Preservation of the inferior mesenteric artery VS ligation of the inferior mesenteric artery in left colectomy: evaluation of functional outcomes-a prospective non-randomized controlled trial

Vascular approach during elective laparoscopic left colectomy impacts post-operative outcomes. The aim of our study was to evaluate how different approaches impact positively defecatory, urinary and sexual functions and quality of life during elective laparoscopic left colectomy. A prospective non-randomized controlled trial at two tertiary center was conducted. All patients who underwent elective laparoscopic left colonic resection from January 2019 to July 2022 were analyzed. They were divided into two groups based on Inferior Mesenteric Artery (IMA) preservation with distal ligation of sigmoid branches close to a colonic wall for complicated diverticular disease and IMA high tie ligation for oncological disease. Patients were asked to fulfil standardized, validated questionnaires to evaluate pre and post-operative defecatory, urinary and sexual functions and quality of life. Defecatory disorders were assessed by high-resolution anorectal manometry preoperatively and six months after surgery. A total of 122 patients were included in the study. The 62 patients with IMA preservation showed a lower incidence of defecatory disorders also confirmed by manometer data, minor incontinence and less lifestyle alteration than the 60 patients with IMA high tie ligation. No urinary disorders such as incomplete emptying, frequency, intermittence or urgency were highlighted after surgery in the IMA preservation group. Evidence of any sexual disorders remained controversial. The IMA-preserving vascular approach seems to be an effective strategy to prevent postoperative functional disorders. It is a safe and feasible technique especially for diverticular disease. New prospective randomized and highly probative studies are needed to confirm the effectiveness in specific clinical situations.

Surgical site infection after intracorporeal and extracorporeal anastomosis in laparoscopic left colectomy for colon cancer: a multicenter propensity score-matched cohort study

BACKGROUND

Intracorporeal anastomosis (IA) is associated with reduced surgical site infection (SSI) and other postoperative complications in laparoscopic right colectomy (LRC). However, evidence is inadequate for IA in laparoscopic left colectomy (LLC). This study aimed to determine the effect of IA and extracorporeal anastomosis (EA) on SSI and other short-term postoperative complications in LLC.

METHODS

In this retrospective multicenter propensity score-matched (PSM) cohort study, we enrolled consecutive patients who underwent LLC with IA (TLLC/IA) and laparoscopic-assisted left colectomy with EA (LALC/EA) at two medical centers between January 2015 and September 2021. Propensity score matching with a 1:2 ratio was employed. The primary outcome was SSI occurrence. Secondary outcomes were operating time, intraoperative hemorrhage, other postoperative complications, and pathological outcomes.

RESULTS

Overall, 574 and 99 patients received LALC/EA and TLLC/IA, respectively. After PSM, 84 patients with TLLC/IA were matched with 141 patients with LALC/EA. Thirty patients (13.3%) patients experienced SSI (17.0% in LALC/EA vs 7.1% in TLLC/IA). IA was associated with a reduced risk of overall SSI and superficial/deep SSI compared with EA after PSM, with OR of 0.375 (95% CI, 0.147-0.959, P = 0.041). and 0.148 (95% CI, 0.034-0.648, P = 0.011), respectively. Multivariate analysis of unmatched patients indicated similar results. In the analysis of secondary outcomes, LALC/EA may have a shorter operating time (absolute mean difference - 13.41 [95% CI, - 23.76 to - 3.06], P = 0.002) and a higher risk of intraoperative hemorrhage (absolute risk difference 4.96 [95% CI, - 0.09 to 9.89], P = 0.048).

CONCLUSIONS

IA in LLC is associated with a reduced risk of overall SSI and superficial/deep SSI. However, it may require a longer operating time.

SAGES masters program: the top 10 seminal articles for the laparoscopic left and sigmoid colectomy pathway for complex disease

BACKGROUND

The SAGES University Colorectal Masters Program is a structured educational curriculum that is designed to aid practicing surgeons develop and maintain knowledge and technical skills for laparoscopic colorectal surgery. The Colorectal Pathway is based on three anchoring procedures (laparoscopic right colectomy, laparoscopic left and sigmoid colectomy for uncomplicated and complex disease, and intracorporeal anastomosis for minimally invasive right colectomy) corresponding to three levels of performance (competency, proficiency and mastery). This manuscript presents focused summaries of the top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease.

METHODS

A systematic literature search of Web of Science for the most cited articles on the topic of laparoscopic complex left/sigmoid colectomy yielded 30 citations. These articles were reviewed and ranked by the SAGES Colorectal Task Force and invited subject experts according to their citation index. The top 10 ranked articles were then reviewed and summarized, with emphasis on relevance and impact in the field, study findings, strength and limitations and conclusions.

RESULTS

The top 10 seminal articles selected for the laparoscopic left/sigmoid colectomy for complex disease anchoring procedure include advanced procedures such as minimally invasive splenic flexure mobilization techniques, laparoscopic surgery for complicated and/or diverticulitis, splenic flexure tumors, complete mesocolic excision, and other techniques (e.g., Deloyers or colonic transposition in cases with limited colonic reach after extended left-sided resection).

CONCLUSIONS

The SAGES Colorectal Masters Program top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease anchoring procedure are presented. These procedures were the most essential in the armamentarium of practicing surgeons that perform minimally invasive surgery for complex left and sigmoid colon pathology.

Ureteral injury during left colectomy for cancer: Laparoscopic management. A case report

INTRODUCTION

Iatrogenic ureteral lesions may occur after any abdominal and pelvic surgery. They are severe and can affect renal function and even vital prognosis. This study aimed to determine the clinical aspects and the therapeutic approaches of a lower third injury of the ureter during a laparoscopic left colectomy.

PRESENTATION OF CASE

An 81 year-old-man with left-sided colon cancer underwent laparoscopic left colectomy. During surgery there was a continuous full-thickness solution of the left ureter for which an end-to-end ureteral anastomosis was performed. In the postoperative period the patient underwent multiple urological and radiological interventional procedures due to the aforementioned injury.

DISCUSSION

Ureteral injury was defined as any laceration, transection or ligation of the ureter that required an unexpected procedure for repair, stent or drainage. It can be managed with several procedures. An appropriate repair should be chosen according to length and position of ureteral injuries. The lower third of the ureter, as the lesion of our patient, has a profuse blood supply resulting in this way less susceptible to ischemia.

CONCLUSION

In the last decade urological surgery, laparoscopy, ureteroscopic procedures and gynecological surgery are the main causes of iatrogenic ureteral lesions. Prognosis is conditioned by early diagnosis and the anatomic condition of the ureter. Laparoscopic end-to-end ureteral anastomosis could be considered a good option in the case of intraoperative iatrogenic lower ureteral injuries.

Management of postoperative bleeding after laparoscopic left colectomy

BACKGROUND

Lower gastrointestinal bleeding after left colectomy is an uncommon complication that can lead to critical situation. Diagnostic and therapeutic manoeuvres should be performed in emergency with step-by-step strategy in order to avoid reoperation. This study aims to identify bleeding risks factors and describe a management strategy.

METHODS

This is a retrospective study of patients who underwent left colectomy with primary anastomosis, from May 2004 to December 2013. We studied their demographic characteristics, surgical procedures and postoperative courses, more specifically hemorrhagic complications, management of bleeding and outcomes.

RESULTS

Hemorrhagic anastomotic complication occurred in 47 of the 729 (6.4 %) patients after left colectomy. Neither anticoagulant nor antiaggregant treatment was associated with postoperative bleeding. Among the 47 patients with bleeding, endoscopy was performed in 37 (78.7 %). At the time of endoscopy, the bleeding was spontaneously stopped in nine (24.3 %). Therapeutic strategy used clips in 10 (27.0 %) cases, mucosal sclerosis in 11 (29.7 %) and both in 7 (18.9 %) cases. Four (8.5 %) patients required blood transfusion for treatment of this gastrointestinal bleeding. Five (10.6 %) patients with bleeding were reoperated in this group because early endoscopy showed associated anastomotic leakage. Based on a multivariate analysis, stapled anastomosis and diverticular disease were independent factors associated with anastomotic bleeding.

CONCLUSIONS

Postoperative anastomotic bleeding is not so uncommon after left colectomy. This complication should be particularly dreaded in patients who underwent stapled colorectal anastomosis for diverticular disease. With the use of clip or mucosal sclerosis, early endoscopy is a safe and efficient treatment.