Extended Left Colectomy with Coloanal Anastomosis by Indocyanine Green-guided Deloyers Procedure: A Case Report

Deloyers Technique for Restoration of Bowel Continuity Following Extended Left Hemicolectomy: A Comprehensive Analysis of 97 Cases and Literature Review

BACKGROUND

Deloyers technique addresses challenges in restoring bowel continuity after extended left hemicolectomies. Despite being first described in 1958, the technique remains underused, with limited data on long-term outcomes.

OBJECTIVE

To evaluate the indications of surgical and functional outcomes of the Deloyers technique and review existing literature.

DESIGN

Using a prospectively maintained database, patient demographics and perioperative data were collected. A telephone interview was conducted to assess bowel function, and statistical analysis identified factors affecting bowel function.

SETTINGS

Single tertiary care center.

PATIENTS

Patients who underwent the Deloyers technique from January 1995 to February 2023.

RESULTS

A total of 97 patients were included. The most common indications were colorectal cancer (50.5%) and diverticular disease (21.6%). In 53.6% of cases, Deloyers technique was performed at reoperations, and in 70.1% of cases, a diverting loop ileostomy was created. Early surgical complications occurred in 7.2% of patients, including 5 anastomotic leaks, 1 colonic conduit ischemia, and 1 small-bowel obstruction. Late complications occurred in 8.2% of cases, including 6 anastomotic strictures and 2 chronic leaks. There was no perioperative mortality. A total of 40 patients were interviewed and reported an average of 3.5 bowel movements per day and 0.5 at night; 17.5% of patients used bowel stoppers and 52.5% of patients reported that their bowel function did not impact their quality of life. Previous radiotherapy and anastomosis <8 cm from the anal verge were associated with having 4 or more bowel movements per day ( p < 0.01).

MAIN OUTCOME MEASURES

Postoperative morbidity and bowel function.

LIMITATIONS

Retrospective analysis of a heterogeneous group of patients with different pathologies and indications for surgery.

CONCLUSIONS

Deloyers technique is a safe and effective alternative for restoring bowel continuity after extended left hemicolectomy. Postoperative functional results are generally satisfactory, with more favorable outcomes noted in patients with higher anastomoses and those who have not undergone prior pelvic radiotherapy. See Video Abstract .

TCNICA DE DELOYERS PARA LA RECONSTRUCCIN DE LA CONTINUIDAD INTESTINAL TRAS HEMICOLECTOMA IZQUIERDA AMPLIADA ANLISIS EXHAUSTIVO DE CASOS Y REVISIN BIBLIOGRFICA

ANTECEDENTES:La técnica de Deloyers aborda los retos que plantea la reconstrucción de la continuidad intestinal tras hemicolectomías izquierdas ampliadas. A pesar de haber sido descrita inicialmente en 1958, la técnica sigue siendo poco utilizada, con datos limitados sobre sus resultados a largo plazo.OBJETIVO:Evaluar las indicaciones y los resultados tanto quirúrgicos como funcionales de la técnica de Deloyers y revisar la bibliografía existente.DISEÑO:Gracias a una base de datos mantenida de forma prospectiva, se recopiló información demográfica y perioperatoria de los pacientes. Se realizó una entrevista telefónica para evaluar la función intestinal y el análisis estadístico identificó los factores que afectaban a la función intestinal.ENTORNO:Un único centro de atención terciaria.PACIENTES:Aquellos sometidos a técnica de Deloyers entre enero de 1995 y febrero de 2023.RESULTADOS:Se incluyó a un total de 97 pacientes. Las indicaciones más frecuentes fueron cáncer colorrectal (50,5%) y enfermedad diverticular (21,6%). En el 53,6% de los casos se realizó DT en las reoperaciones y en el 70,1% se creó una ileostomía de protección. Se encontraron complicaciones quirúrgicas tempranas en 7,2% de los pacientes, incluidas cinco fugas anastomóticas, una isquemia segmentaria de colon y una obstrucción del intestino delgado. Se describen complicaciones tardías en 8,2% de los pacientes, entre ellas 6 estenosis anastomóticas y 2 fugas crónicas. No hubo mortalidad perioperatoria. Se entrevistó a un total de 40 pacientes, que declararon una media de 3,5 deposiciones al día y 0,5 por la noche; el 17,5% utilizó tapones intestinales y el 52,5% de los pacientes declaró que su función intestinal no repercutía en su calidad de vida. La radioterapia previa y la anastomosis a menos de ocho cm del borde anal fueron asociadas con la evacuación de cuatro o más deposiciones al día ( p < 0,01).MEDIDAS DE RESULTADOS PRINCIPALES:Morbilidad postoperatoria y función intestinal.LIMITACIONES:Análisis retrospectivo de un grupo heterogéneo de pacientes con diferentes patologías e indicaciones quirúrgicas.CONCLUSIÓN:La técnica de Deloyers es una alternativa segura y eficaz para restaurar la continuidad intestinal tras una hemicolectomía izquierda ampliada. Los resultados funcionales postoperatorios son generalmente satisfactorios, observándose resultados más favorables en pacientes con anastomosis más altas y en aquellos que no han recibido radioterapia pélvica previa. (Traducción-Dr. Xavier Delgadillo ).

Colonic Derotation Revisited: The "Deloyers Procedure" for Long-Segment Hirschsprung Disease

Long-segment Hirschsprung disease (HSCR) presents significant challenges in surgical management, often requiring extensive bowel mobilization and creative techniques to achieve tension-free anastomosis. Colonic derotation offers a viable solution for preserving bowel length and maintaining the ileocecal valve, which is crucial for postoperative bowel function. The procedure involves extensive colonic mobilization and strategic vascular divisions of the right and middle colic vessels while preserving the ileocolic and marginal arteries, followed by a 180° counterclockwise rotation of the colon around the ileocolic vascular axis. Critical aspects include ensuring proper bowel orientation post-derotation, the careful assessment of potential compression points, and the preservation of the appendix for potential future antegrade enema conduit creation. The procedure concludes with a transanal pull-through and coloanal anastomosis, achieving optimal bowel positioning without undue tension or laxity. This technique provides a valuable option in the surgical armamentarium for managing complex cases of long-segment Hirschsprung disease.

Firearm injury and the Deloyers procedure: case report and literature review

Following extended colon resections, it may not always be possible to perform colorectal anastomosis. The Deloyers procedure, which involves the transposition of the right colon, has been identified as a viable solution. This report aims to discuss the circumstances under which the Deloyers procedure was performed, as well as to evaluate the early and late postoperative outcomes, by reviewing cases conducted between 2010 and 2023. In a 22-year-old female patient who suffered major organ and tissue loss (with injuries to the sigmoid colon, descending colon, transverse colon, and mesentery) due to a firearm injury, the Deloyers procedure was applied during restorative surgery following initial damage control surgery. The procedure involved mobilizing the cecum and right colon, performing a cranio-caudal rotation over the ileocolic artery pedicle, followed by an appendectomy, and creating a colorectal anastomosis using circular staplers. There were no complications during the postoperative follow-ups. By the 14th postoperative day, the patient was discharged and experienced bowel movements four times a day, managed with 2.5 mg of diphenoxylate hydrochloride and 0.025 mg of atropine sulfate. At the 6-month follow-up, the frequency of bowel movements had decreased to twice daily without the need for medical treatment. Given the functional outcomes in patients after extended left colectomies, the Deloyers procedure, with its low associated morbidity, stands out as a viable option.

Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension

A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ - either rectum or anus - is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy - adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.

Laparoscopic Anterior Resection with Anastomosis of Mid-Transverse to Distal Rectum with Deloyers Procedure Under Indocyanine Green fluorescence Guidance: A Video Case Report

BACKGROUND

Reconstruction with transverse colon-rectal anastomosis after an extended left hemicolectomy can be challenging. The Deloyers procedure, first described in 1964,¹ comprises complete mobilization and rotation of the right colon, while maintaining the ileocolic artery, to achieve a well vascularized, tension-free colorectal anastomosis. We present a video of a laparoscopic Deloyers procedure with Indocyanin green (ICG) fluorescence as a useful adjunct.

METHODS

A middle-aged female underwent a laparoscopic anterior resection with anastomosis of mid-transverse to distal rectum with Deloyers procedure for synchronous splenic flexure adenocarcinoma and mid-rectal malignant polyp. Proximal transection was performed at mid-transverse colon while distal transection was performed at lower rectum. Tension-free mid-transverse colon-low rectal anastomosis was performed with Deloyers procedure. ICG fluorescence was performed for the colonic conduit, proximal, and distal transection margins to confirm perfusion just prior to anastomosis. Defunctioning loop ileostomy was then created 40 cm from the ileocecal valve.

RESULTS

Patient recovered uneventfully with functioning stoma on postoperative Day 1. Intraoperative use of ICG fluorescence has been proven to be an accurate tool assess anastomotic perfusion and has been associated with a lower anastomotic leak rate after colorectal resection.² To our knowledge, this is the first report in which laparoscopic Deloyers procedure was performed under ICG guidance. Open Deloyers procedure with ICG was first reported by Okamoto et al.³ in April 2021 and remains the only other case report of Deloyers with ICG to date.

CONCLUSIONS

The Deloyers procedure can be safely performed laparoscopically and ICG fluorescence is a recommended adjunct to assess such unorthodox colorectal anastomosis.