Emergency treatment of complicated colorectal cancer

Giovanni Domenico Tebala,1 Andrea Natili,1,2 Antonio Gallucci,1 Gioia Brachini,2 Abdul Qayyum Khan,1 Domenico Tebala,3 Andrea Mingoli2 1Colorectal Team, Noble’s Hospital, Strang, Douglas, Isle of Man, UK; 2Emergency Surgery Unit, “P.Valdoni” Department of Surgery, “Umberto I” University Hospital, Rome, Italy; 3National Institute of Statistics (ISTAT), Catanzaro, Italy Aim: To find evidence to suggest the best approach in patients admitted as an emergency for complicated colorectal cancer.Methods: The medical records of 131 patients admitted as an emergency with an obstructing, perforated, or bleeding colorectal cancer to Noble’s Hospital, Isle of Man, and the Umberto I University Hospital, Rome, were retrospectively evaluated. Patients were divided in 3 groups on the basis of the emergency treatment they received, namely 1) immediate resection, 2) damage control procedure and elective or semielective resection, and 3) no radical treatment. Demographic variables, clinical data, and treatment data were considered, and formed the basis for the comparison of groups. Primary endpoints were 90-day mortality and morbidity. Secondary endpoints were length of stay, number of lymph nodes analyzed, rate of radical R0 resections, and the number of patients who had chemoradiotherapy.Results: Forty-two patients did not have any radical treatment because the cancer was too advanced or they were too ill to tolerate an operation, 78 patients had immediate resection and 11 had damage control followed by elective resection. There was no statistically significant difference between immediate resections and 2-stage treatment in 90-day mortality and morbidity (mortality: 15.4% vs 0%; morbidity: 26.9% vs 27.3%), number of nodes retrieved (16.6±9.4 vs 14.9±5.7), and rate of R0 resections (84.6% vs 90.9%), but mortality was slightly higher in patients who underwent immediate resection. The patients who underwent staged treatment had a higher possibility of receiving a laparoscopic resection (11.5% vs 36.4%).Conclusion: The present study failed to demonstrate a clear superiority of one treatment with respect to the other, even if there is an interesting trend favoring staged resection. Keywords: colorectal cancer, colorectal surgery, obstructing colorectal cancer, perforated colorectal cancer, emergency surger

Importance of the Duodenal Window and Fredet's Fascia in Laparoscopic Right Hemicolectomy. Technical Note

Background: Laparoscopic right hemicolectomy requires a precise anatomical dissection to mobilise the right and proximal transverse mesocolon, following the avascular fusion planes of Toldt and Fredet. Fredet's plane is crucial to the preparation of the origin of vessels. Easy access to Fredet's and Toldt's fasciae can be obtained through the "duodenal window", a flimsy area of the root of the proximal transverse mesocolon, the margins of which are the right border of the superior mesenteric pedicle, the ileocolic pedicle, the right colic pedicle and the marginal artery. Method: We propose that dissection of the duodenal window should be the first step in laparoscopic right hemicolectomy, to obtain easy access to the duodenopancreatic plane and prepare the fascia. Results: This "duodenal window-first" technique has been applied in 45 laparoscopic right hemicolectomies and 14 laparoscopic extended right hemicolectomies, with only two conversions to open surgery. The duodenal window was easily identified in all but 3 cases with significant visceral obesity. No significant intra- or postoperative morbidity was recorded in these cases and the median postoperative length of stay was 4 days. All resections were R0 and an adequate number of retrieved lymph nodes were obtained in almost all cases. Conclusion: The duodenal window-first approach is a feasible and safe technique to standardise the first steps of radical laparoscopic right hemicolectomy, allowing prompt and complete anatomical identification and dissectio