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Colorectal Disease : the Official... Jan 2021Recurrence after surgery for Crohn's disease is common. Anastomotic configuration may influence recurrence and the mesentery may be key. Recently the Kono-S anastomosis... (Review)
Review
AIM
Recurrence after surgery for Crohn's disease is common. Anastomotic configuration may influence recurrence and the mesentery may be key. Recently the Kono-S anastomosis and radical mesenteric excision have been proposed as methods of reducing recurrence. We analysed the literature pertaining to these novel techniques.
METHOD
We searched MEDLINE, Embase and the Cochrane Library for, and selected, studies evaluating Kono-S anastomosis and/or radical mesenteric excision in Crohn's disease. We assessed methodological quality and risk of bias using the Cochrane risk of bias tool for randomized controlled trials and the Joanna Briggs Institute tool for nonrandomized trials. A narrative synthesis was used to summarize the findings.
RESULTS
Nine studies (896 patients) were identified. Apart from one randomized controlled trial with a low risk of bias the overall level of evidence was poor (Grade IV). The Kono-S anastomosis was associated with a lower incidence of endoscopic and surgical recurrence (0%-3.4% vs 15%-24.4% respectively). Complications, particularly anastomotic leak rate, were also lower (1.8% vs 9.3% respectively). Evidence from a single poor quality study suggested that mesenteric excision may reduce surgical recurrence rates compared with mesentery preservation.
CONCLUSION
The existing literature suggests that the Kono-S anastomosis is safe and may reduce endoscopic and surgical recurrence, but level of evidence is mainly poor. One element of the Kono-S technique, preservation of the mesentery, may be detrimental to recurrence. Further, higher quality, studies are required to investigate these techniques. Such studies should consider the impact of the degree of mesenteric resection in addition to the anastomosis on disease recurrence.
Topics: Anastomosis, Surgical; Anastomotic Leak; Crohn Disease; Humans; Ileum; Mesentery; Randomized Controlled Trials as Topic; Recurrence
PubMed: 32418300
DOI: 10.1111/codi.15136 -
Cureus Jul 2023Autoimmune diseases manifest in genetically predisposed individuals exposed to certain triggers that aggravate immune dysfunction and result in an exacerbated immune... (Review)
Review
Autoimmune diseases manifest in genetically predisposed individuals exposed to certain triggers that aggravate immune dysfunction and result in an exacerbated immune response in the form of hyperactivity to both the humoral and cell-mediated response. The devastating reality apart from the severity of the disease is that multiple immune diseases could co-occur, increasing the patient's physical, psychological, and financial burden. Autoimmune diseases are utterly deranging. One of the dreadful autoimmune diseases is systemic lupus erythematosus (SLE). SLE is a rheumatological disease that affects multiple systems, and there are no predictors to know which system will be affected in the future. It could affect the mucocutaneous system. It could also present with hematological, rheumatological, neuronal, renal, pulmonary, and cardiac manifestations. SLE is prevalent in females, predominantly in the childbearing age group. The pharmacological therapy and bombarding pathophysiology of the disease lead to obstetrical and gynecological complications such as infertility, abortion, miscarriage, and stillbirth. Over the past decade, the autoimmune disease comorbidity increased eminently. One of the common associations is rheumatological diseases (like rheumatoid arthritis, Sjogren syndrome, and SLE) with gynecological diseases (e.g., endometriosis and uterine fibroids). SLE and endometriosis have strong associations, and the prevalence of each condition is relatively high among the female population. is a chronic disease triggered by inflammation, hormonal milieu, and other predisposing factors that lead to the fibrous tissue that lines the uterus (endometrial tissue) to be implanted at sites other than the uterus, commonly in the peritoneum and mesentery. The pathogenesis of this association remains unexplained. The approved theory is that their immune dysfunction is summarized by the elevated humoral and cell-mediated response, which leads to an attack to the epithelium, mesothelium, and Serosa and leads to fibrous tissue deposition in different sites other than the uterus. Statistical evaluations have shown a remarkable association between autoimmune diseases and both gynecological and nongynecological diseases.
PubMed: 37621818
DOI: 10.7759/cureus.42362 -
Complete mesocolic excision for right hemicolectomy: an updated systematic review and meta-analysis.Techniques in Coloproctology Nov 2023Complete mesocolic excision improves lymphadenectomy for right hemicolectomy and respects the embryological planes. However, its effect on cancer-free and overall... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Complete mesocolic excision improves lymphadenectomy for right hemicolectomy and respects the embryological planes. However, its effect on cancer-free and overall survival is questioned. Therefore, we aimed to determine the potential benefits of the technique by performing a systematic review of the literature and meta-analysis of the available evidence.
METHODS
Web of Science, PubMed/Medline, and Embase were searched on February 22, 2023. Original studies on short- and long-term oncological outcomes of adult patients undergoing right hemicolectomy with complete mesocolic excision as a treatment for primary colon cancer were considered for inclusion. Outcomes were extracted and pooled using a model with random effects.
RESULTS
A total of 586 publications were identified through database searching, and 18 from citation searching. Exclusion of 552 articles left 24 articles for inclusion. Meta-analysis showed that complete mesocolic excision increased the lymph node harvest (5 studies, 1479 patients, MD 9.62, 95% CI 5.83-13.41, p > 0.0001, I 84%), 5-year overall survival (5 studies, 2381 patients, OR 1.88, 95% CI 1.14-3.09, p = 0.01, I 66%), 5-year disease-free survival (4 studies, 1376 patients, OR 2.21, 95% CI 1.51-3.23, p < 0.0001, I 0%) and decreased the incidence of local recurrence (4 studies, 818 patients, OR 0.27, 95% CI 0.09-0.79, p = 0.02, I 0%) when compared to standard right hemicolectomy. Perioperative morbidity was similar between the techniques (8 studies, 3899 patients, OR 1.04, 95% CI 0.89-1.22, p = 0.97, I 0%).
CONCLUSION
Meta-analysis of observational and randomised studies showed that right hemicolectomy with complete mesocolic excision for primary right colon cancer improves oncologic results without increasing morbidity/mortality. These results need to be confirmed by high-quality evidence and randomised trials in selected patients to assess who may benefit from the procedure.
Topics: Adult; Humans; Colonic Neoplasms; Lymph Node Excision; Lymph Nodes; Disease-Free Survival; Colectomy; Mesocolon; Laparoscopy; Treatment Outcome
PubMed: 37632643
DOI: 10.1007/s10151-023-02853-8 -
European Journal of Trauma and... Jun 2016The aim of this study is to establish the biomechanics, presentation and diagnosis of mesenteric avulsions following blunt abdominal trauma and reach a consensus on... (Review)
Review
PURPOSE
The aim of this study is to establish the biomechanics, presentation and diagnosis of mesenteric avulsions following blunt abdominal trauma and reach a consensus on their overall management.
MATERIALS AND METHODS
A systematic review of literature in MedLine, Embase, Scopus and CINHAL in English language from 1951 to November 2014 was performed. A total of 20 reported cases were identified. Variables including patient's demographics, signs and symptoms, mechanism of injury, investigative modality, management, length of stay, follow-up and outcomes were reviewed and analyzed.
RESULTS
The median age of the cohort was 28.5 years (range 10-58 years), with a male-to-female ratio of 3:1. The commonest mechanism of injury was road traffic accident due to seat belt restraint (n = 12, 60 %). The commonest presentation was diffuse abdominal tenderness (n = 10, 45 %) followed by ecchymosis/bruising (n = 9, 40 %). Computed tomography (CT) remained the investigative modality of choice (n = 9, 45 %). All cases had an emergency exploratory laparotomy (n = 18, 90 %) within the initial 24 h and the median length of stay was 19 days (range 4-90 days). The overall mortality was 15 % (n = 3).
CONCLUSION
Mesenteric avulsion is rare and has a complex and vague presentation. Due to its potential mortality and morbidity, emergency physicians should keep a high index of suspicion in individuals with blunt abdominal trauma from any mechanism of injury.
Topics: Abdominal Injuries; Accidents, Traffic; Biomechanical Phenomena; Early Diagnosis; Humans; Laparoscopy; Laparotomy; Mesentery; Multidetector Computed Tomography; Referral and Consultation; Seat Belts; Trauma Severity Indices; Wounds, Nonpenetrating
PubMed: 26038032
DOI: 10.1007/s00068-015-0514-z -
Reviews in Endocrine & Metabolic... Dec 2023Knowledge of ectopic insulinomas comes from single cases. We performed a systematic review through PubMed, Web of Science, Embase, eLibrary and ScienceDirect of all...
Knowledge of ectopic insulinomas comes from single cases. We performed a systematic review through PubMed, Web of Science, Embase, eLibrary and ScienceDirect of all cases reported in the last four decades. We also describe one unreported patient. From 28 patients with ectopic insulinoma, 78.6% were female and mean age was 55.7 ± 19.2 years. Hypoglycaemia was the first symptom in 85.7% while 14.3% complained of abdominal pain or genital symptoms. Median tumour diameter was 27.5 [15-52.5] mm and it was localised by CT (73.1%), MRI (88.9%), [Ga]Ga-DOTA-exedin-4 PET/CT (100%), Ga-labelled-DOTA-conjugated somatostatin analogue PET/TC (100%), somatostatin receptor scintigraphy (40%) and endoscopic ultrasound (50%). Ectopic insulinomas were located at duodenum (n = 3), jejunum (n = 2), and one respectively at stomach, liver, appendix, rectum, mesentery, ligament of Treitz, gastrosplenic ligament, hepatoduodenal ligament and splenic hilum. Seven insulinomas were affecting the female reproductive organs: ovary (n = 5), cervix (n = 2) and remaining tumours were at retroperitoneum (n = 3), kidney (n = 2), spleen (n = 1) and pelvis (n = 1). 89.3% underwent surgery (66.7% surgery vs. 33.3% laparoscopy) and 16% underwent an ineffective pancreatectomy. 85.7% had localized disease at diagnosis and 14.3% developed distant metastasis. Median follow-up time was 14.5 [4.5-35.5] months and mortality was reported in 28.6% with median time until death of 60 [5-144] months. In conclusion, ectopic insulinomas are presented as hypoglycaemia with female preponderance. Functional imaging [Ga]Ga-DOTA-exedin-4 PET/CT and Ga-labelled-DOTA-conjugated somatostatin analogue PET/TC have very high sensitivity. Clinicians should be alert to the possibility of extra-pancreatic insulinomas when classic diagnostic tests and intraoperative pancreas exploration failed to locate the tumour.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Gallium Radioisotopes; Hypoglycemia; Insulinoma; Pancreatic Neoplasms; Positron Emission Tomography Computed Tomography; Somatostatin
PubMed: 37434098
DOI: 10.1007/s11154-023-09824-2 -
International Journal of Colorectal... Jun 2023Complete mesocolic excision (CME) consists of the complete removal of tumor-bearing soft tissues enveloped by the mesocolic fascia and radical lymphadenectomy at the... (Review)
Review
BACKGROUND
Complete mesocolic excision (CME) consists of the complete removal of tumor-bearing soft tissues enveloped by the mesocolic fascia and radical lymphadenectomy at the origin of feeding vessels. We conducted a systematic review, evaluating the efficacy of the robotic CME (RCME) in patients with right-sided colon cancer and presenting the data in comparison to those concerning the open RC (right colectomy) with CME.
METHODS
One independent researcher searched the MEDLINE-PubMed database for published and unpublished material.
RESULTS
Eighty-three articles were found to refer to CME, 17 of which met the selection criteria following the PRISMA guidelines. All researchers presented short-term outcomes and agreed on the oncologic safety of CME. Different surgical approaches were proposed; however, no significant differences were noticed regarding the peri-operative outcomes.
CONCLUSION
Although long-term outcomes are needed to establish it as a standard of care in right-sided colon cancer, RCME is a procedure that gains more and more grounds due to its oncologic safety. The standard medial-to-lateral approach seems to have similar results to other approaches.
Topics: Humans; Robotic Surgical Procedures; Mesocolon; Lymph Node Excision; Colonic Neoplasms
PubMed: 37382665
DOI: 10.1007/s00384-023-04477-8 -
Journal of Cardiothoracic Surgery Aug 2023Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric malperfusion represents the greatest risk to patients with respect to increased short-term mortality. In select patients, it may be feasible to offer a staged approach by treating the mesenteric malperfusion first, optimizing the patient in the intensive care setting and then, following with a central aortic repair. The aim of this systematic review is to summarize cohort studies assessing the role of pre-operative interventions for mesenteric malperfusion.
METHODS
An electronic literature search of five databases was performed to identify all relevant studies providing studies examining short-term mortality on patients who underwent either endovascular or open revascularisation of mesenteric ischemia prior to central aortic repair. The primary outcome was all-cause, short-term mortality. Secondary outcomes were comparative mortality between a delayed repair vs. aortic repair first strategy, rates of postoperative laparotomy, bowel resection, and mortality following delayed aortic repair.
RESULTS
The search strategy identified 8 studies qualifying for inclusion, with a total of 180 patients who underwent delayed aortic surgery in the setting of mesenteric MPS. The weighted short-term mortality following a mesenteric revascularisation first, delayed aortic surgery strategy was 22.5%. This strategy was also associated with a significantly lower mortality than a central repair first strategy (OR 0.07, 95% CI 0.02-0.27), and a significantly lower rate of postoperative laparotomy/bowel resection (OR 0.05, 95% CI 0.02-0.14). If patients survive to receive central repair, the weighted short-term mortality postoperatively is low (2.1%).
CONCLUSION
A summary of this evidence reveals a lower short-term mortality in hemodynamically stable patients with mesenteric malperfusion, along with a reduction in postoperative laparotomy/bowel resections. Of those patients who survive to receive central repair, short-term mortality remains very low in the select group of hemodynamically stable patients. Further high-quality studies with randomized or propensity matched data are required to verify these results.
Topics: Humans; Aortic Dissection; Mesenteric Ischemia; Mesentery; Syndrome; Aorta; Treatment Delay; Angioplasty
PubMed: 37596605
DOI: 10.1186/s13019-023-02341-y -
European Journal of Surgical Oncology :... Apr 2022The hepatic flexure and transverse colon have a complex intermingled lymphovascular anatomy crossing between mesocolon and mesogastrium. Few studies have investigated... (Review)
Review
INTRODUCTION
The hepatic flexure and transverse colon have a complex intermingled lymphovascular anatomy crossing between mesocolon and mesogastrium. Few studies have investigated the oncological relevance of metastatic infrapyloric and gastroepiploic lymph nodes (IGLN) from hepatic flexure and transverse colon tumors. This study aimed to evaluate the incidence and risk factors for IGLN metastases, and the indications, surgical morbidities, and oncological outcome following extended lymphadenectomy.
MATERIALS AND METHODS
According to the PRISMA statement, a systematic review on IGLN lymphadenectomy for colon cancer was conducted into PubMed, Embase, and Cochrane databases. A critical appraisal of study was performed according to the Joanna Briggs Institute Tools.
RESULTS
Nine studies were included. IGLN metastases incidence ranged 0.7-22%. IGLN positivity for patients with metastatic mesocolic lymph nodes ranged 1.7-33.3%. Postoperative complication rate ranged 8.5-36.9%, mostly low grade according to Clavien-Dindo's classification. Postoperative mortality rate ranged 0-5.4% at 30-days. IGLN metastases were associated with advanced disease with a 5-year progression-free survival rate up to 33.9%. Two authors reported perineural invasion and N stage as risk factors, while another reported endoscopic obstruction, signet ring adenocarcinoma, CEA level ≥17 ng/ml, and M1 stage to be risk factors for IGLN involvement. Apart from one study, all other studies were of moderate/high quality.
CONCLUSIONS
Metastatic IGLNs are not uncommon and should be highly considered. IGLN metastases could be potentially associated with an aggressive disease. IGLN dissection is not associated with higher morbidity and mortality than standard CME. Preoperative risk factors of IGLN involvement could guide surgical indication for extended lymphadenectomy.
Topics: Colectomy; Colon, Ascending; Colon, Transverse; Colonic Neoplasms; Humans; Laparoscopy; Lymph Node Excision; Lymph Nodes; Mesocolon
PubMed: 34893366
DOI: 10.1016/j.ejso.2021.12.005 -
Techniques in Coloproctology Nov 2023Complete mesocolic excision (CME) has been associated with improved oncological outcomes in treatment of colon cancer. However, widespread adoption is limited partly... (Meta-Analysis)
Meta-Analysis Review
Complete mesocolic excision versus standard resection for colon cancer: a systematic review and meta-analysis of perioperative safety and an evaluation of the use of a robotic approach.
PURPOSE
Complete mesocolic excision (CME) has been associated with improved oncological outcomes in treatment of colon cancer. However, widespread adoption is limited partly because of the technical complexity and perceived risks of the approach. The aim of out study was to evaluate the safety of CME compared to standard resection and to compare robotic versus laparoscopic approaches.
METHODS
Two parallel searches were undertaken in MEDLINE, Embase and Web of Science databases 12 December 2021. The first was to evaluate IDEAL stage 3 evidence to compare complication rates as a surrogate marker of perioperative safety between CME and standard resection. The second independent search compared lymph node yield and survival outcomes between minimally invasive approaches.
RESULTS
There were four randomized control trials (n = 1422) comparing CME to standard resection, and three studies comparing laparoscopic (n = 164) to robotic (n = 161) approaches. Compared to standard resection, CME was associated with a reduction in Clavien-Dindo grade 3 or higher complication rates (3.56% vs. 7.24%, p = 0.002), reduced blood loss (113.1 ml vs. 137.6 ml, p < 0.0001) and greater mean lymph node harvest (25.6 vs. 20.9 nodes, p = 0.001). Between the robotic and laparoscopic groups, there were no significant differences in complication rates, blood loss, lymph node yield, 5-year disease-free survival (OR 1.05, p = 0.87) and overall survival (OR 0.83, p = 0.54).
CONCLUSIONS
Our study demonstrated improved safety with CME. There was no difference in safety or survival outcomes between robotic and laparoscopic CME. The advantage of a robotic approach may lie in the reduced learning curve and an increased penetration of minimally invasive approach to CME. Further studies are required to explore this.
PROSPERO ID
CRD42021287065.
Topics: Humans; Robotic Surgical Procedures; Lymph Node Excision; Colectomy; Colonic Neoplasms; Robotics; Mesocolon; Laparoscopy; Treatment Outcome
PubMed: 37414915
DOI: 10.1007/s10151-023-02838-7 -
Colorectal Disease : the Official... Nov 2021Dissection with subsequent ligation and resection of arteries at their origin (central vascular ligation) is essential for adequate oncological resection during right... (Meta-Analysis)
Meta-Analysis Review
A systematic review and meta-analysis of variants of the branches of the superior mesenteric artery: the Achilles heel of right hemicolectomy with complete mesocolic excision?
AIM
Dissection with subsequent ligation and resection of arteries at their origin (central vascular ligation) is essential for adequate oncological resection during right hemicolectomy with complete mesocolic excision. This technique is technically demanding due to the highly variable arterial pattern of the right colon. Therefore, this study aims to provide a comprehensive evidence-based assessment of the arterial vascular anatomy of the right colon.
METHODS
A thorough systematic literature search through September 2020 was conducted on the electronic databases PubMed, Scopus and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using MetaXl software.
RESULTS
A total of 41 studies (n = 4691 patients) were included. The ileocolic artery (ICA), right colic artery (RCA) and middle colic artery (MCA) were present in 99.7% (95% CI 99.4%-99.8%), 72.6% (95% CI 61.3%-82.5%) and 96.9% (95% CI 94.2%-98.8%) respectively of patients. Supernumerary RCA and MCA were observed in 3.2% and 11.4% respectively of all cases. The RCA shared a common trunk with the ICA and MCA in 13.2% and 17.7% respectively of patients. A retro-superior mesenteric vein course of the ICA and RCA was observed in 55.1% and 11.4% respectively of all cases.
CONCLUSION
The vascular anatomy of the right colon displays several notable variations, namely the absence of some branches (RCA absent in 27.4% of cases), supernumerary branches, common trunks, and retro-superior mesenteric vein courses. These variations should be taken into consideration during right hemicolectomy with complete mesocolic excision to ensure adequate oncological resection while minimizing intra-operative complications.
Topics: Colectomy; Colonic Neoplasms; Humans; Laparoscopy; Mesenteric Artery, Superior; Mesocolon
PubMed: 34358401
DOI: 10.1111/codi.15861