Segmental resection of splenic flexure colon cancers provides an adequate lymph node harvest and is a safe operative approach – an analysis of the ACS-NSQIP database

Introduction Fewer than 10% of colon cancers are found at the splenic flexure. A standard surgical approach to these cancers has not been defined. The goal of this study was to compare lymph node harvest and post-operative morbidity between segmental resection and formal left hemicolectomy for splenic flexure colon cancers. Method Patients diagnosed with a splenic flexure cancer were identified from the 2012–2018 ACS-NSQIP colectomy-targeted database. Patients were categorized based on type of surgical resection – left hemicolectomy with colorectal anastomosis or segmental colectomy with colocolonic anastomosis. Demographic, clinicopathologic, and post-operative outcomes were compared between groups. Factors independently associated with lymph node harvest, operative time, and post-operative morbidity were investigated by linear and binomial logistic regression models. Results A total of 3,049 patients underwent colectomy for a splenic flexure cancer. Of these, 83.6% had a segmental colectomy and 73% were performed by a minimally invasive approach. T- and N-stage did not differ between segmental and left hemicolectomy groups (p = 0.703 and p = 0.429, respectively). Inadequate nodal harvest (< 12 nodes) was infrequent and similar between the two procedures (7.4% vs. 9.1%, p = 0.13). Operative time was significantly shorter for segmental colectomy (213 ± 83.5 min vs. 193 ± 84.1 min, p < 0.0001) and major morbidity was similar between the two surgical techniques (8.4% vs. 8.9%, p = 0.75). After accounting for demographic, clinicopathologic, and operative factors, binomial logistic regression showed that type of procedure was not significantly associated with LN harvest (OR 0.80, 95%CI 0.54–1.17) or major morbidity (OR 1.17, 95%CI 0.36–3.81). However, on linear regression, segmental splenic flexure resection was associated with shorter operative time (estimate 20.29, 95%CI 12.61–27.97, p < 0.0001). Conclusion Splenic flexure resection for colon cancer is associated with an adequate lymph node harvest. Compared to a formal left hemicolectomy, a segmental resection also has a shorter operative time with equivalent post-operative morbidity.

RISK FACTOR ANALYSIS OF TYPE COLORECTAL OPERATION AND INTRAABDOMEN CONTAMINATION ON EVENT POST OPERATIVE ADHESION: SYSTEMATIC REVIEW AND METAANALYSIS

BACKGROUND: Colorectal surgery is the highest incidence of adhesion-related problems. The type of surgery might be total coletomy, right hemicolectomy, left hemicolectomy, segmental colectomy, Hartmann procedure, and colostomy. Surgical procedures performed on the colon could be contaminated. The most common contamination is faecal contamination. Various causes of peritoneal irritation result in localized brin production, which results in adhesion to the surfaces in contact. PURPOSE: This study focused on the type of colorectal surgery and intra-abdominal contamination on the incidence of postoperative adhesions. METHOD: Systematic review and meta-analysis. We searched for published journal on types of colorectal surgery and contamination with adhesion events published from 2010-2020 using electronic database : Pubmed, Science Direct and Cochrane. RESULT: Ten journals (8 cohort and 2 case control) were included in the meta-analysis. In the risk factors for colorectal surgery: APR surgery, total colectomy and rectal resection had a signicant risk of postoperative adhesions with a pooled odds ratio of 1.74 (95% CI 1 respectively). ,10-2,78); 2.89 (95% CI 2.44-3.41) and 9.91 (95% CI 8.66-11.35). Intra-abdominal contamination also had a risk of adhesions with a pooled odds ratio of 863.47 (95% CI 177.73-4194.13). CONCLUSION: Types of colorectal surgery : APR, total colectomy, and rectal resection and intra-abdominal contamination had a risk of postoperative adhesions.

Dedifferentiated Liposarcoma of the Transverse Colon

While liposarcoma is one of the most common soft tissue sarcomas, it is rarely seen within the gastrointestinal tract, and even less frequently seen within the colon. Dedifferentiated liposarcoma is a subtype of liposarcoma, which along with the pleomorphic subtype is considered a high-grade, aggressive tumor; both possess the ability to metastasize and are associated with decreased survival. Despite complete resection, recurrence is common. While surgical excision is the cornerstone of treatment for liposarcoma of the colon, there is no consensus on adjuvant therapies. We present the case of a 66-year-old woman who presented with abdominal pain with rectal bleeding and was found on colonoscopy to have a high-grade dedifferentiated liposarcoma of the transverse colon. She underwent robotic segmental colectomy. Due to absence of nodal involvement or distal metastasis, adjuvant therapy was not administered. On 1-year follow-up, the patient remains disease free.

Idiopathic Megacolon in an Adolescent Girl: a Case Report on a Rare Disease

Introduction: Idiopathic Megacolon is a rare condition where there is persistent dilatation of colon in the absence of identifiable cause. Symptoms start as early as in childhood or in adulthood. Colectomy have shown to have high success rate in patient with idiopathic megacolon. We reported a case of an adolescent girl with idiopathic megacolon that was successfully treated with colectomy.Presentation of case: A 15 years old girl presented with a complaint of abdominal pain associated with gradual abdominal distension for 1 week duration, not passing flatus and had multiple episodes of vomiting. She was diagnosed to have sigmoid volvulus and underwent endoscopy decompression, however symptoms recurred. Segmental colectomy was performed and she had an uneventful recovery. Discussion: Patient presented with acute intestinal obstruction attributed to sigmoid volvulus with a history of constipation. A diagnostic dilemma between Hirschsprung’s disease with other causes of megacolon occurred as these diseases have similar presenting symptoms. A confirm histopathology of presence of ganglionic cells within the plexus exclude the diagnosis of Hirschsprung’s disease hence the diagnosis of Idiopathic Megacolon was made. Segmental colectomy give good result in relieving patient symptoms of abdominal pain and constipation and one of the recommended surgical options in treating Idiopathic Megacolon.Conclusion: Idiopathic megacolon is a rare disease and for a long time has been a disease of exclusion. Rectal biopsy is important to exclude the diagnosis of Hirschsprung’s Disease. There are wide variety of surgical treatment available in treating Idiopathic megacolon. Segmental Colectomy have shown good success rate.

The Pitfalls and Strategies of Endoscopic Localization in Laparoscopic Colectomy: A Case Report

Background: laparoscopic segmental colectomy is suitable for removing difficult polyps that are large, broad-based, or located in tortuous bowel segments. As we know, accurate segmental resection depends on precise localization. So far, intraoperative labeling of lesions by colonoscopy is increasingly performed for achieving appropriate resection margins, but a certain deviation is also found. There is no unified and standard endoscopic polyp localization method at present.Case presentation: A 63-year-old woman was admitted because she was diagnosed as a large and broad-based colonic polyp which was unsuitable for colonoscopic polypectomy. During endoscopy-assisted laparoscopic segmental colectomy, the irradiation angle of colonoscopy light on the polyp head was responsible for the localization errors. We proposed three-step measures of correct endoscopic polyp localization to ensure the accurate resection in laparoscopic segmental colectomy.Conclusions: Three-step measures of correct endoscopic polyp localization ensured the successful resection of colonic polyps in laparoscopic colectomy. Their advantages include simplicity, practicality and reliable localization.

Self-Expandable Metal Stents for Left Sided Colon Obstruction from Diverticulitis. A Single Center Retrospective Series

Background and Objectives: The incidence of diverticulitis is increasing in western countries. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Colonic symptomatic strictures are often treated with segmental colectomy. The aim of our study is to report our experience with Self Expandable Metal Stents (SEMS) placement to relieve sigmoid obstruction secondary to diverticulitis, either as a permanent solution or as a bridge to elective colectomy. Material and Methods: From January 2016 to December 2018, 21 patients underwent SEMS placement for sigmoid obstruction secondary to diverticulitis at our institution. In four patients with poor general conditions, SEMS was considered the definitive form of treatment. In 17 patients, the stent was placed as bridge to elective colectomy. Data were prospectively collected and retrospectively analyzed. Primary outcomes were postoperative mortality and morbidity after SEMS and subsequent elective colectomy. Results: There was no mortality or major morbidity after SEMS placement or subsequent elective colectomy. No stoma was performed. Conclusions: Placement of Colorectal Self Expandable Stent represents a useful tool to relieve obstruction in patients with left-sided colonic diverticulitis. SEMS placement makes it possible to transform an emergency clinical condition into an elective condition, giving time to resolve the inflammation and the infection inevitably associated with complicated diverticulitis.

Role for colorectal teams to support non-colorectal teams to improve clinical outcomes and adherence to ERAS guidelines for segmental colectomy: a cohort study

Background To identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards. Methods Consecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days). Results Analysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS. Conclusions Non-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team’s expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.