Laparoscopic subtotal proctocolectomy for synchronous triple colorectal cancers: a case report

A 42‐year‐old woman presented with abdominal pain. On the basis of CT results, we diagnosed her condition as bowel obstruction caused by advanced transverse colon cancer. Colonoscopy findings showed three lesions: (i) an advanced tumor in the transverse colon; (ii) a laterally spreading descending colon tumor; and (iii) a rectal polyp. The tumors and the polyp were all pathologically diagnosed as adenocarcinoma. After inserting a self‐expanding metallic stent into the main tumor of the transverse colon to decompress the bowel, we performed endoscopic submucosal dissection of the laterally spreading descending colon tumor. Pathological examination results showed submucosal invasion and a positive margin. Because we endoscopically identified that the rectal polyp was invading the submucosa, we performed laparoscopic subtotal proctocolectomy and ileorectal anastomosis with lymph node dissection along the surgical trunk; we also performed central vascular ligation of the ileocolic artery, right and left branches of the middle colic artery, and inferior mesenteric artery. The patient's postoperative course was uneventful. We present this case because there have been few reports on laparoscopic subtotal or total proctocolectomy for synchronous multiple colorectal cancers.     

Clostridium difficile infection and inflammatory bowel disease: understanding the evolving relationship

Clostridium difficile(C.difficile)infection(CDI)is the leading identifiable cause of antibiotic-associated diarrhea.While there is an alarming trend of increasing incidence and severity of CDI in the United States and Europe,superimposed CDI in patients with inflammatory bowel disease(IBD)has drawn considerable attention in the gastrointestinal community.The majority of IBD patients appear to contract CDI as outpatients.C.difficile affects disease course of IBD in several ways,including triggering disease flares,sustaining activity,and in some cases,acting as an"innocent"bystander.Despite its wide spectrum of presentations,CDI has been reported to be associated with a longer duration of hospitalization and a higher mortality in IBD patients.IBD patients with restorative proctocolectomy or with diverting ileostomy are not immune to CDI of the small bowel or ileal pouch.Whether immunomodulator or corticosteroid therapy for IBD should be continued in patients with superimposed CDI is controversial.It appears that more adverse outcomes was observed among patients treated by a combination of immunomodulators and antibiotics than those treated by antibiotics alone.The use of biologic agents does not appear to increase the risk of acquisition of CDI.For CDI in the setting of underlying IBD,vancomycin appears to be more efficacious than metronidazole.Randomized controlled trials are required to clearly define the appropriate management for CDI in patients with IBD.     

Laparoscopic Colorectal Surgery: Summary of the Current Evidence

INTRODUCTION

Laparoscopic colectomy has not been accepted as quickly as laparoscopic cholecystectomy. This is because of its steep learning curve, concerns with oncological outcomes, lack of randomised controlled trials (RCTs) and initial reports on port-site recurrence after curative resection. The aim of this review is to summarise current evidence on laparoscopic colorectal surgery.

PATIENTS AND METHODS

Review of literature following Medline search using key words ‘laparoscopic’, ‘colorectal’ and ‘surgery’.

CONCLUSIONS

Laparoscopic colorectal surgery proved to be safe, cost-effective and with improved short-term outcomes. However, further studies are needed to assess the role of laparoscopic rectal cancer surgery and the value of enhanced recovery protocols in patients undergoing laparoscopic colorectal resections.     

Surgery for Obscure Lower Gastrointestinal Bleeding in India

Western patients with obscure lower gastrointestinal hemorrhage (OLGIH) are usually 60 years or older, bleed from colonic diverticulosis or angiodysplasia, and need localizing investigations. In India, patients are younger, the causes of bleeding different, and health resources scarce. We followed a policy of early surgical exploration operation and excision of the bleeding source or, if this was not identified, did a right hemicolectomy. The outcome of this strategy was evaluated. Between 1996 and 2003, we managed 62 patients with OLGIH. Localizing investigations such as enteroclysis, radioisotope scanning, angiography, and peroperative enteroscopy were infrequently performed. Fifty patients underwent surgery, emergency (35 pts) or elective (15 pts), and comprised the study group. At operation the lesion was localized in 33 (66%) patients (jejunum in 9 and terminal ileum or cecum in 24) and was resected. In 17 patients no lesion was found and they had a right hemicolectomy. The 30-day mortality was six patients (12%) and included persistent bleeding (three), liver failure (one), and chest infection (one). Five (10%) patients rebled after operation at a mean follow-up of 31 months. Cirrhosis (P=0.003) as a comorbid illness was the only significant factor for rebleed in the right hemicolectomy group. Advanced age (>60 years; P=0.08) might be another risk factor in a larger study. In conclusion, patients with obscure OLGIH in India should have an early operation. If a lesion is not detected, a right hemicolectomy may be done. In this group those with cirrhosis have a higher chance of rebleed, as well as, perhaps, elderly patients.     

The Gap in Laparoscopic Colorectal Experience Between Colon and Rectal and General Surgery Residency Training Programs

Purpose In this article, we review the laparoscopic experience of general surgery and colorectal residency training programs in the United States during the past 5 and 12 years, respectively. The purpose of this study was to determine whether an adequate experience was being provided, and at what level of training, to safely and effectively perform advanced laparoscopy. Methods General Surgery Operative Reports from the training years 2000 to 2004 were obtained from the Accreditation Council for Graduate Medical Education. Similarly, colorectal operative performance logs from the training years 1994 to 2005 were obtained from the American Board of Colon and Rectal Surgery. Results From 2000 to 2004, basic and advanced laparoscopic cases (as designated by the Accreditation Council for Graduate Medical Education) have increased from 10.1 to 12.2 percent and 2.1 to 3.7 percent, respectively. Within this period, the number of laparoscopic colon cases/resident/career has increased from 1.8 to 4.6. The percentage of cases performed laparoscopically increased from 3.9 to 22.5 percent from 1993–1994 to 2004–2005 training years. From 1993 to 2001, the average number of laparoscopic cases/resident increased from 6.3 to 16.1. In 2004, the average number of cases/resident increased to 45.3. Of this number, 30 were colon, 9.4 were rectal, and the remaining 5.9 were miscellaneous colorectal procedures. Conclusions Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. Based on the most recent data reviewed, colon and rectal resident experience is trending toward this threshold. Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in laparoscopic colorectal surgery. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 8, 2006.     

Totally intracorporeal laparoscopic colorectal anastomosis using circular stapler

Background A number of surgical techniques for colorectal anastomosis have been described for laparoscopic left-sided colectomies. Due to the complexity of these procedures, open preparation of the proximal bowel for circular stapler anastomosis through a Pfannenstiel incision has become the gold standard. We report a new laparoscopic technique for totally intracorporeal colorectal circular anastomosis (TLCCA) using a circular stapler. Methods Preliminary experience using TLCCA in three patients scheduled for laparoscopic left colectomies (two) and sigmoidectomy (one). Results Side-to-end colorectal anastomosis through TLCCA was feasible in all patients scheduled for preliminary experience. Median time from anvil insertion into abdominal cavity to anastomosis was 14 (11–17) minutes. No postoperative complications were recorded. Conclusion Side-to-end anastomosis can be easily and safely performed using conventional circular stapler through TLCCA. TLCCA is performed using four laparoscopic ports without additional skin incision (except trocars incision) and allows the retrieval of surgical pieces through a specimen bag.     

Medical comorbidities predict the need for colectomy for complicated and recurrent diverticulitis

Objective

The objective of this study was to identify risk factors for recurrent or complicated diverticulitis requiring colectomy.

Methods

A total of 112 patients were admitted to the West Haven Veterans Affairs Medical Center with the diagnosis of colonic diverticular disease from January 1998 to December 2006. Patients' records were assessed for demographics, past medical history, and physical and biochemical features of presentation. Student t tests, analysis of variance, and chi-square analysis were used to compare binary and categoric data.

Results

The medical records of 112 patients admitted to the West Haven Veterans Affairs hospital with the diagnosis of diverticulitis were analyzed retrospectively. A total of 97.3% were male (n = 109), with a mean age of 63.3 years, and a significant smoking history greater than 30 pack-years was present in 70.5% (n = 79) of patients. Eighty-four percent (n = 94) of patients presented with localized abdominal pain and 69.6% (n = 78) had abdominal tenderness without peritoneal signs. Computed tomography was performed in 85.7% (n = 96) of cases. A total of 23.2% (n = 26) of patients proceeded to laparotomy, with free perforation being the most common indication (38.4%, n = 12) followed by a history of 2 or more antecedent attacks of diverticulitis (23.1%, n = 6). Analysis of variance showed that serum albumin levels were significantly lower in the group undergoing colectomy compared with those who did not (3.4 vs 4.1 mg/dL; P = .016). The need for colectomy owing to complicated or recurrent attacks correlated with glucocorticoid use (P < .001) and a history of chronic obstructive pulmonary disease (P < .038), but not with diabetes mellitus, collagen vascular disease, or inflammatory bowel disease.

Conclusions

The rules regarding the treatment of diverticulitis are evolving. Comorbid conditions such as hypoalbuminemia, chronic obstructive pulmonary disease, and glucocorticoid use may predispose patients to recurrent or complicated attacks of diverticulitis requiring colectomy. Stratification and reduction of risks may reduce the overall morbidity and mortality of diverticulitis.     

Laparoscopic colectomy

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer. Received: 26 March 1996/Accepted: 15 October 1996     

Scintigraphic assessment of slow transit constipation with special reference to right- or left-sided colonic delay

OBJECTIVE: Subtotal colectomy and ileorectal anastomosis for slow transit constipation has several side-effects. The motor abnormality in some patients may be segmental which could motivate a limited resection of the colon. Therefore a diagnostic tool to identify a segmental colonic motor dysfunction is needed. The aim of this study was to evaluate a scintigraphic method to assess colonic transit with special reference to right- or left-sided delay. METHODS: Twenty-three constipated patients (19 women, mean age 50 years) with slow colonic transit on radio-opaque marker studies and 13 healthy individuals (11 women, mean age 46 years) were studied. All subjects were examined with oral (111)Indium-DTPA scintigraphy. The scintigraphic results for patients and controls were presented as geometric centre of radioactivity and percent activity over time in the right, the left and the recto-sigmoid colon. The inter-observer variation in the interpretation of the scans was also evaluated. RESULTS: There was no difference in transit time between the groups of patients and controls in the right colon whereas the patients had a significant delay in the left colon (P < 0.05). Two patients had a marked delay in the right colon followed by relatively rapid transit in the left colon. The inter-observer correlation was good comparing the right, the left and the recto-sigmoid colon (r = 0.58-0.98, P < 0.01-0.001). CONCLUSION: The results indicate that colonic scintigraphy with oral (111)Indium-DTPA may help to select patients for a left or, in a few cases, a right hemicolectomy for slow transit constipation.     

The oncologic safety of left colectomy with modified complete mesocolic excision for distal transverse colon cancer: Comparison with descending colon cancer

BackgroundThe optimal surgical approach for distal transverse colon cancer has not been well established. This study aimed to evaluate the oncologic safety of left colectomy with a modified complete mesocolic excision for distal transverse colon cancer as compared with descending colon cancer.Material and methodsThis study involved 383 patients who underwent left colectomy with modified complete mesocolic excision for non-metastatic distal transverse and splenic flexure colon (transverse group, N = 110) and descending colon cancer (descending group, N = 237) from 3 institutions. Recurrence-free survival (RFS) and overall survival (OS) were compared between the two groups.ResultsBaseline characteristics between the two groups were similar except for the length of the distal margin (transverse group = 11.0 cm vs descending group = 9.0 cm, p = 0.004). During a median follow-up of 47.0 months, RFS and OS were not different between the transverse and descending groups (5-year RFS: 82% vs 71%, p = 0.139; 5-year OS: 83% vs 79%, p = 0.416, respectively). In multivariable analysis, RFS and OS were not different between the two groups (transverse group vs. descending group: adjusted hazard ratio [aHR] = 1.557, 95% CI = 0.786–3.084, p = 0.204; aHR = 1.251, 95% CI = 0.530–2.952, p = 0.609).ConclusionThe oncologic outcomes of left colectomy with a modified complete mesocolic excision of distal transverse colon cancer were comparable to those of descending colon cancer. Left colectomy with a modified complete mesocolic excision can be an acceptable surgical treatment for distal transverse colon cancer.