Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy

Background: The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: “Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography” in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed. Methods: Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews. Results: Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p = 0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p = 0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores. Conclusions: Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery.acceptedVersio

Right Colectomy with Extended D3- Mesenterectomy: What can we say about the extent and the consequences of the injury to the superior mesenteric plexus?

The extended D3-mesenterectomy during right colectomy for cancer aims for improved cancer survival by removing the draining lymph nodes around the superior mesenteric vessels. The procedure, however, causes an injury to a significant portion of the extrinsic nerves in the superior mesenteric plexus (SMP) distal to the pancreatic notch. The exact anatomical image and physiological importance of the nerve plexus at this level are not well studied. This thesis studied the anatomy, defined the nerve damage, and explored its consequences to bowel motility, bowel function, and Quality of Life. The nerve plexus and its damage were mapped using dissection, histological slides, and nano-CT. The studies confirmed that the SMP follows the superior mesenteric artery (SMA) in a well-defined paravasculare sheath. In this sheath, the nerve plexus has a spiral structure. 59% of the nerves at the middle colic artery level were transected during the procedure. However, the total nerve damage caused by the procedure is probably more extensive if we take the spiral structure of the plexus into account. The significantly reduced small bowel transit time three weeks after the procedure (Tool: Wireless Motility Capsule) manifested itself through a transient short period with frequent, loose stools (Diary-based study). At six months, the small bowel transit time showed a clear tendency towards normalization. In the long-term surveys (Tools: Gastrointestinal Quality of Life Index and Diarrhea Assessment Score), the stools still tended to be slightly looser and more frequent than the stools of the patients operated with right colectomy without the nerve injuring mesenterectomy. However, the quality of life was equal in both groups

The effect of vascular anatomy and gender on bowel function after right colectomy with extended D3-mesenterectomy

Background: Extended D3-mesenterectomy for right-sided colon cancer, removes all tissue around the superior mesenteric vessels beneath pancreas leading to transection of superior mesenteric plexus. In a previous study, the denervation was associated with 0.48 more stools/day. The study aims are to examine how presence of arterial branches proximal to the dissection area, gender and prolonged observation time after surgery affect bowel function following denervation. Methods: The study compares bowel function and Quality of Life in two groups undergoing right colectomy with extended D3-mesenterectomy and traditional D2-mesenterectomy. For further comparison, the denervated group was divided into groups with and without arterial branches arising proximal to the denervation. Instruments used were Gastrointestinal Quality of Life Index (0–144; 144= best) (GIQLI), Diarrhea Assessment Scale (0–12; 0= best) (DAS) and 3 additional questions (Ability to postpone defecation, night defecation, degree of distress). A second interview with prolonged observation time was performed for patients with abnormal bowel habits, defined as a) having 4 or more stools/day or b) being much or very much bothered. Results: Eighty-three D3-patients and 61 D2-patients, comparable for age and sex with shorter follow-up in the D3-group. In the D3-group 67 patients (80.7%) had one or more arteries proximal to the denervation. Sixteen patients (19.3%) had no proximal arteries. Regression analysis (correcting for confounding factors) revealed 0.30 (P=0.012) lower consistency score (increased consistency) and 0.27 (P=0.096) fewer stools/day in the D2- than the D3-group. DAS subscores, DAS, GIQLI and GIQLI-subscales revealed no differences between the groups. Within the D3-group, the estimated differences between patients with and without proximal arteries (adjusted for age, gender and time between surgery and interview) were significant for DAS and subscores; DAS: −1.526 (P=0.012), stool frequency: −0.653 (P=0.007), stool consistency: −0.432 (P=0.054), stool urgency: −0.595 (0.009). Negative scores represent lower (better) scores in the group with proximal arteries. GIQLI scores and subscales showed no difference. When genders were compared separately, the T-test revealed significantly lower (better) DAS and subscores for D2-females than D3-females, a difference not found in the male group. When controlled for observation time and age (regression) the difference disappears. A second interview with prolonged observation time (1. interview: 15.1 months, 2. interview: 56.4 months) for patients with abnormal bowel function reveals reduced (better) Extended DAS score (DAS + additional questions) in 8 of the 10 patients interviewed. 7 had no longer abnormal bowel function. Conclusions: D3-patients without arteries proximal to the nerve transection have significantly higher (worse) DAS-scores and subscores. The allover difference between the D2 and the D3 patients is small and only significant for consistency. Normalizing of the bowel function takes longer than assumed and continues for months and even years. Women are less able to compensate for the altered bowel habits during normalization

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

Stool dynamics after extrinsic nerve injury during right colectomy with extended D3-mesenterectomy

Introduction: To improve oncological outcome in right colon cancer surgery, an extended mesenterectomy (D3) is under evaluation. In this procedure, all tissue anterior and posterior to the superior mesenteric vessels from the middle colic to ileocolic artery origin is removed, causing injury to the superior mesenteric nerve plexus. The aim was to study the effects of this injury on bowel dynamics and quality of life (QoL). Methods: Patients undergoing right colectomy with conventional D2- and extended D3-mesenterectomy were asked to record stool number and consistency for 60 d after surgery and complete questionnaires regarding QoL and bowel function (BF) before and after recovery from surgery. We compared early postoperative stool dynamics and long-term QoL in the groups and presented graphs depicting the temporal profile of stool numbers and consistency. Results: Thirty-three patients operated with a D3-resection and 12 patients with a D2-resection participated. The results revealed significantly higher stool numbers in the D3-group until day 26, with significantly more loose-watery stools until day 40. The most pronounced difference was found on day 9 (Mean difference in the total number of stools: 2.25 stools/day, p¼.004. Mean difference in loose watery stools/day: 2.81 p<.001). About 25% in the D2- and 69.7% in the D3-group reported having more than three stools/day in the early postoperative phase. There were no differences in long-term QoL and BF between the groups except in stool consistency (p¼.039). Discussion/conclusions: Denervation following extended D3-mesenterectomy leads to transitory reduced consistency and increased frequency. It does not affect long-term QoL or BF

Bowel motility after injury to the superior mesenteric plexus during D3 extended mesenterectomy

Background: Improvement of lymphadenectomy in right colectomy requires removal of all tissue surrounding the superior mesenteric vessels beneath the pancreatic notch. Shortand long-term bowel motility disorders after D3 extended mesenterectomy with consecutive superior mesenteric plexus transection are studied. Methods: Patients without pre-existing motility disorders undergoing D3 extended mesenterectomy were examined 3 times using the wireless motility capsule: before, at 3 wk, and 6 mo after surgery. Segmental transit times and contractility were analyzed using mixed effect modeling. Correlation between contractility and transit time was assessed by the Pearson correlation coefficient. Results: Fifteen patients (4 men), with median age 62 y, were included. Mean values for the three consecutive examinations are as follows. Gastric transit time increased from 237 to 402 and 403 min, respectively. Small bowel transit time decreased from 246 to 158 (P < 0.01) and 199 (P ¼ 0.03) min, respectively. Colonic transit time decreased from 1742 to 1450 and 1110 (P ¼ 0.02) min, respectively. Gastric contractions per minute (CPM) varied from 1.73 to 1.05 (P ¼ 0.01) and 2.47 (P < 0.01), respectively. Small bowel CPM decreased from 3.43 to 2.68 and 3.34, respectively. Colonic CPM ranged from 1.59 to 1.45 and 1.91 (P ¼ 0.08), respectively. Correlation between small bowel (SB) transit time and CPM was _0.45 (P ¼ 0.09) preoperatively, and _0.03 (P ¼ 0.91) 6 mo postoperatively. Conclusions: Extrinsic SB denervation leads to significantly accelerated SB transit, reduced contractility, and disturbed correlation between transit time and contractility early after denervation. Both number of contractions and transit time in the denervated SB show a clear tendency toward normalization at 6 mo

A safe treatment option for esophageal bezoars

AbstractINTRODUCTIONBezoar in the esophagus is a rare condition and associated with structural or functional abnormalities of the esophagus. Endoscopy is the main tool for diagnosis and treatment for bezoar in the esophagus.PRESENTATION OF CASEHere we present a case where an endoscopic evacuation of an esophageal bezoar was unsuccessful. We treated the bezoar through a nasogastric tube using a cocktail composed of pancreatic enzymes dissolved in Coca-Cola.DISCUSSIONEndoscopy is regarded as the mainstay for the diagnosis and treatment of esophageal bezoars. However, when this approach fails, other treatment options include dissolution therapy, and surgical exploration and removal of the bezoar. Surgical removal of an esophageal bezoar is associated with a high risk of morbidity and mortality. We advocate that dissolving therapy should be the first choice of treatment when endoscopic evacuation is not possible.CONCLUSIONThis is the first report describing a successful treatment of an esophageal bezoar with a cocktail of Coca-Cola and pancreatic enzymes. It is an effective, inexpensive, and worldwide available treatment and should be considered when endoscopic evacuation fails

Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy

Background The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: ‘‘Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography'' in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed. Methods Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews. Results Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p = 0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p = 0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores. Conclusions Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery

Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy

Background: The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: “Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography” in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed. Methods: Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews. Results: Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p = 0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p = 0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores. Conclusions: Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery

Reconstructing topography and extent of injury to the superior mesenteric artery plexus in right colectomy with extended D3 mesenterectomy: a composite multimodal 3‑dimensional analysis

Background Superior mesenteric artery plexus (SMAP) injury is reported to cause postoperative intractable diarrhea after pancreatic/colonic surgery with extended lymphadenectomy. This study aims to describe the SMAP microanatomy and extent of injury after right colectomy with extended D3 mesenterectomy for cancer. Methods Three groups (I) anatomical dissection, (II) postmortem histology, and (III) surgical specimen histology were included. Nerve count and area were compared between groups II and III and paravascular sheath thickness between groups I and II. 3D models were generated through 3D histology, nanoCT scanning, and finally through 3D printing. Results A total of 21 specimens were included as follows: Group (I): 5 (3 females, 80–93 years), the SMAP is a complex mesh surrounding the superior mesenteric artery (SMA), branching out, following peripheral arteries and intertwining between them, (II): 7 (5 females, 71–86 years), nerve count: 53 ± 12.42 (38–68), and area: 1.84 ± 0.50 mm2 (1.16–2.29), and (III): 9 (5 females, 55–69 years), nerve count: 31.6 ± 6.74 (range 23–43), and area: 0.889 ± 0.45 mm2 (range 0.479–1.668). SMAP transection injury is 59% of nerve count and 48% of nerve area at middle colic artery origin level. The median values of paravascular sheath thickness decreased caudally from 2.05 to 1.04 mm (anatomical dissection) and from 2.65 to 1.17 mm (postmortem histology). 3D histology models present nerve fibers exclusively within the paravascular sheath, and lymph nodes were observed only outside. NanoCT-derived models reveal oblique nerve fiber trajectories with inclinations between 35° and 55°. Two 3D-printed models of the SMAP were also achieved in a 1:2 scale. Conclusion SMAP surrounds the SMA and branches within the paravascular sheath, while bowel lymph nodes and vessels lie outside. Extent of SMAP injury on histological slides (transection only) was 48% nerve area and 59% nerve count. The 35°–55° inclination range of SMAP nerves possibly imply an even larger injury when plexus excision is performed (lymphadenectomy). Reasons for later improvement of bowel function in these patients can lie in the interarterial nerve fibers between SMA branche