The effect of ileal resection length on postoperative complications and prognosis in right colon cancer.

BACKGROUND: There is a lack of literature on the length of the terminal ileum to be resected in right hemicolectomy for colon cancer. Therefore, we aimed to determine the mean ileal loop length and the effect of this variation on postoperative complications and long-term oncological outcomes in patients who underwent right hemicolectomy. METHODS: Right hemicolectomy surgeries performed for colon cancer in a tertiary care hospital between January 2011 and December 2018 were retrospectively analyzed from a prospective database. Two patient groups were established based on the mean length of the resected ileum above and below 7 cm. The two groups were compared for clinicopathological data, postoperative complications, mortality, long-term overall survival (OS) and disease-free survival (DFS). The factors contributing to OS and DFS were analyzed. RESULTS: The study included 217 patients. Body mass index (BMI) values were significantly higher in the ileum resection length > 7 cm group (p = 0.009). Pathological N stage, tumor diameter, and number of metastatic lymph nodes were significantly higher in the ileum resection length > 7 cm group (p = 0.001, p = 0.001, and p = 0.026, respectively). There was no significant difference for postoperative complication and mortality rates between the two groups. The mean follow-up period was 61.2 months (2-120) in all patients. The total number of deaths was 29 (11.7%) while the 60-month OS was 83.5% and 50-month DFS was 81.8%. There was no significant difference between the groups in terms of OS and DFS rates (p > 0.05). CONCLUSIONS: Excessive resection of the distal ileum in right hemicolectomy does not provide any benefit in terms of prognosis and complications.The ileum resection length and values close to it in our study appear to be sufficient.

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.

Diffuse large B-cell lymphoma-induced intussusception: A case report and literature review.

Adult intussusception necessitates early surgical intervention. We emphasis the significance of considering diffuse large B-Cell lymphoma in differential diagnoses for adult intussusception, particularly in the colon, to ensure precise diagnosis and optimal management.

A retrospective cohort study of intra-corporeal versus extra-corporeal anastomosis for right hemicolectomy with cost-effectiveness analysis.

BACKGROUND: We aimed to compare outcomes and cost effectiveness of extra-corporeal anastomosis (ECA) versus intra-corporeal anastomosis (ICA) for laparoscopic right hemicolectomy using the National Surgical Quality Improvement Programme data. METHODS: Patients who underwent elective laparoscopic right hemicolectomy for colon cancer from January 2018 to December 2022 were identified. Non-cancer diagnoses, emergency procedures or synchronous resection of other organs were excluded. Surgical characteristics, peri-operative outcomes, long-term survival and hospitalisation costs were compared. Incremental cost-effectiveness ratio (ICER) was used to evaluate cost-effectiveness. RESULTS: A total of 223 patients (175 ECA, 48 ICA) were included in the analysis. Both cohorts exhibited comparable baseline patient, comorbidity, and tumour characteristics. Distribution of pathological TMN stage, tumour largest dimension, total lymph node harvest and resection margin lengths were statistically similar. ICA was associated with a longer median operative duration compared with ECA (255 min vs. 220 min, P < 0.001). There was a quicker time to gastrointestinal recovery, with a shorter median hospital stay in the ICA group (4.0 versus 5.0 days, P = 0.001). Overall complication rates were comparable. ICA was associated with a higher surgical procedure cost (£6301.57 versus £4998.52, P < 0.001), but lower costs for ward accommodation (£1679.05 versus £2420.15, P = 0.001) and treatment (£3774.55 versus £4895.14, P = 0.009), with a 4.5% reduced overall cost compared with ECA. The ICER of -£3323.58 showed ICA to be more cost effective than ECA, across a range of willingness-to-pay thresholds. CONCLUSION: ICA in laparoscopic right hemicolectomy is associated with quicker post-operative recovery and may be more cost effective compared with ECA, despite increased operative costs.

[Robotic vs. laparoscopic right hemicolectomy-An analysis of costs]. / Robotische vs. laparoskopische Hemikolektomie rechts ­ eine Kostenanalyse.

The use of robotic surgical methods for performing right-sided hemicolectomy has been somewhat controversial, primarily due to concerns related to costs. The purpose of this study is to document the initial robotic right hemicolectomies conducted at our institution and to compare them with a laparoscopic reference group. A significant focus of this study is the detailed analysis of the costs associated with both techniques within the German healthcare system.Surgical and cost-related data for 34 cases each for robotic and laparoscopic right-sided hemicolectomy performed at Nürnberg Hospital were compared. This comparison was conducted through a retrospective single-center case-matched analysis. Cost analysis was carried out following the current guidelines provided by the Institute for the Hospital Remuneration System (InEK) of Germany.The average age of the patient cohort was 70 years, with a male patient proportion of 57.4%. Analysis of perioperative parameters indicated similar outcomes for both surgical techniques. Regarding the incidence of complications of Clavien-Dindo stages III-V (8.8% vs. 17.6%; p = 0.48), a positive trend towards robotic surgery was observed. The cost analysis showed nearly identical total costs for the selected cases in both groups (mean €13,423 vs. €13,424; p = 1.00), with the most significant cost difference noted in surgical (operative) costs (€5,779 vs. €3,521; p < 0.01). The lower costs for laparoscopic cases were primarily due to the reduced material costs (mean €2,657 vs. €702; p < 0.05).In conclusion, both surgical approaches are clinically equivalent, with only minor differences in the total case costs.

Cecal volvulus in pregnancy: A rare case report.

INTRODUCTION AND IMPORTANCE: Cecal volvulus is a rare cause of obstruction in pregnancy. It accounts for ∼1.5 % of all intestinal obstructions. The diagnosis is challenging and causes increased morbidity and mortality to the mother and fetus. This case report will highlight the life-threatening nature of this condition and emphasize the critical importance of early diagnosis and intervention. CASE PRESENTATION: A 30-year-old gravida-3 para-2 patient presented with colicky abdominal pain of 24 h duration. She had associated abdominal distension, vomiting and fever. She had amenorrhea of 05-months. The past medical and surgical histories were negative. Her vital signs were deranged and had tenderness all over the abdomen. Ultrasound showed gaseous abdomen and viable fetus in the uterus. Laparotomy has revealed gangrenous cecal volvulus. A right hemicolectomy and end-to-side ileo-transverse colon anastomosis were performed. She expelled a dead fetus after 12 h. She was discharged in good clinical status. DISCUSSION: Cecal volvulus involves axial rotation of the ascending colon, cecum, and terminal ileum about associated mesentery. Pregnancy is among the pre-disposing factor for cecal volvulus. The diagnosis is often challenging because of non-specific presentations. Radiologic procedures are helpful in the diagnosis. The primary treatment is surgical intervention. CONCLUSION: Cecal volvulus is a rare life-threatening cause of obstruction in pregnancy. It is an emergency situation, and early diagnosis and intervention are crucial to decreasing morbidity and mortality. The most effective treatment is surgical resection.

Three twisted tales: A case series of caecal volvulus.

INTRODUCTION: Caecal volvulus is a form of intestinal obstruction with life-threatening potential. While rare, it represents a perilous aetiology of intestinal blockage, with clinical manifestations spanning from abdominal discomfort to mortality. CASE SERIES: We report the cases of three young adults (two males and one female) who presented to the emergency department with different manifestations of severe abdominal pain. All occurred within one month in a tertiary referral centre. Radiological evaluations confirmed the diagnosis of caecal volvulus in all. Subsequently, these individuals underwent right hemicolectomies with end-to-end anastomosis. All experienced an uncomplicated perioperative course. CLINICAL DISCUSSION: Caecal volvulus is uncommon, but its yearly incidence is increasing. Early detection and a heightened level of suspicion lead to a timely diagnosis, reducing morbidity and mortality rates. CONCLUSION: We report a case series of caecal volvulus, emphasizing its variable presentation and highlighting the critical importance of an early diagnosis. Typically, patients have a history of similar episodes that resolve without any medical intervention. Definitive treatment involves right hemicolectomy while conservative management is associated with very high recurrence rates. Early detection allows for prompt intervention, resulting in reduced morbidity and mortality rates.

An Unusual Presentation of Adult Intussusception.

Intussusception is a condition characterized by the invagination of a proximal segment of the intestine into a distal segment. In adults, intussusception is commonly associated with a lead point. The most alarming lead point is an obstructing malignancy. Here, we present the case of a 57-year-old woman with ileocolic intussusception secondary to colonic adenocarcinoma. The patient presented to the emergency department following an incidental finding of bradycardia, with a heart rate of around 40 beats per minute. She presented with several weeks of cramping, right lower quadrant abdominal pain, lightheadedness, fatigue, and palpitations. A computed tomography scan revealed ileocolic intussusception. After the placement of a semi-permanent right subclavian pacer, the patient underwent a right hemicolectomy. Surgical findings were consistent with ileocolic intussusception suspicious of being initiated by a mass in the right cecum involving the appendiceal orifice and ileocecal valve that invaded through the muscularis propria into subserosal tissue. The mass was resected and sent to pathology, where it was classified as stage II colonic adenocarcinoma. This case highlights a nonspecific presentation of intussusception that was only identified due to incidental bradycardia.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy for overweight colon cancer patients: a case-control study.

INTRODUCTION: Either extracorporeal anastomosis (EA) or intracorporeal anastomosis (IA) could be selected for digestive reconstruction in laparoscopic right hemicolectomy (LRH). However, whether LRH with IA is feasible and beneficial for overweight right-side colon cancer (RCC) is unclear. This study aims to investigate the feasibility and advantage of IA in LRH for overweight RCC. METHODS: Forty-eight consecutive overweight RCC patients undergoing LRH with IA were matched with 48 consecutive cases undergoing LRH with EA. Both clinical and surgical data were collected and analyzed. RESULTS: The incidence of postoperative complications was 20.8% (10/48) in the EA group and 14.6% (7/48) in the IA group respectively, with no statistical difference. Compared to the EA group, patients in the IA group revealed faster gas (40.2 + 7.8 h vs. 45.6 + 7.9 h, P = 0.001) and stool discharge (4.0 + 1.2 d vs. 4.5 + 1.1 d, P = 0.040), shorter assisted incision (5.3 + 1.3 cm vs. 7.5 + 1.2 cm, P = 0.000), and less analgesic used (3.3 + 1.3 d vs. 4.0 + 1.3 d, P = 0.012). There were no significant differences in operation time, blood loss, or postoperative hospital stays. In the IA group, the first one third of cases presented longer operation time (228.4 + 29.3 min) compared to the middle (191.0 + 35.0 min, P = 0.003) and the last one third of patients (182.2 + 20.7 min, P = 0.000). CONCLUSION: LRH with IA is feasible and safe for overweight RCC, with faster bowel function recovery and less pain. Accumulation of certain cases of LRH with IA will facilitate surgical procedures and reduce operation time.

Cecal Volvulus in an Elderly Woman: A Rare Cause of Bowel Obstruction.

Cecal volvulus is a rare, life-threatening form of bowel obstruction caused by the entanglement of the bowel around the mesenteric axis, compromising blood supply and leading to obstruction and ischemia. The diagnosis is challenging due to its highly variable clinical presentation and differential diagnoses, which may delay timely intervention. This is a case report of an 89-year-old woman who presented with a two-day history of lower right quadrant abdominal pain, nausea, and a temporary loss of consciousness. She also reported a history of chronic constipation. Clinical examination and imaging were suggestive of bowel obstruction, prompting further investigation. Plain radiography and abdominal CT confirmed bowel obstruction, with suspicion of volvulus. The diagnostic uncertainty between cecal and sigmoid volvulus prompted a colonoscopy, which excluded sigmoid volvulus. Emergency laparotomy revealed cecal volvulus and a distended cecum with ischemic changes but without necrosis. A right hemicolectomy was performed, and the patient recovered well postoperatively. This case report aims to expand the medical knowledge around the topic of cecal volvulus. It underscores the challenges in diagnosing and managing this condition and emphasizes the importance of prompt recognition and surgical intervention to improve patient outcomes.

Neuroendocrine tumor of the appendix masquerading as acute appendicitis with a mucocele on CT scan: a rare finding.

INTRODUCTION: Neuroendocrine tumors (NETs) of the appendix are rare and are often discovered incidentally during surgery for acute appendicitis or other unrelated conditions (Modlin et al. in Gastroenterology 128:1717-1751, 2005, Alsaad et al. in Oncol Rep 16:1105-1109, 2006, Frilling et al. in Lancet Oncol 15:e8-e21, 2014). These tumors can range from asymptomatic incidental findings to clinically significant tumors with metastases (Alsaad et al. in Oncol Rep 16:1105-1109, 2006, Gomes et al. in World J Emerg Surg 10:60, 2015, Paiva et al. in Eur J Cancer 38:702-705, 2002, Burke et al. in Am J Surg Pathol. 9:661-674, 1985). This case report presents a rare case of a NET of the appendix presenting as acute appendicitis. CASE DESCRIPTION: A 23-year-old male presented with right lower quadrant abdominal pain, nausea, and vomiting for 2 days. A CT scan revealed a mucocoele of the appendix. The patient underwent laparoscopic appendectomy, and the appendix was sent for histopathological examination. The final pathological report confirmed a NET of the appendix with a Ki-67 index of 1% and no lymphovascular invasion. Due to tumor invasion to the cecum and its large size (3-4 cm), the patient underwent right hemicolectomy. The final histopathology report of the resected specimen confirmed the diagnosis of NET of the appendix. DISCUSSION: The clinical diagnosis of NETs of the appendix can be challenging due to their rarity and non-specific presentation. Symptoms of NETs of the appendix can mimic those of acute appendicitis, making it difficult to differentiate between the two conditions. Imaging studies, such as CT scans, can provide valuable information about the size and location of the tumor (Gomes et al. in World J Emerg Surg 10:60, 2015, Maggard et al. in Ann Surg 240:117-122, 2004, Burke et al. in Am J Surg Pathol. 9:661-674, 1985, Frilling et al. in Lancet Oncol 15:e8-e21, 2014). However, the definitive diagnosis is made through histopathological examination of the resected specimen. The treatment of NETs of the appendix depends on factors such as the size, location, and grade of the tumor. Small tumors confined to the appendix with no lymph-vascular invasion can be treated with appendectomy alone, while larger tumors or those that have spread beyond the appendix may require more extensive surgery, such as right hemicolectomy (Gomes et al. in World J Emerg Surg 10:60, 2015, Mestier et al. in Dig Liver Dis 52:899-911, 2020, Maggard et al. in Ann Surg 240:117-122, 2004, Burke et al. in Am J Surg Pathol. 9:661-674, 1985, Frilling et al. in Lancet Oncol 15:e8-e21, 2014, Pavel et al. in Neuroendocrinology 103:172-185, 2016). In some cases, additional treatments such as chemotherapy or radiation therapy may be recommended. CONCLUSION: This case report emphasizes the importance of considering NETs of the appendix in the differential diagnosis of acute appendicitis. Imaging studies can provide valuable information, but the definitive diagnosis is made through histopathological examination. The treatment approach for NETs of the appendix depends on various factors and requires a multidisciplinary approach for optimal management.

Utility of articulating instruments as an alternative to robotic devices in laparoscopic right hemicolectomy.

Laparoscopic complete mesocolic excision with central vessel ligation has been widely accepted for its oncological benefits in colon cancer surgery. However, laparoscopic right hemicolectomy involves a risk for vascular injury during dissection around the surgical trunk. This technical difficulty has been attributed to the limited movement of conventional laparoscopic forceps. Although robotic devices can overcome the restricted motion of laparoscopic devices, they are not yet widely used. The ArtiSential is an articulating laparoscopic instrument that has a two-joint end-effector that enables a wide range of motion precisely reflecting the surgeon's finger movements, and is designed to compensate for the drawbacks of conventional laparoscopic tools. The present study demonstrated the utility of articulating instruments in laparoscopic right hemicolectomy by comparing the authors' laparoscopic procedures, using articulating instruments, with robotic procedures. Articulating laparoscopic instruments can be successfully maneuvered in virtually the same manner as robotic devices and, as such, represent a viable alternative to robotic surgery. Supplementary Information: The online version contains supplementary material available at 10.1007/s13691-024-00654-w.

A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group).

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Large Cell Neuroendocrine Carcinoma Presenting as Adult Intussusception.

Large cell neuroendocrine carcinoma (LCNEC) is an extremely rare malignant tumor of the colon, presenting with more severe clinical outcomes in comparison to colonic adenocarcinoma. There are very few reported cases in the literature. We hereby add our voice to the incidence of this disease by presenting the first report of a patient with ileocolic intussusception secondary to a large cell neuroendocrine cancer of the cecum. The patient was a 48-year-old woman who presented with acute onset of generalized abdominal pain and leukocytosis. CT scan revealed an ileocecal intussusception and multiple liver metastases suggestive of a malignant bowel lesion. She underwent emergency surgery, and an extended right hemicolectomy with ileo-transverse anastomosis was performed. Histology of the resected lesion revealed large cell neuroendocrine carcinoma of the cecum with invasion through the muscularis propria into peri colorectal tissues. The tumor retained mismatch repair (MMR) proteins with low potential for microsatellite instability (MSI). With a clinical diagnosis of stage IV LCNEC, the patient began platinum doublet chemotherapy with carboplatin and etoposide; however, her disease progressed, and the patient expired within a few months after her diagnosis. Clinical diagnosis of adult intussusception should prompt clinicians to rule out malignant etiology. This patient had a large cell neuroendocrine carcinoma of the colon, a rare and extremely aggressive malignancy. Patients with LCNEC will benefit from a multidisciplinary approach to treatment.

Tube Stoma for the Management of Ileocolic Anastomotic Leak in a Patient With Metastatic Colon Cancer.

This case involves a 53-year-old male who was diagnosed with stenotic ascending colon cancer and peritoneal metastatic deposits. He was initially planned for cytoreductive surgery and heated intraperitoneal chemotherapy (CRS and HIPEC), along with resection of the primary tumor in the form of right hemicolectomy. Intraoperatively, the disease was found to be more extensive than anticipated. Consequently, the plan was modified to include debulking right hemicolectomy with hand-sewn ileocolic anastomosis and extensive peritoneal procedures. Postoperatively, he experienced an anastomotic leak, leading to another laparotomy. However, due to anatomical challenges, creating a stoma was considered unsafe. Therefore, innovative interventions were performed, including controlling the anastomotic defect with a 30Fr Foley catheter without disrupting the anastomosis. A collaborative effort from various medical teams facilitated the patient's discharge home after an extended stay in the critical care unit (CCU).

Effectiveness and safety of self-pulling and latter transection reconstruction in totally laparoscopic right hemicolectomy.

Background: Laparoscopic right hemicolectomy is a standard treatment modality for right colon cancer. However, performing intracorporeal anastomosis (IA) for totally laparoscopic right hemicolectomy (TLRH) remains a challenge for some surgeons. To simplify IA in TLRH we used self-pulling and latter transection (SPLT) reconstruction in TLRH, and compared this procedure with overlap IA and laparoscopy-assisted right hemicolectomy (LARH) in order to evaluate its safety and effectiveness. Methods: Patients with right colon cancer who underwent SPLT-TLRH, TLRH with overlap IA or LARH between July 2019 and June 2023 were evaluated retrospectively. Basic information, oncological features, perioperative outcomes, and postoperative complications were compared between groups. Results: In total, 188 patients with right colon cancer that underwent SPLT-TLRH (n = 60), TLRH(n=21) or LARH (n = 107) were included in the study. No patient required conversion to open surgery. The operation time in SPLT-TLRH group was significantly shorter than that in TLRH group (P<0.05). Compared with LARH group, SPLT-TLRH group had significantly longer distal margins, shorter skin incisions (P < 0.001), time to first flatus, time to first defecation, and postoperative hospital stays (P<0.05). Conclusion: We introduced SPLT to TLRH. The SPLT-TLRH group demonstrated better short-term outcomes. Therefore, we believe that SPLT reconstruction is effective and safe in TLRH for right colon cancer, and can simplify reconstruction.

Lower Gastrointestinal Bleeding Secondary to Appendiceal Mucinous Neoplasm: A Report of Two Cases and a Review of the Literature.

Appendicular mucinous neoplasms, constituting less than 1% of gastrointestinal tract neoplasms, are heterogeneous entities. They may be asymptomatic, discovered incidentally, or present as large tumors due to mucin accumulation. The lack of standardized treatment complicates management. Imaging studies, particularly CT scans, are crucial for diagnosis and follow-up. This case report presents two clinical cases of women in their sixth and seventh decades of life with a history of lower gastrointestinal bleeding, mild anemia in laboratory studies, and incomplete colonoscopies. The diagnosis, confirmed through CT scans, led to the decision for surgical intervention in both cases, involving laparoscopic right hemicolectomy with ileotransverse anastomosis. Subsequently, histopathological reports confirmed the diagnosis of high-grade appendicular mucinous neoplasms, and a follow-up plan was established with imaging studies every six months with no recurrence at two years. Over 50% of appendicular tumors are mucinous neoplasms originating from low-grade mucinous neoplasms. Given the low lymph node invasion (2%), appendectomy may suffice if the entire tumor is excised. Extensive resections or right hemicolectomy are reserved for larger tumors or high-grade neoplasms to minimize local recurrence risk. Mucinous neoplasms with acellular mucin and peritoneal invasion may require cytoreduction or right hemicolectomy, while those with mucinous epithelium may need hyperthermic intraperitoneal chemotherapy (HIPEC) due to the risk of local recurrence, worsened by the presence of extra appendiceal epithelial cells. Disease-free and overall survival depend on treatment and initial lesion characterization. A five-year survival rate of 86% is reported for low-grade mucinous neoplasms. Follow-up approaches lack an ideal standard, generally involving physical examinations and imaging studies every six months to one year during the first six years.

Laparoscopic right hemicolectomy: a SICE (Società Italiana di Chirurgia Endoscopica e Nuove tecnologie) network prospective study on the approach to right colon lymphadenectomy in Italy: is there a standard?-CoDIG 2 (ColonDx Italian Group).

BACKGROUND: Colon cancer is a disease with a worldwide spread. Surgery is the best option for the treatment of advanced colon cancer, but some aspects are still debated, such as the extent of lymphadenectomy. In Japanese guidelines, the gold standard was D3 dissection to remove the central lymph nodes (203, 213, and 223), but in 2009, Hoenberger et al. introduced the concept of complete mesocolic excision, in which surgical dissection follows the embryological planes to remove the mesentery entirely to prevent leakage of cancer cells and collect more lymph nodes. Our study describes how lymphadenectomy is currently performed in major Italian centers with an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH). METHODS: CoDIG 2 is an observational multicenter national study that involves 76 Italian general surgery wards highly specialized in colorectal surgery. Each center was asked not to modify their usual surgical and clinical practices. The aim of the study was to assess the preference of Italian surgeons on the type of lymphadenectomy to perform during RH and the rise of any new trends or modifications in habits compared to the findings of the CoDIG 1 study conducted 4 years ago. RESULTS: A total of 788 patients were enrolled. The most commonly used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%), side-to-side (98.7%), or isoperistaltic (96.0%) anastomosis. The lymph nodes at the origin of the vessels were harvested in an inferior number of cases (203, 213, and 223: 42.4%, 31.1%, and 20.3%, respectively). A comparison between CoDIG 1 and CoDIG 2 showed a stable trend in surgical techniques and complications, with an increase in the robotic approach (7.7% vs. 12.3%). CONCLUSIONS: This analysis shows how lymphadenectomy is performed in Italy to achieve oncological outcomes in RH, although the technique to achieve a higher lymph node count has not yet been standardized. Trial registration (ClinicalTrials.gov) ID: NCT05943951.