BR Yoo

D Tessier

DG Jayne

DM Hunsaker

G Jamieson

Heita Ozawa

JC Stanley

K Kotake

Kenjiro Kotake

Konosuke Moritani

MJ Arca

N Tulsyan

Osamu Wada

Shin Fujita

T Hirokawa

Y Kanemitsu

World Journal of Surgical Oncology

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WORLD JOURNAL OF SURGICAL ONCOLOGYMoritani et al. World Journal of Surgical Oncology  (2015) 13:170 DOI 10.1186/s12957-015-0595-5CASE REPORT Open AccessLaparoscopic radical right hemicolectomy forcecal cancer and middle colic artery aneurysmKonosuke Moritani*, Osamu Wada, Heita Ozawa, Shin Fujita and Kenjiro KotakeAbstractBackground: Middle colic artery (MCA) aneurysms are very rare and exclusively reported with symptoms orrupture. We report successful laparoscopic elective surgery for both cecal cancer and MCA aneurysm in an87-year-old man who presented with bloody stools.Methods: Diagnostic colonoscopy revealed a cecal tumor 40 mm in diameter that was histologically confirmedas a well-differentiated adenocarcinoma. The three-phase dynamic computed tomography showed a cecal tumorwithout any metastasis and an MCA aneurysm 10 mm in diameter. Radical right hemicolectomy with D3 lymphnode dissection that included the MCA aneurysm was performed. The postoperative course was uneventful, andthe patient survived without recurrence.Conclusions: Even though the present patient was very elderly, the postoperative course of laparoscopic radicalsurgery for both an MCA aneurysm and cecal cancer was uneventful with good short-term outcomes.Keywords: Laparoscopic surgery, Cecal cancer, Middle colic artery aneurysmBackgroundThe middle colic artery (MCA) branches from the su-perior mesenteric artery near the pancreatic head andsupplies the transverse colon and, occasionally, the hep-atic flexure [1]. Although the incidence of visceral arteryaneurysm is extremely low, the most frequent site is thesplenic artery [2]. To the best of our knowledge, therehave been no reports of treatment for MCA aneurysmoccurring simultaneously with cecal cancer, likely owingto the rare occurrence. Laparoscopic surgery has becomea practical treatment option for colorectal cancer, andthe safety and efficacy of this approach has been demon-strated in clinical trials [3]. Here, we report the success-ful use of laparoscopic surgery for very elderly patientswith both cecal cancer and an MCA aneurysm.Case presentationAn 87-year-old man presented with a positive fecal oc-cult blood test. He had no history of abdominal colic ordistension. His medical history included hypertensionand acute appendicitis that was resected 60 years previ-ous. He had no family history of aneurysm, infectious* Correspondence: konosuke125@gmail.comDepartment of Surgery, Tochigi Cancer Center, 4-9-13, Yohnan, Tochigi-ken,Utsunomiya 320-0834, Japan© 2015 Moritani et al.; licensee BioMed CentraCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.disease, or autoimmune disorder. He quit smoking30 years previously. His diagnostic colonoscopy re-vealed a cecal tumor of approximately 40 mm, and thebiopsy specimen showed a well-differentiated adeno-carcinoma. Preoperative three-phase dynamic com-puted tomography for disease staging showed a cecaltumor of 4 × 4 cm without metastasis and an MCAaneurysm of 10 × 7 mm (Figure 1).The patient was placed in the modified lithotomy pos-ition under general anesthesia. First, a 12-mm trocarwas placed using an open approach, and the abdominalcavity was explored with a 5-mm semi-flexible laparo-scope (LTFVH; Olympus Medical, Tokyo, Japan). Pneu-moperitoneum was induced and maintained at 8 mmHgwith carbon dioxide gas. Three 5-mm ports and a 12-mm port were inserted into the abdominal cavity. TheMCA aneurysm was clearly identified using a laparo-scope (Figure 2). As the terminal ileum and the rightand transverse colon were attached to the retroperito-neum, we mobilized them using Harmonic ACE shears(Ethicon Endo-Surgery, Cincinnati, OH, USA). A 5-cmabdominal incision was made via the umbilicus. A smallwound retractor (ALEXIS wound retractor S, Appliedl. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Figure 1 Preoperative computed tomography (CT) scan imaging(a) and CT angiography (b) showing a middle colic artery aneurysm(black arrow) measuring 10 × 7 mm without extravasation.Figure 2 Laparoscopic view of a middle colic artery (MCA)aneurysm (a). The MCA was ligated and divided at the root duringradical right hemicolectomy with D3 lymph node dissection (b).acRCV, accessory right colic vein; GCT, gastrocolic trunk; MCA,middle colic artery; SMA, superior mesenteric artery; SMV, superiormesenteric vein.Moritani et al. World Journal of Surgical Oncology  (2015) 13:170 Page 2 of 4Medical, Santa Margarita, CA, USA) was introduced forextracorporealization of the colon. Radical right hemico-lectomy with D3 lymph node dissection was performed,and the MCA was ligated and divided at the root of theartery. Then, ileocolic functional end-to end anastomosiswas conducted using staplers. Figure 3 shows theresected cecal tumor and MCA aneurysm. Pathologicalexamination of the tumor revealed moderately differenti-ated tubular adenocarcinoma of the cecum without evi-dence of lymph node metastasis and that of the MCAaneurysm showed mediolysis and hyalization with frag-mented and degenerated elastic fibers that were compat-ible with an arteriosclerotic change. The postoperativecourse was uneventful, and the patient survived withoutrecurrence.DiscussionThe true incidence of MCA aneurysms is unknown;however, they account for ≤3% of all visceral aneurysms[4]. Diagnosis of this disease rarely occurs in asymptom-atic patients; instead, it usually occurs in patients suffer-ing from complications of aneurysm, and 90% of thesecomplications involve aneurysm ruptures [5,6]. Althoughthe true etiology of MCA aneurysms remains unknown,connective tissue disorders including Marfan syndrome,Ehlers-Danlos syndrome, fibromuscular dysplasia, her-editary hemorrhagic telangiectasia, Osler-Weber-Rendudisease, and Kawasaki disease are considered to contrib-ute. However, the present patient had no history of theseconnective tissue diseases or synchronous multipleFigure 3 Resected Bormann type-2 cecal cancer specimen andshrunken middle colic artery aneurysm. (a) Both cecal cancer andaneurysm. (b) Aneurysm only.Moritani et al. World Journal of Surgical Oncology  (2015) 13:170 Page 3 of 4aneurysms. This case was an incidental finding of MCAaneurysm without symptoms when we performed thepreoperative three-phase dynamic computed tomog-raphy for disease staging.The available evidence suggests that active treatmentshould be initiated with aneurysms ≥2 cm in diameter inpatients at high risk of rupture (for example, pregnancy,childbearing age, and post-liver transplantation) [7]. Cur-rently, transcatheter embolization is the first procedureof choice in most patients with visceral aneurysms be-cause it can be carried out under local anesthesia withminimal physical burden [8].However, we were unable to perform embolization inthe present patient because it could hamper blood flowto his colonic anastomosis. In any event, elective inter-vention by either embolization or ligation should beconsidered for an asymptomatic aneurysm [5].In this case, we considered that resection of ileo-colicand right colic arteries for cecal cancer could change thehemodynamics of the middle colic artery to increase riskof growing aneurysm. Further, in case of need to treatthe aneurysm, impeded blood flow of the remaining left-side colon could occur especially in very elderly personwho bear a risk of arteriosclerosis. Therefore, we per-formed combined resection of cecal cancer and theaneurysm by laparoscopic surgery which resulted ingood short-term outcomes.As a less invasive alternative to open surgery, laparo-scopic resection of visceral aneurysms has been espousedby some authors [9]. The CLASICC trial conducted by theUK Medical Research Council confirmed the efficacy oflaparoscopic surgery for both colon and rectal cancer interms of short-term outcomes. Furthermore, improvedshort-term outcomes with laparoscopic surgery do notcompromise the long-term oncological outcomes [3].Using the laparoscopic approach, we were able to easilyobtain information on the entire abdominal cavity and toperform a number of procedures through incisions includ-ing mobilization of the colon.Kotake reported that D3 dissection is significantly su-perior to D2 dissection in terms of overall survival forpatients with T3 and T4 colon cancer [10]. Recently,Kanemitsu and colleagues reported excellent long-termoutcome of D3 dissection in right hemi-colectomy fromsingle-institute non-randomized retrospective study inJapan [11].To the best of our knowledge, the present case is thefirst reported in the English literature to undergo simul-taneous laparoscopic surgery for both cecal cancer andan MCA aneurysm. We believe the advantages of laparo-scopic surgery may result in safe and less invasive treat-ment in these patients.ConclusionsLaparoscopic radical right hemicolectomy for cecal can-cer and an MCA aneurysm was successfully performedin an elderly patient. Laparoscopic surgery offers goodshort-term outcomes with uneventful postoperative re-covery. The laparoscopic approach to visceral aneurysmsmay be a useful treatment option in patients for whomtranscatheter treatment is not feasible.ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.AbbreviationsacRCV: accessory right colic vein; GCT: gastrocolic trunk; MCA: middle colicartery; SMA: superior mesenteric artery; SMV: superior mesenteric vein.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsKM, OW, HO, and SF contributed to the study conception, the dataanalysis, the data interpretation, and the drafting and final revisions of themanuscript. KK conceived of the study and participated in its design andcoordination and helped to draft the manuscript. All authors read andapproved the final manuscript.AcknowledgementsThe authors would like to thank Dr. Kotake for her valuable help and support.Moritani et al. World Journal of Surgical Oncology  (2015) 13:170 Page 4 of 4Received: 28 December 2014 Accepted: 24 April 2015References1. Jamieson G, Hoffmann DC. Colectomy: colonic conduits: the anatomy ofthe colon. In: The anatomy of general surgical operations. United Kingdom:Churchill Livingstone; 2006. p. 75–6.2. Stanley JC, Fry WJ. Pathogenesis and clinical significance of splenic arteryaneurysms. Surgery. 1974;76:898–909.3. Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ. Five-yearfollow-up of the Medical Research Council CLASICC trial of laparoscopicallyassisted versus open surgery for colorectal cancer. Br J Surg.2010;97(11):1638–45.4. Hirokawa T, Sawai H, Yamada K. Middle-colic artery aneurysm associatedwith segmental arterial mediolysis, successfully managed by transcatheterarterial embolization: report of a case. Surg Today. 2009;39:144–7.5. Tessier D, Abbas M, Fowl R, Stone W, Bower T, McKusick M, et al.Management of rare mesenteric arterial branch aneurysms. Ann Vasc Surg.2002;16:586–90.6. Yoo BR, Han HY, Cho YK, Park SJ. Spontaneous rupture of a middle colicartery aneurysm arising from superior mesenteric artery dissection:diagnosis by color doppler ultrasonography and CT angiography. J ClinUltrasound. 2012;40:255–9.7. Hunsaker DM, Turner S, Hunsaker JC. Sudden and unexpected deathresulting from splenic artery aneurysm rupture: two case reports ofpregnancy-related fatal rupture of splenic artery aneurysm. Am J ForensicMed Pathol. 2002;23:338–41.8. Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al. Theendovascular management of visceral artery aneurysms andpseudoaneurysms. J Vasc Surg. 2007;45:276–83.9. Arca MJ, Gagner M, Heniford BT, Sullivan TM, Beven EG. Splenic arteryaneurysms: methods of laparoscopic repair. J Vasc Surg. 1999;30:184–8.10. Kotake K, Mizuguchi T, Moritani K, Wada O, Ozawa H, Oki I, et al. Impact ofD3 lymph node dissection on survival for patients with T3 and T4 coloncancer. Int J Colorectal Dis. 2014;29:847–52.11. Kanemitsu Y, Komori K, Kimura K, Kato T. D3 lymph node dissection in righthemicolectomy with a no-touch isolation technique in patients with coloncancer. Dis Colon Rectum. 2013;56:815–24.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit

Laparoscopic radical right hemicolectomy for cecal cancer and middle colic artery aneurysm

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Laparoscopic radical right hemicolectomy for cecal cancer and middle colic artery aneurysm

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