLUSIONS: Herein, we report the first colorectal cancer surgery performed using the da Vinci SP system in Japan. The use of this robotic surgical system with access forms for right hemicolectomy is safe and oncologically appropriate.

Colitis Cystica Profunda of the Hepatic Flexure: A Case Report.

A 72-year-old woman with a prior sigmoid resection for colon cancer underwent a right hemicolectomy after a colonoscopy revealed a mass in the hepatic flexure. A preoperative biopsy at colonoscopy showed tubulovillous dysplasia with high-grade neoplasm. The final specimen pathology revealed benign mucosal elements with mucin pools consistent with colitis cystica profunda (CCP). CCP is a benign lesion; no further treatment was necessary after resection. To our knowledge, this is the first reported case of CCP in the right colon, presenting atypically in the hepatic flexure. This case report brings to light the difficulty and importance of making an accurate diagnosis of CCP.

Concurrent ascending colon adenocarcinoma and colonic tuberculosis: a case report from Syria.

Introduction and importance: Tuberculosis (TB) has been one of the most devastating diseases to humanity in recent decades; although pulmonary infection is the most common, infection of any other organ is familiar as well. Colon cancer is another disease affecting the gastrointestinal (GI) system and mostly targets people over 50. Only a few studies mentioned the co-existence of cancer and TB occurring at the same place and time. Hence, the authors report a rare case of concurrent ascending colon adenocarcinoma and colonic TB. Case presentation: A 49 -year-old man presented to our clinic with constipation and abdominal pain. Two colonoscopies were performed, and two biopsies were taken; the first one showed granulomatous inflammation consistent with TB, and the second one showed low-grade adenocarcinoma. Computed tomography showed annular thickening of the ascending colon with infiltrates around the lesions. A right hemicolectomy was performed, and the final pathology confirmed adenocarcinoma grade II and extensive TB granulomas involving the colon into the serosa and the lymph nodes. Anti-TB medications were administered after surgery. Clinical discussion: Due to appropriate diagnostic methods, TB and cancer were detected at an early stage. In our treatment protocol, no adjuvant chemotherapy was applied after surgery due to the possibility of drug interaction with anti-TB medications. Conclusion: The two diseases may co-exist; thus, diagnosing them may not be the easiest, not to mention the lack of a clear treatment protocol in case of their accompany.

Isolation of mucosa-associated microbiota dysbiosis in the ascending colon in hepatitis C virus post-sustained virologic response cirrhotic patients.

Background: Achieving sustained virologic response (SVR) in patients infected with hepatitis C virus (HCV) reduces all-cause mortality. However, the mechanisms and risk factors for liver fibrosis and portal hypertension post-SVR remain incompletely understood. In the gut-liver axis, mucosa-associated microbiota (MAM) substantially influence immune and metabolic functions, displaying spatial heterogeneity at the anatomical intestinal site. We analyzed MAM composition and function to isolate the locoregional MAM involved in chronic liver disease progression in HCV post-SVR patients. Methods: We collected MAM samples from three intestinal sites (terminal ileum, ascending colon, and sigmoid colon) via brushing during colonoscopy in 23 HCV post-SVR patients and 25 individuals without liver disease (controls). The 16S rRNA of bacterial DNA in specimens collected with a brush and in feces was sequenced. The molecular expression of intestinal tissues and hepatic tissues were evaluated by quantitative real-time PCR. Results: In the post-SVR group, the microbial ß-diversity of MAM, especially in the ascending colon, differed from the control group and was associated with liver fibrosis progression. In PICRUSt analysis, MAM in the ascending colon in the liver cirrhosis (LC) group showed compromised functions associated with the intestinal barrier and bile acid production, and FGF19 expression was markedly decreased in the terminal ileum biopsy tissue in the LC group. At the genus level, six short-chain fatty acid (SCFA)-producing bacterial genera, Blautia, Alistipes, Roseburia, Agathobaculum, Dorea, and Pseudoflavonifractor were reduced in the ascending colon of post-SVR LC patients. Conclusion: In patients of HCV post-SVR, we identified the association between the degree of liver fibrosis and dysbiosis of mucosa-associated SCFA-producing bacterial genera that may be related to intestinal barrier and bile acid production in the ascending colon.

Ascending Colon Schwannoma: A Rare Submucosal Tumour.

We present a rare case of schwannoma in the ascending colon of a 60-year-old female with dyslipidemia. A series of diagnostic procedures, including colonoscopy and CT colonography, led to the successful robotic-assisted right hemicolectomy. Histological and immunohistochemical analyses confirmed the diagnosis of schwannoma, and the patient achieved a complete recovery post-surgery.

Atypical Duplex appendix arising from the ascending colon: a case report.

BACKGROUND: Duplex or vermiform appendix refers to the presence of an appendix beside the naturally occurring one. Although, duplex appendix emerges from the caecum most of the time, yet it is encountered in other parts of the colon. Inflammation of duplex appendix may represent not only a clinical, but also a surgical dilemma, and this would be confusing further among patients who already had prior appendectomy. CASE PRESENTATION: We present a case of 29-years old Egyptian male patient with history of appendectomy one and half year before presenting to the emergency department with recurrent acute abdominal pain that was linked to duplex appendicitis abnormally emerged from the mid-ascending colon. The first episode was treated conservatively considering atypical right colon diverticulitis as a potential differential diagnosis. Seven months later the patient was treated by laparoscopic appendectomy and experienced an uneventful pot-operative course. CONCLUSION: Duplex appendicitis, though rare, should be considered in the differential diagnosis of recurrent acute abdomen even after appendectomy.

Ascending colon injury and ileal perforation due to blunt abdominal trauma: A case report.

A rare case of an ascending colon injury and ileal perforation in a 34-year-old male patient due to blunt abdominal trauma caused by a road traffic accident is reported in this study. This paper reports the clinical and imaging findings of seat belt syndrome. The seat belt syndrome primarily involves soft tissue injury; however, lacerations of the colon, small intestine, and mesentery have rarely been reported in the literature. However intestinal injuries, including bowel perforation and mesenteric injuries due to seat belt syndrome, must not be underestimated because they usually require emergency laparotomy because of accompanying peritonitis and hemorrhaging, and can be lethal if left untreated. Therefore, when an ascending mesocolon hematoma and free gas in the peritoneal cavity are present, gastrointestinal perforation due to seat belt syndrome should be suspected. In this case, gastrointestinal perforation was suspected based on the computed tomography findings, and emergency surgery was performed; the patient's course was uneventful without any postoperative complications. Early diagnosis and management are essential to prevent associated morbidity and mortality.

Intracorporeal versus extracorporeal anastomosis in minimally invasive right hemicolectomy: systematic review and meta-analysis of randomized controlled trials.

Purpose: Compared with extracorporeal anastomosis (ECA), intracorporeal anastomosis (ICA) is expected to provide some benefits, including a shorter operation time and less intraoperative bleeding. Nevertheless, the benefits of ICA have mainly been evaluated in nonrandomized studies. Owing to the recent update of randomized controlled trials (RCTs) for minimally invasive surgery (MIS) of right hemicolectomy (RHC), the need to measure the actual effect by synthesizing the outcomes of these studies has emerged. Methods: We performed a comprehensive search of the PubMed, Embase, and Cochrane databases (from inception to January 30, 2023) for studies that applied ICA and ECA for RHC with MIS. We included 7 RCTs. The operation time, intraoperative blood loss, conversion rate, length of incision, and postoperative outcomes such as ileus, anastomosis leakage, length of hospitalization, and postoperative pain were compared between ICA and ECA. Results: A total of 740 patients were included in the study. Among them, 377 and 373 underwent ICA and ECA, respectively. There were significant differences in age (P = 0.003) and incision type (P < 0.001) between ICA and ECA. ICA was associated with a significantly longer operation time (P = 0.033). Although the postoperative pain associated with ICA was significantly lower than that associated with ECA on postoperative day 2 (POD 2) (P = 0.003), it was not different on POD 3 between the groups. Other perioperative outcomes were similar between the 2 groups. Conclusion: In this meta-analysis, ICA did not significantly improve short-term outcomes compared to ECA; other advantages to overcome ICA's longer operation time are not clear.

Prognostic Impact of Primary Tumor Sidedness in Stage III Colorectal Cancer: Real-World Evidence from a Brazilian Cohort.

BACKGROUND: Primary tumor sidedness (PTS) is an independent prognostic factor in patients with metastatic colorectal cancer (CRC), with a worse prognosis for right-sided tumors. There are limited data on the prognostic impact of PTS in stage III CRC. The main objective of this study was to analyze the prognostic impact of PTS in stage III CRC. PATIENTS AND METHODS: A retrospective and uni-institutional cohort study was performed in an oncology reference center. Patients with stage III CRC treated with a 5-fluorouracil and oxaliplatin-based chemotherapy regimen (mFLOX regimen) from October 2007 to February 2013 were included. The primary outcome was the probability of overall survival (OS) at 5 years stratified by PTS. Secondary outcomes were the probability of disease-free survival (DFS) at 5 years and an analysis of the prognostic impact of clinical and molecular biomarkers. Kaplan‒Meier curves were used, and Cox models were used to evaluate prognostic factors associated with OS and DFS. RESULTS: Overall, 265 patients were evaluated. Transverse colon tumors, multicentric tumors, and undetermined primary subsites were excluded, resulting in 234 patients classified according to PTS: 95 with right sidedness (40.6%) and 139 with left sidedness (59.4%). The median follow-up time was 66 months [interquartile range (IQR): 39-81]. The 5-year OS probabilities for right-sided and left-sided tumors were 67% (95% CI: 58%-77%) and 82% (75%-89%), respectively [hazard ratio (HR): 2.02, 95% CI: 1.18-3.46; P = .010]. The 5-year probabilities of DFS for right-sided and left-sided tumors were 58% (49%-69%) and 65% (58%-74%), respectively (HR: 1.29, 0.84-1.97; P = 0.248). CONCLUSION: These data suggest that there may be a worse prognosis (inferior OS at 5 years) for resected right-sided stage III CRC patients treated in the real world. However, these data need to be confirmed by prospective studies with a larger number of participants.

Long-term Survival after Treatment of Synchronous Isolated Right External Iliac Lymph Node Metastasis from Ascending Colon Cancer: A Case Report.

BACKGROUND: Synchronous isolated external iliac lymph node metastasis of ascending colon cancer is extremely rare, and its treatment strategy has not been established. In this report, we present a case of long-term survival after surgical resection and adjuvant chemotherapy for ascending colon cancer with synchronous isolated right external iliac lymph node metastasis. CLINICAL CASE: A 65-year-old woman with anorexia and anemia was referred to our hospital. Colonoscopy and computed tomography revealed a three-quarter circumferential type 2 tumor from the cecum to the ascending colon, along with regional and right external iliac lymph node swelling. We diagnosed ascending colon cancer with right external iliac artery lymph node metastasis. An open right hemicolectomy with D3 and right external iliac lymph node dissections were performed. Results of histopathological examination showed that both lymph nodes were metastasized from ascending colon cancer. The patient received eight courses of capecitabine and oxaliplatin therapy as adjuvant chemotherapy. At 60 months after surgery, the woman has not had a recurrence. CONCLUSIONS: Surgical resection and adjuvant chemotherapy may be an effective treatment strategy for synchronous isolated right external iliac lymph node metastases from ascending colon cancer.

Mucosa-Associated Lymphoid Tissue Lymphoma of the Ascending Colon Successfully Removed With Endoscopic Submucosal Dissection.

Mucosa-associated lymphoid tissue (MALT) lymphoma is a type of non-Hodgkin lymphoma with characteristic histopathological features and can occur in various extranodal sites, including the gastrointestinal tract. While gastric MALT lymphoma has been extensively researched, primary lymphoma presentation in the colorectal mucosa is rare and lacks any association with Helicobacter pylori infection. Furthermore, there are currently no standardized treatment guidelines for this condition. This report presents a rare case of primary MALT lymphoma that manifested as a broad-based polyp. The diagnosis was confirmed through histopathological and immunohistochemical examination, and the polyp was resected endoscopically with the endoscopic submucosal dissection technique.

An unusual case of gallstone ileus within the cecum and ascending colon: a case report.

Gallstone ileus is a rare cause of intestinal obstruction. Due to long-standing inflammation of the gallbladder, fistulization can occur within nearby structures, most commonly to the duodenum or hepatic flexure of the colon. Through these fistulas, a stone can migrate and result in a small bowel obstruction or a large bowel obstruction. This case exemplifies the diagnosis and treatment of gallstone ileus, along with potential complications due to stone migration. Early recognition and treatment of gallstone ileus is important, as stone migration can lead to increased mortality with delayed diagnosis.

Synchronous Volvulus of Ascending and Transverse Colon.

Introduction: Colonic volvulus is the torsion of a part of the colon causing large bowel obstruction by strangulation, which may lead to ischemia and then necrosis. Synchronous colonic volvulus is extremely rare; even if there are some case reports on synchronous colonic volvulus, there are no reported cases of synchronous ascending and transverse colon volvulus in the medical literature to our knowledge. Case Presentation: A 25-year-old girl with a previous history of epilepsy presented with a one-day duration of abdominal cramps with associated symptoms of vomiting of bilious matter, failure to pass faeces, and flatus of the same duration. The patient underwent surgical intervention, and ascending and transverse volvulus were discovered. Conclusion: In spite of ascending and transverse colon volvulus rarity, we advised including these in the differential diagnosis of patients associated with large bowel obstruction.

Histological transformation to signet-ring cell carcinoma in a patient with clinically aggressive poorly differentiated adenocarcinoma of the ascending colon after response to chemotherapy plus cetuximab: a case report.

BACKGROUND: Alteration of chemosensitivity or tumor aggressiveness in response to chemotherapy has been reported, and liquid biopsy assessment during chemotherapy for colorectal cancers has confirmed the acquisition of mutations in various oncogenes. However, the occurrence of histological transformation seems to be extremely rare in colorectal cancers, and the few existing case reports of this transformation are from lung cancer and breast cancer. In this report, we describe the histological transformation of clinically aggressive scirrhous-type poorly differentiated adenocarcinoma of the ascending colon to signet-ring cell carcinoma in almost all recurrent tumors that were confirmed by autopsy after response to chemotherapy plus cetuximab. CASE PRESENTATION: A 59-year-old woman visited our hospital with whole abdominal pain and body weight loss and was diagnosed with scirrhous-type poorly differentiated adenocarcinoma of the ascending colon with aggressive lymph node metastases. The intrinsic chemosensitivity of the tumors was evident upon initiation of mFOLFOX6 plus cetuximab therapy, and right hemicolectomy was performed, and the tumor obviously remained in the peripancreatic area, paraaortic region, or other retroperitoneal areas. The ascending colon tumors mainly consisted of poorly differentiated adenocarcinoma and were not associated with signet-ring cell components except for minute clusters in a few lymphatic emboli in the main tumor. Chemotherapy was continued, and metastases were eliminated at 8 months after the operation; this response was maintained for an additional 4 months. Discontinuation of chemotherapy plus cetuximab resulted in immediate tumor recurrence and rapid expansion, and the patient died of the recurrent tumor 1 year and 2 months after the operation. Autopsy specimens revealed that almost all of the recurrent tumors exhibited transformation and consisted of signet-ring cell histology. CONCLUSION: This case might suggest that various oncogene mutations or epigenetic changes resulting from chemotherapy, especially regimens that include cetuximab, contribute to the transformation of non-signet-ring cell colorectal carcinoma to signet-ring cell carcinoma histology and can promote the aggressive clinical progression characteristic of signet-ring cell carcinoma.

Squamous cell carcinoma of ascending colon with pMMR/MSS showed a partial response to PD-1 blockade combined with chemotherapy: A case report.

Primary colon squamous cell carcinoma (SCC) is extremely rare and associated with a poor prognosis. Moreover, there is no treatment guideline for this disease. Proficient mismatch repair/microsatellite-stable (pMMR/MSS) colorectal adenocarcinoma is refractory to immune monotherapy. Although the combination of immunotherapy with chemotherapy in pMMR/MSS colorectal cancer (CRC) is currently under investigation, the clinical activity of this approach in colorectal SCC remains unknown. In this article, we report the case of a pMMR/MSS CRC patient with ascending colon SCC who had high programmed cell death-ligand 1 (PD-L1) expression and the a missense mutation in codon 600 of the B-Raf proto-oncogene (BRAF V600E) mutation. The patient exhibited a significant response to the combination of immunotherapy and chemotherapy. After eight cycles of treatment with the combination of sintilimab and mFOLFOX6 (oxaliplatin, fluorouracil, and leucovorin), computed tomography-guided microwave ablation of the liver metastasis was performed. The patient achieved excellent durable response and continues to experience a good quality of life. The present case indicates that programmed cell death 1 blockade combined with chemotherapy may be an effective therapy for patients with pMMR/MSS colon SCC and high PD-L1 expression. Furthermore, PD-L1 expression may be a biomarker for immunotherapy in patients with colorectal SCC.

Experience of surgical treatment in a granular cell tumor in the qscending colon: a case report.

We report a case about successful surgical treatment of a granular cell tumor in the ascending colon. A 36-year-old man underwent screening colonoscopy. An endoscopic examination revealed a 10-mm yellowish and hemispheric mass in the ascending colon, and lower endoscopic ultrasonography revealed a hypoechoic-to-isoechoic mass invaded the submucosal layer. The mass was suspected to be a colonic carcinoid tumor. Based on the preoperative evaluation, endoscopic complete resection was considered difficult. Therefore, the lesion was removed via laparoscopic right hemicolectomy. Histological examination revealed that the tumor consisted of nests of polygonal cells with abundant granular eosinophilic cytoplasm. Immunohistochemical staining revealed diffuse positivity for S100 and CD68. Therefore, the tumor was diagnosed as a granular cell tumor. We suggest that surgical resection should be considered if it is located in the thin-walled ascending colon prone to perforation, difficult to rule out malignant tumor due to submucosal invasion, or to remove endoscopically.

Congenital Segmental Dilatation of Ascending Colon with Distal Microcolon: A Diagnostic Dilemma.

A 5-day-old male presented with bilious vomiting, a grossly distended abdomen, and passage of a small amount of stool. The anal opening was at a normal position. X-ray abdomen showed a large bowel loop with a single air-fluid level occupying more than half of the abdominal width. On laparotomy, the ascending colon was dilated to form a pouch-like structure, and the ileum and appendix were opening into it. Colon distal to pouch was present as microcolon. Histopathology of the dilated segment was suggestive of congenital segmental dilatation (CSD). In CSD, the distal bowel is of normal caliber. This is a rare case of CSD of ascending colon with distal microcolon.