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Anania G, Campagnaro A, Chiozza M, Randolph J, Resta G, Marino S, Pedon S, Agrusa A, Cuccurullo D, Cirocchi R. A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group). Updates Surg 2024; 76:933-941. [PMID: 38526696 PMCID: PMC11129964 DOI: 10.1007/s13304-024-01787-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/12/2024] [Indexed: 03/27/2024]
Abstract
Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.
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Affiliation(s)
- G Anania
- Unit of General Surgery, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, Cona, FE, Italy
- Department of Medical Science, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, FE, Italy
| | - A Campagnaro
- Unit of General Surgery, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, Cona, FE, Italy.
- Department of Medical Science, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, FE, Italy.
| | - M Chiozza
- Unit of General Surgery, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, Cona, FE, Italy
- Department of Medical Science, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, FE, Italy
| | - J Randolph
- Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, 30341, USA
| | - G Resta
- Unit of General Surgery, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, Cona, FE, Italy
| | - S Marino
- Unit of General Surgery, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, Cona, FE, Italy
| | - S Pedon
- Unit of General Surgery, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, Cona, FE, Italy
- Department of Medical Science, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, FE, Italy
| | - A Agrusa
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, PA, Italy
| | - D Cuccurullo
- Division of Laparoscopic and Robotic Surgery Unit, A.O.R.N. Colli Monaldi Hospital, Napoli, NA, Italy
| | - R Cirocchi
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, PG, Italy
- Division of Digestive and Emergency Surgery, Santa Maria Hospital, Via Tristano di Joannuccio 05100, Terni, TR, Italy
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Grüter AAJ, Toorenvliet BR, Belgers EHJ, Belt EJT, van Duijvendijk P, Hoff C, Hompes R, Smits AB, van de Ven AWH, van Westreenen HL, Bonjer HJ, Tanis PJ, Tuynman JB. Nationwide standardization of minimally invasive right hemicolectomy for colon cancer and development and validation of a video-based competency assessment tool (the Right study). Br J Surg 2024; 111:znad404. [PMID: 38103184 PMCID: PMC10763527 DOI: 10.1093/bjs/znad404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Substantial variation exists when performing a minimally invasive right hemicolectomy (MIRH) due to disparities in training, expertise and differences in implementation of innovations. This study aimed to achieve national consensus on an optimal and standardized MIRH technique for colon cancer and to develop and validate a video-based competency assessment tool (CAT) for MIRH. METHOD Statements covering all elements of MIRH were formulated. Subsequently, the Delphi technique was used to reach consensus on a standardized MIRH among 76 colorectal surgeons from 43 different centres. A CAT was developed based on the Delphi results. Nine surgeons assessed the same 12 unedited full-length videos using the CAT, allowing evaluation of the intraclass correlation coefficient (ICC). RESULTS After three Delphi rounds, consensus (≥80% agreement) was achieved on 23 of the 24 statements. Consensus statements included the use of low intra-abdominal pressure, detailed anatomical outline how to perform complete mesocolic excision with central vascular ligation, the creation of an intracorporeal anastomosis, and specimen extraction through a Pfannenstiel incision using a wound protector. The CAT included seven consecutive steps to measure competency of the MIRH and showed high consistency among surgeons with an overall ICC of 0.923. CONCLUSION Nationwide consensus on a standardized and optimized technique of MIRH was reached. The CAT developed showed excellent interrater reliability. These achievements are crucial steps to an ongoing nationwide quality improvement project (the Right study).
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Affiliation(s)
- Alexander A J Grüter
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Eric H J Belgers
- Department of Surgery, Zuyderland Medisch Centrum, Heerlen, The Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | | | - Christiaan Hoff
- Department of Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Anke B Smits
- Department of Surgery, St.Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | | | | | - Hendrik J Bonjer
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Grüter AAJ, Vlug MS, Spaanderman IT, Bins AD, Buffart TE, Tuynman JB. Challenging case of deficient mismatch repair right-sided locally advanced adenocarcinoma of the ascending colon with duodenal involvement: A case report including step-by-step video of operation. Int J Surg Case Rep 2024; 114:109137. [PMID: 38091709 PMCID: PMC10758974 DOI: 10.1016/j.ijscr.2023.109137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Irresectable colon cancer presents a complex clinical challenge. Neoadjuvant immunotherapy has shown potential in improving resectability. Additionally, advancements in surgical techniques, including complete mesocolic excision (CME) with central vascular ligation (CVL), have contributed to better outcomes for right-sided colon cancer. This case report aims to demonstrate the successful laparoscopic resection of initial appearing irresectable colon cancer with suspected duodenal involvement. CASE PRESENTATION A 70-year-old female presented with an irresectable mismatch repair deficient (dMMR) adenocarcinoma of the ascending colon with suspected duodenal ingrowth. Neoadjuvant treatment with pembrolizumab and ataluren resulted in a significant response, allowing for surgical resection. A laparoscopic right hemicolectomy with CME, including CVL, intracorporeal anastomosis and extraction through a Pfannenstiel incision, was performed. Additionally, the serosal layer of the duodenum was shaved after observing the absence of intraluminal invasion. Postoperatively, transient gastroparesis occurred, but overall outcomes were favourable. CLINICAL DISCUSSION This case emphasizes the potential of immunotherapy in improving resectability for irresectable dMMR colon cancer with suspected involvement of surrounding organs. The combination of neoadjuvant therapy and advanced surgical techniques, such as CME with CVL, shows promise in achieving favourable clinical outcomes. However, further studies are needed to validate the effectiveness and safety of this combined approach in a larger cohort of patients. CONCLUSION The successful laparoscopic resection of initially irresectable dMMR colon cancer with duodenal involvement, following neoadjuvant immunotherapy, demonstrated promising outcomes. This case advocates for further exploration of neoadjuvant treatments' efficacy, coupled with advanced surgical techniques, in managing locally advanced right-sided colon cancer.
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Affiliation(s)
- Alexander A J Grüter
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Surgery, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and quality of life, Amsterdam, the Netherlands.
| | - Malaika S Vlug
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Surgery, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Ide T Spaanderman
- Amsterdam UMC, Department of Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Adriaan D Bins
- Amsterdam UMC, Department of Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Tineke E Buffart
- Amsterdam UMC, Department of Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Jurriaan B Tuynman
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Surgery, De Boelelaan 1117, Amsterdam, the Netherlands
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