The introduction and implementation of right colectomy with extended D3 mesenterectomy anterior and posterior to the mesenteric vessels

Lymphatic spread is one of the ways colon cancer disseminates. The main aim of these studies is to report on RD3APM, a new surgical procedure for right sided colon cancer comprising extended central lymphat-ic tissue resection of the D3 volume, which was defined after lymph vessel studies. Three-dimensional re-constructed (3DR) abdominal CT scans were used to investigate and classify normal variations of vascular crossing patterns as well as arterial and venous abnormalities central in the mesentery. We found that 3DR provided reliable information when vascular anatomy found with 3DR were compared to that found at surgery. 3DR can therefore be used as a roadmap for surgery making challenging operations central in the mesentery easier and safer. Open and laparoscopic RD3APM were found to be feasible and the lymph node yield was larger compared to standard procedures. The complications and adverse effects of RD3APM seem to be comparable to those of other procedures. The impact of the open RD3APM on vessel stump lengths and the completeness of the lymphadenectomy were assessed and deemed acceptable in all investigated patients

Detecting the Non-physiological, Surgically Tailored Ileocolic Anastomosis Using the Wireless Motility Capsule. A Pre- and Post-operative, Prospective, Within Subject Trial

Background/Aims: Wireless motility capsule (WMC) detects the ileocolic junction (ICJ) in most non-operated patients. We find no data concerning this examination in patients where the ileocolic valve is replaced by a per definition incompetent, surgically created ICJ. We wanted to see if WMC could detect the ICJ after a right colectomy and assess the competency. Methods: Prospective cohort study using a within-subject design to eliminate subject-subject variability. Selected patients operated with right colectomy underwent 3 WMC examinations (pre-operatively, 3 weeks, and 6 months after surgery). Results: Twenty patients (8 men) included, 7 (4 men) excluded due to poor recordings (4) and unforeseen events (3). Thirteen patients (4 men), median age 63 years completed 3 tests. Median bowel lengths removed were 11 cm for ileum and 21 cm for colon. Thirty-nine examinations analyzed by 2 physicians who found all 13 ICJs at 3 examinations with high inter-rater reliability (intra-class correlation coefficient: 0.99, 0.91, and 0.99 respectively), whereas the computer found 9, 8, and 10 out of the 13 ICJs, respectively. Computed values significantly more often deviated from the 2 raters. Mean magnitude and duration of pH-drop at the ICJ (3 examinations) was 1.16–1.02–1.13 pH units and 3.15–4.78–3.75 minutes, respectively. pH-drop was smaller and duration longer at 3 weeks. We found no differences between the pre-operative (competent ICJ) and post-operative 6-month examinations (incompetent ICJ). Highest pressure immediately prior to ICJ was equal before and after surgery. Conclusion: WMC can identify the non-physiological ICJ after right colectomy. Ileocolic competence cannot be assessed

Introducing anatomically correct CT-guided laparoscopic right colectomy with D3 anterior posterior extended mesenterectomy: Initial experience and technical pitfalls

Background: Laparoscopic D3 anterior posterior extended mesenterectomy (D3APEM) in right colectomy has received increased attention. The aim of this study is to prove feasibility, systemize technical accomplishment, and provide short-term outcomes data. Methods: From July 2013 to February 2017, 18 patients with adenocarcinoma in the right colon underwent right colectomy with laparoscopic D3APEM, including lymph nodes anterior and posterior to the superior mesenteric vessels. A reconstructed three-dimensional anatomy map derived from the staging computed tomography was used as a road map at surgery. The procedure was systematized into seven operative steps: Step 1, trocar placement and inspection; Step 2, release of the transverse colon; Step 3, identification of the terminal mesenteric vessels; Step 4, release of the anterior flap; Step 5, division of the transverse mesocolon; Step 6, release of the posterior flap; and Step 7, anastomosis and specimen removal. Patient disposition and variations regarding vascular anatomy and ability to expose consequentially may necessitate a variation in the sequence of the steps. Results: A total of 7 (39%) cases were converted, 3 due to bleeding and 4 due to challenging dissection. Median operative time and blood loss were 276 minutes (168–439 minutes) and 200 mL (< 50–1300 mL), respectively. Postoperative complications occurred in 6 (33%), including 2 (11%) major complication requiring reoperation. Median hospital stay was 5 days (3–13 days). R0 resection was achieved in all cases. Median number of the lymph nodes harvested was 40 (25–86), including 11.5 (4–35) in the D3 volume. Six patients (33%) had positive nodes, 3 of them affecting the D3 zone, including 1 case of a skip metastasis. There was no mortality, and at present all the patients are alive. One patient developed distant lymph node metastases. Conclusion: Laparoscopic right colectomy with D3APEM is feasible, associated with acceptable morbidity and fast recovery; now in readiness for introduction in specialized colorectal institutions