Splenic flexure colon cancer occurs at a relatively lower rate than colon cancer of other sites. It is also associated with more advanced disease and higher rate of acute obstruction. The splenic flexure receives blood supply from both superior and inferior mesenteric arteries (SMA and IMA), and therefore has lymphatic drainage to both areas. The blood supply is also highly variable, causing difficulties in determining the main feeding vessels and the main direction of lymph drainage. Few studies with limited cases focused on this specific tumor site with respect to the patterns of lymph node spread, especially the main lymph node status and the value of its dissection. The lack of information limits the development of a consensus on the extent of surgical resection and lymphadenectomy. Adequate mobilization of the colon facilitates a sufficient length of bowel resection and the high ligation of feeding arteries from both SMA and IMA. Further evidence on the chnoice of procedures and the extent of lymph node dissection need multicenter collaboration, with the use of modern techniques, including CT 3D reconstruction of the colon and angiography, as well as intraoperative fluorescent real-time imaging of lymph nodes.
Colon, Transverse/surgery* ; Colonic Neoplasms/surgery* ; Humans ; Laparoscopy ; Lymph Node Excision/methods* ; Lymph Nodes/pathology* ; Mesenteric Artery, Inferior/surgery*

PURPOSE: Hand-assisted laparoscopic surgery (HALS) is a minimally invasive surgical technique with the combined benefits of laparoscopic surgery while allowing the use of the surgeon's hand for better tactile control. Obesity has been associated with higher conversion rates with multiport laparoscopic surgery, but not with HALS. This study aimed to examine the versatility of HALS in various clinical contexts. METHODS: All HALSs performed at 2 major tertiary centers in Sydney were prospectively collected for retrospective analysis. Variables including age, sex, body mass index (BMI), previous surgeries, pathologies including size and T-stage, and the number of conversions to a midline laparotomy were examined. RESULTS: A total of 121 HALS colorectal resections were analyzed. The median age of the patients was 62 years, with 63.6% being women. Seven patients required conversion to a midline laparotomy. Of the 121 patients, 50.2% were overweight or obese, and 52.9% had undergone previous abdominal/pelvic operations. However, neither obesity nor abdominal adhesions from previous operations were an indication for conversion to an open laparotomy in any of the 7 converted patients. The presence of intra-abdominal adhesions did not impact the operative time. HALS allowed access to the entire colon and rectum and allowed resection of the bladder, uterus, and ureter, when these organs were involved. CONCLUSION: HALS is a versatile, minimally invasive technique, which is independent of the patient's BMI, for performing a colorectal resection.
Body Mass Index ; Colon ; Colorectal Surgery ; Female ; Hand ; Hand-Assisted Laparoscopy* ; Humans ; Laparoscopy ; Laparotomy ; Obesity ; Operative Time ; Overweight ; Pathology ; Prospective Studies ; Rectum ; Retrospective Studies ; Surgeons* ; Ureter ; Urinary Bladder ; Uterus

OBJECTIVETo investigate the risk factors of low anterior resection syndrome (LARS) after anal sphincter preserving surgery (SPS) for rectal cancer patients.

METHODSClinicopathological and follow-up data of rectal cancer patients who underwent SPS from January 2010 to June 2014 in Department of Gastroenterological Surgery, Peking University People's Hospital, were retrospectively analyzed. Patients receiving permanent colostomy and local resection were excluded. Meanwhile, during October 2014 and March 2015, the enrolled patients were asked to fill out a specially designed questionnaire for LARS through face-to-face interview or telephone inquiry, according to the chronological order of operation. Based on the score of questionnaire, patients were divided into three groups: 0-20 points: non LARS; 21-29: minor LARS; 30-42: major LARS. The demographic and clinicopathologic features were compared among groups and the risk factors of major LARS were tested by logistic regression analysis.

RESULTSA total of 100 patients (61 males, 39 females) completed the bowel function survey, with an average age of 66.2(41-86) years, 33 patients <60 years versus 67 patients ≥60 years. No significant difference was observed in age distribution (P=0.204). Interval from operation to first follow-up was more than 1 year in 70 patients, and the median follow-up was 23 months. Thirty-seven patients were non LARS, 18 were minor LARS and 45 were major LARS. No significant differences in clinicopathological data (all P>0.05) were observed among three groups except radiotherapy history (P=0.025), tumor location(P=0.000) and distance from anastomotic site to anal verge(P=0.008). After comparison of non LARS group combined with minor LARS group versus major LARS, re-analysis of risk factors showed that radiotherapy history (RR=5.608, 95%CI:1.457 to 21.584, P=0.006), distance from tumor lower margin to anal verge (RR=0.125, 95%CI:0.042 to 0.372, P=0.000), distance from anastomotic site to anal verge (RR=0.255, 95%CI:0.098 to 0.665, P=0.004) and preventive ileostomy history(RR=3.643, 95%CI:1.058 to 12.548, P=0.032) were associated with major LARS. One potential risk factor detected in combined analysis was female (RR=2.138, 95%CI: 0.944 to 4.844, P=0.078). Multivariate analysis revealed that female (RR=2.654, 95%CI: 1.005 to 7.014, P=0.049), radiotherapy history (RR=10.422, 95%CI:2.394 to 45.368, P=0.002) and distance from tumor lower margin to anal verge ≤7 cm (RR=8.935, 95%CI:2.827 to 28.243, P=0.000) were independent risk factors of major LARS.

CONCLUSIONSLARS is a significant problem in most rectal cancer patients after SPS. The risk of major LARS increases on condition of radiotherapy, low tumor position and female. When dealing with these patients, preventive measures should be taken into consideration during SPS.

Adult ; Aged ; Aged, 80 and over ; Anal Canal ; pathology ; surgery ; Anastomosis, Surgical ; adverse effects ; Colon ; surgery ; Defecation ; physiology ; Factor Analysis, Statistical ; Female ; Follow-Up Studies ; Humans ; Long Term Adverse Effects ; epidemiology ; Male ; Middle Aged ; Radiotherapy ; adverse effects ; Rectal Neoplasms ; complications ; pathology ; surgery ; Rectum ; physiopathology ; surgery ; Retrospective Studies ; Risk Assessment ; methods ; Risk Factors ; Sex Factors ; Surveys and Questionnaires ; Syndrome

BACKGROUND/AIMS: Diverticular bleeding can occasionally cause massive bleeding that requires urgent colonoscopy (CS) and treatment. The aim of this study was to identify significant risk factors for colonic diverticular hemorrhage. METHODS: Between January 2009 and December 2012, 26,602 patients underwent CS at our institution. One hundred twenty-three patients underwent an urgent CS due to acute lower gastrointestinal hemorrhage. Seventy-two patients were diagnosed with colonic diverticular hemorrhage. One hundred forty-nine age- and sex-matched controls were selected from the patients with nonbleeding diverticula who underwent CS during the same period. The relationship of risk factors to diverticular bleeding was compared between the cases and controls. RESULTS: Uni- and multivariate conditional logistic regression analyses demonstrated that the use of nonsteroidal anti-inflammatory drugs (odds ratio [OR], 14.70; 95% confidence interval [CI], 3.89 to 55.80; p<0.0001), as well as the presence of cerebrovascular disease (OR, 8.66; 95% CI, 2.33 to 32.10; p=0.00126), and hyperuricemia (OR, 15.5; 95% CI, 1.74 to 138.00; p=0.014) remained statistically significant predictors of diverticular bleeding. CONCLUSIONS: Nonsteroidal anti-inflammatory drugs, cerebrovascular disease and hyperuricemia were significant risks for colonic diverticular hemorrhage. The knowledge obtained from this study may provide some insight into the diagnostic process for patients with lower gastrointestinal bleeding.
Adult ; Aged ; Aged, 80 and over ; Anti-Inflammatory Agents, Non-Steroidal/adverse effects ; Case-Control Studies ; Cerebrovascular Disorders/complications ; Colonic Diseases/*etiology/surgery ; Colonoscopy ; Diverticulum, Colon/*complications/pathology/surgery ; Female ; Gastrointestinal Hemorrhage/*etiology/surgery ; Humans ; Hyperuricemia/complications ; Logistic Models ; Male ; Middle Aged ; Retrospective Studies ; Risk Factors

OBJECTIVETo investigate the application value of colonic transit test (CTT) combined with anorectal manometry (ARM), barium enema (BE) and defecography (DFG) in accurately evaluating colonic lesions of slow transit constipation complicated with adult megacolon.

METHODSClinical data of 47 above patients admitted between October 2007 and February 2015 in the People's Hospital of Hunan Province were analyzed retrospectively. All the patients were examined with≥2 times of CTT combined with ARM and BE, and 42 cases received additional DFG at the same time, to evaluate colonic lesions before operation. Operative biopsy pathology was used as the standard. The sensitivity, specificity, positive predictive value(PPV) and negative predictive value(NPV) of positioning in the ascending colon and caecum, transverse colon and descending colon were calculated, and the consistency was represented by Kappa test(Kappa value≥0.75 indicates good consistency, meanwhile higher Kappa value indicates better consistency). The Heikkinen score was used to evaluate defecation function at postoperative 6 months.

RESULTSThe age of 47 patients was from 18 to 56 years old. Compared with intraoperative findings and biopsy pathology, the diagnostic coincidence rate was 89.4% by CTT combined with BE and DFG positioning, which suggested pathology-changed colonic segment locating in the ascending colon and cecum (n=12), transverse colon (n=26) and descending colon (n=9), while intraoperative findings and biopsy pathology suggested pathology-changed colonic segment locating in the ascending colon and cecum (n=11), transverse colon (n=23) and descending colon (n=13). The sensitivity was 88.3%, specificity 93.5%, PPV 92.1%, NPV 94.9% and Kappa value was 0.827(P<0.001). Procedures performed included segmental colectomy (n=8), subtotal colectomy (n=29), total colectomy (n=10). There was no serious complication during and after operation. Defecatory function was excellent in 24 cases (60.0%), good in 10 (25.0%), and moderate in 6 (15.0%) evaluated by Heikkinen score at postoperative 6 months. A total of 40 patients were followed up from 1 to 7 years (median 3 years) and there was no long-term diarrhea and recurrence of constipation or giant colon after operation.

CONCLUSIONPreoperative detection of CTT combined with ARM, BE and DFG in patients with slow transit constipation complicated with adult megacolon can make a more precise assessment of the extent of colonic lesions in advance, which has a good clinical predictive value.

Adolescent ; Adult ; Barium Enema ; Cecum ; pathology ; physiopathology ; surgery ; Colectomy ; methods ; Colon ; pathology ; physiopathology ; surgery ; Constipation ; complications ; diagnosis ; pathology ; surgery ; Defecography ; Female ; Gastrointestinal Transit ; physiology ; Humans ; Male ; Manometry ; Megacolon ; complications ; pathology ; surgery ; Middle Aged ; Predictive Value of Tests ; Preoperative Period ; Prognosis ; Recovery of Function ; physiology ; Retrospective Studies ; Sensitivity and Specificity

No abstract available.
Colon/pathology/surgery ; Colonoscopy ; Female ; Humans ; Intestinal Perforation/*etiology ; Plastics ; Stents/*adverse effects

Most cases of intussusception in adults present with chronic and nonspecific symptoms, and can sometimes be challenging to diagnose. We herein report on a patient with the rare symptom of colonic intussusceptions presenting with rectal prolapse and review the existing literature of similar case reports to discuss how to reach an accurate diagnosis. A 75-year-old woman with dementia presented with per rectal bleeding, rectal prolapse and lower abdominal pain. An operation was scheduled and a large sigmoid intussusception with a polyp as a leading point was found intraoperatively. She subsequently recovered well and was discharged. As large sigmoid intussusceptions may present as rectal prolapse, intussusception should be considered as a differential diagnosis for immobile patients, especially when the leading point is a lesion.
Abdominal Pain ; Aged ; Colectomy ; Colon, Sigmoid ; pathology ; surgery ; Dementia ; complications ; Diagnosis, Differential ; Female ; Hemorrhage ; complications ; Humans ; Intussusception ; complications ; diagnosis ; surgery ; Necrosis ; Prolapse ; Rectal Prolapse ; diagnosis ; Rectum ; pathology ; surgery

Contrast-enhanced computed tomography colonography (CE-CTC) is a useful guide for the laparoscopic surgeon to avoid incorrectly removing the colonic segment and the failure to diagnose of synchronous colonic and extra-colonic lesions. Lymph node dissection and vessel ligation under a laparoscopic approach can be time-consuming and can damage vessels and organs. Moreover, mesenteric vessels have extreme variations in terms of their courses and numbers. We describe the benefit of using an abdominal vascular map created by CE-CTC in laparoscopic colorectal surgery candidates. We describe patients with different diseases (colorectal cancer, diverticular disease, and inflammatory bowel disease) who underwent CE-CTC just prior to laparoscopic surgery.
Adult ; Aged ; Colectomy/*methods ; Colon/blood supply/pathology/radiography ; Colonography, Computed Tomographic/*methods ; Colorectal Neoplasms/pathology/*radiography/*surgery ; Contrast Media ; Female ; Humans ; Laparoscopy/*methods ; Lymph Node Excision/methods ; Male ; Middle Aged ; Neoplasm Staging/methods

BACKGROUND/AIMS: Colonoscopic polypectomy is highly efficient in preventing colorectal cancer, but polyps may not always be completely removed. Improved knowledge of the risk factors for incomplete polyp resection after polypectomy may decrease the cancer risk and additional costs. The aim of this study was to investigate the conditions that can cause incomplete polyp resection (IPR) after colonoscopic polypectomy. METHODS: A total of 12,970 polyps that were removed by colonoscopic polypectomy were investigated. Among them, we identified 228 cases with a positive resection margin and 228 controls with a clear resection margin that were matched for age, gender, and polyp size. We investigated the location, morphology, and histological type of the polyps and evaluated the skills of the endoscopist and assisting nurse. RESULTS: Multivariate analysis revealed that the polyps, which were located in the proximal part of the colon and rectum, were at significant risk of IPR. Histologically, an advanced polyp and an inexperienced assistant were also independent risk factors for IPR. CONCLUSIONS: Polypectomy should be performed more carefully for polyps suspected to be cancerous and polyps located in the proximal part of the colon or rectum. A systematic training program for inexperienced assistants may be needed to decrease the risk of IPR.
Adult ; Aged ; Aged, 80 and over ; Case-Control Studies ; Clinical Competence ; Colon/pathology/surgery ; Colonic Polyps/pathology/*surgery ; *Colonoscopy ; Female ; Humans ; Male ; Middle Aged ; Retrospective Studies ; Risk Factors ; Treatment Failure

OBJECTIVE: The aim of this paper was to describe the operative details for en bloc removal of the adnexal tumor, uterus, pelvic peritoneum, and rectosigmoid colon with colorectal anastomosis in advanced epithelial ovarian cancer patients with widespread pelvic involvement. METHODS: The patient presented with good performance status and huge pelvic tumor extensively infiltrating into adjacent pelvic organs and obliterating the cul-de-sac. The patient underwent en bloc pelvic resection as primary cytoreductive surgery. En bloc pelvic resection procedure is initiated by carrying a circumscribing peritoneal incision to include all pan-pelvic disease within this incision. After retroperitoneal pelvic dissection, the round ligaments and infundibulopelvic ligaments are divided. The ureters are dissected and mobilized from the peritoneum. After dissecting off the anterior pelvic peritoneum overlying the bladder with its tumor nodules, the bladder is mobilized caudally and the vesicovaginal space is developed. The uterine vessels are divided at the level of the ureters, and the paracervical tissues (or parametria) are divided. The proximal sigmoid colon is divided above the most proximal extent of gross tumor using a ligating and dividing stapling device. The sigmoid mesentery is ligated and divided including the superior rectal vessels. The pararectal and retrorectal spaces are further developed and dissected down to the level of the pelvic floor. The posterior dissection is progressed and moves to the right and then to the left of the rectum. The rectal pillars including the middle rectal vessels are ligated and divided. Hysterectomy is completed in a retrograde fashion. The distal rectum is divided using a linear stapler. The specimen is removed en bloc with the uterus, adnexa, pelvic peritoneum, rectosigmoid colon, and tumor masses leaving a macroscopically tumor-free pelvis. Colorectal anastomosis was completed using stapling device. RESULTS: En bloc pelvic resection was performed by total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic peritonectomy, and rectosigmoid colectomy with colorectal anastomosis using a stapling device. Complete clearance of pelvic disease leaving no gross residual disease was possible using en bloc pelvic resection. CONCLUSION: En bloc pelvic resection is effective for achieving maximal cytoreduction with the elimination of the pelvic disease in advanced primary ovarian cancer patients with extensive pelvic organ involvement.
Anastomosis, Surgical ; Colon, Sigmoid/pathology/surgery ; Disease Progression ; Female ; Humans ; Hysterectomy/*methods ; Neoplasm Invasiveness ; Neoplasm, Residual ; Neoplasms, Glandular and Epithelial/*pathology/*surgery ; Ovarian Neoplasms/*pathology/*surgery ; Ovary/pathology/surgery ; Pelvic Exenteration/*methods ; Pelvis/pathology/surgery ; Rectum/pathology/surgery ; Salpingectomy ; Surgical Stapling