Complete mesocolic excision requires central mesenteric dissection near the middle colic vein (MCV) confluence, where anatomic variability may increase operative risk. However, MCV multiplicity, confluence patterns, and relationships to the middle colic artery (MCA) are not sufficiently defined. We performed a retrospective secondary analysis of 300 consecutive three-dimensional vascular reconstructions from a prospectively maintained database of patients undergoing surgery for right-sided colon cancer (age 65 ± 9 years; 59

Purpose: Complete mesocolic excision requires central mesenteric dissection near the middle colic vein (MCV) confluence, where anatomic variability may increase operative risk. However, MCV multiplicity, confluence patterns, and relationships to the middle colic artery (MCA) are not sufficiently defined. Methods: Three-dimensional vascular reconstructions were performed on 300 multidetector CT datasets from patients with right-sided colon cancer (age 65±9 years; 59% female). MCV branches (MCV1–3, right to left), their confluence patterns, and their spatial relationships to the MCA were analyzed using descriptive statistics. The reconstruction method had been previously validated intraoperatively and was performed by a single investigator. Results: The MCV was identified in all cases (397 veins total). It was single in 68.7%, double in 30.3%, and triple in 1.0% of patients. Confluences were most often into the superior mesenteric vein (65.7%), followed by the inferior mesenteric vein (12.6%) and gastrocolic trunk (9.8%). MCV1 drained mainly into the SMV (72.7%). MCV2 showed variable drainage into the SMV (45.7%), IMV (31.9%), jejunal vein (9.6%), left SMV (3.2%), and left colic angular vein (2.1%). MCV3 drained into the IMV in 66.7% and the left SMV in 33.3%. The MCV and MCA were separate in 67.0% of cases, with anterior crossing in 17.7% and posterior crossing in 15.3%. Left-sided drainage patterns were seen in 20–50% of patients with double or triple MCVs. Conclusions: MCV anatomy is highly variable, with multiplicity in 31.3% and frequent atypical confluences. Preoperative 3DCT can identify high-risk variants and may support safer, tailored vascular ligation during lymphadenectomy.

Purpose: The anatomical extent of the left colonic dissection three area (D3A) is crucial for lymphadenectomy for left‑sided colon cancer but remains poorly standardized. We aimed to define this D3A morphometrically using preoperative three‑dimensional reconstruction of vascular anatomy (3DRVA) and cadaveric dissection. Methods: Thirty‑four anonymized 3DRVAs were analyzed. The inferior mesenteric artery (IMA), left colic artery (LCA), and inferior mesenteric vein (IMV) were segmented. The D3A trapezoid borders were the IMA segment (origin to first branch), the IMV trajectory, and distances between IMA/IMV at the IMA and LCA origin levels. D3A shape and surface‑area groups (<5, 5–10, >10 cm²) were related to IMA length (<4 vs ≥4 cm) and IMV drainage. Two Jores‑embalmed cadavers were dissected for anatomical validation. A video of the proposed surgical procedure is presented. Results: Mean age was 67±8 years; 58.8% female. IMA and LCA were present in all cases; IMV drained to the splenic vein in 11 and the superior mesenteric/jejunal veins in 23. Mean IMA segment length was 3.74±0.97cm. The IMA–IMV distance was greater at the IMA origin than at the LCA level (2.83±1.03 vs 1.26±0.61cm;p < 0.001). Mean D3A surface was 7.66±3.24cm²; 94.1% of D3As were cone‑shaped. Large D3As (>10 cm²) occurred predominantly with long IMA segments (χ² = 11.19;p< 0.01). Cadaveric dissection confirmed a lymphovascular mesh within the D3A. Conclusions: The left colonic D3A is a variable morphometric field whose size correlates with IMA segment length. Preoperative 3DRVA supports planning and performance of central lymphadenectomy in left‑sided colon cancer.

The arterial ligation level and the lymphadenectomy extent for surgical treatment of distal duodenal/proximal jejunal tumors are not standardized. To define morphometric and topographic specifics of the superior jejunal artery (SJA) and the superior jejunal vein (SJV), and the width of arterial lymphovascular bundles through lymphatic clearances. By extrapolating results from two methodologies, the goal is to determine the arterial ligation level and the lymphadenectomy extent for duodenojejunal tumor treatment. The first series included an analysis of preoperative 3D-CT vascular reconstructions from 97 patients. The second series included 11 dissected cadavers where the course of the proximal mesenteric lymphatics was followed. The SJA was defined as the uppermost jejunal artery (JA) counted from the ileocolic artery (ICA) origin. SJA proper was present in 72 cases (74.2 https://classic.clinicaltrials.gov/ct2/show/NCT05670574 NCT05670574

BACKGROUND: The jejunum has a wide lymphatic drainage field, making radical surgery difficult. OBJECTIVE: Extrapolate results from 2 methodologies to define jejunal artery lymphatic clearances and lymphovascular bundle shapes for radical bowel-sparing surgery. DESIGN: Two cohort studies. SETTINGS: The first dataset comprised dissections of cadavers at the University of Geneva. The second dataset incorporated preoperative 3D-computed tomography vascular reconstructions of patients included in the “Surgery with Extended (D3) Mesenterectomy for Small Bowel Tumors” clinical trial. PATIENTS: Eight cadavers were dissected. The 3D-computed tomography dataset included 101 patients. MAIN OUTCOME MEASURES: Lymph vessels ran parallel and interlaced with jejunal arteries. Lymphatic clearance was minimal at the jejunal artery’s origin, radially spreading thereafter. Jejunal arteries were categorized into 3 groups based on position to the middle colic artery origin on 3D-computed tomography. Group A: jejunal artery origins lie cranially and caudally to the middle colic artery. Group B: jejunal artery origins lie caudal to the middle colic artery. Group C: jejunal artery origins lie cranial to the middle colic artery. Jejunal veins were classified into 3 groups based on their trajectories to the superior mesenteric artery (dorsally/ventrally/combined). RESULTS: Lymph vessel clearances were 1.5 ± 1.0 mm at jejunal artery origins. Group A was present in 81 (80.2%), group B in 13 (12.9%), group C in 7 (6.9%) cases. Jejunal artery median was 4. A 57 (56.4%) of jejunal veins ran dorsally to the superior mesenteric artery, 16 (15.8%) ran ventrally, and 28 (27.8%) had combined course. LIMITATIONS: Lymph nodes weren’t counted during dissection because the main observation was the position of lymph vessels. CONCLUSION: Minimal jejunal artery lymphatic clearance implies ligating tumor-feeding vessels at origin. The intermingled jejunal artery lymphatics imply lymph node dissection along the proximal and distal vessels to the level of the first arcade. Classifying jejunal arteries and veins could simplify the anatomy for surgeons. See Video Abstract Clinical trial registration number: NCT05670574.

The D3 lymphadenectomy with extended mesenteric/mesocolic excision is becoming a standard in the surgery of small and large bowel carcinoma. The aim of this study is to present the feasibility of macro- and microdissection of the mesenteric lymphatics in the root of the mesentery with accompanying morphometry of the lymphatic clearances. The study was carried out on three embalmed cadavers from the body donor program. After the removal of the anterolateral abdominal wall, the greater omentum was retracted cranially, giving access to the mesentery, right, and transverse mesocolon. After marking the pertinent landmarks (ileocolic fold, middle colic fold, duodenojejunal angle), the visceral peritoneum was carefully incised along the approximate larger perimeter of the D3 volume and removed. The subperitoneal fatty and connective tissue was removed by gentle centrifugal scraping, revealing the underlying deep lymphatic and blood vessel network. We used narrow spatulas, micro-dissection scissors, small tweezers, curved forceps, and 5x magnifying lens with a fluorescent ring. The centrally positioned superior mesenteric vessels were pivotal in identifying their branches, affluents, and the accompanying lymphatic network. The lymph vessels were identified by continuity with the collector vessels and their link to the lymph nodes. Finally, the lymphatic clearances, i.e., distances between the mentioned arteries and their neighboring vessels, were measured by a digital caliper. In conclusion, the dissection of the mesenteric lymphatics gives a synoptic view of the lymph vessels network and provides valuable information for D3 surgery of small and large bowel tumors.

Although laparoscopic lavage for perforated diverticulitis with peritonitis has been grabbing the headlines, it is known that the clinical presentation of peritonitis can also be caused by an underlying perforated carcinoma. The aim of this study was to determine the incidence of patients undergoing inadvertent laparoscopic lavage of perforated colon cancer as well as the delay in cancer diagnosis. The PubMed database was systematically searched to include all studies meeting inclusion criteria. Studies were screened through titles and abstracts with potentially eligible studies undergoing full-text screening. The primary endpoints of this meta-analysis were the rates of perforated colon cancer patients having undergone inadvertent laparoscopic lavage as well as the delay in cancer diagnosis. This was expressed in pooled rate

AIM:Stage III colon cancer is routinely treated with adjuvant chemotherapy, which causes significant short-term morbidity. Its effect on long-term quality of life (QoL) is poorly investigated. The aim of this study was to investigate long-term QoL after curative treatment for colon cancer and explore the impact of chemotherapy on general and disease-specific QoL. METHOD:All patients aged under 75 years operated on for colon cancer between 30 September 2007 and 1 October 2019 were identified by the Cancer Registry of Norway. Exclusion criteria were distant metastasis, recurrence, dementia and rectal/rectosigmoid cancer operation. The primary outcome measure was Gastrointestinal Quality of Life Index (GIQLI). Secondary outcome measures included the Short Form Health Survey (SF-36). To achieve balanced groups when assessing differences in outcome measures the analyses were weighted by inverse probability weights based on a multiple logistic regression model with prechosen confounders. RESULTS:A total of 8627 patients were invited and 3109 responded (36% response rate). After exclusions 3025 patients were included, of whom 1148 (38%) had received adjuvant chemotherapy and 1877 (62%) had surgery alone, with mean follow-up of 75.5 versus 74.5 months, respectively. The GIQLI differed significantly between the groups [mean 111.0 (SD 18.4) vs. 115.6 (SD 17.8), respectively; mean difference: -4.6 (95% CI -5.9; -3.2); p < 0.001]. Those with the highest neurotoxicity exhibited the lowest GIQLI. The adjuvant chemotherapy group scored significantly lower in six of eight SF-36 domains compared with the surgery alone group. The main differences were found in social, physical and emotional function. CONCLUSION:Long-term QoL was significantly lower in patients who received adjuvant chemotherapy than in patients who did not. Neurotoxicity was closely related to reduced QoL in these patients. The low response rate limits the generalizability of the results.

This communication study integrates composite multimodal research on postmortem human submandibular glands, based on macromorphometry. The normal ductographic sialograms were pairwise analyzed using linear morphometry, whole-gland planimetry and fractal properties, such as main duct length, caliber and tortuosities, side branches and accessory ducts/lobes. All the examined parameters presented a significant correlation, i.e., symmetry between the left and the right submandibular glands. The morphometric data presented can serve as a valuable reference in clinical practice.

Background: This study aims to delineate anatomical landmarks crucial for complete mesocolic excision, focusing on Gerota’s fascia, which guides surgical dissection in right-sided colon cancer, forming the posterior limit. Employing a multimodal approach, the research aims to understand the fascial anatomy and its variations under pathological conditions. Methods: Three methods were applied: a pilot dissection on an embalmed cadaver for clear anatomical presentation of prerenal fascia, Mimics segmentation of the fascia and its relationship with the colon, and a retrospective analysis of MDCTA scans from 196 patients (mean age 65.73 y, 118 F/78 M). Systematic measurements of fascial thickness were taken at key renal levels—upper pole, hilum, lower pole, and infra-renal. Covariates analyzed included Body Mass Index, age, and sex. Results: The pilot dissection revealed the renal fascia of Gerota as the only true retrocolic compact connective tissue and the fusion fascia of Toldt as a mesh of strands of loose connective tissue and fat lobules. MDCTA showed clearer visualization of Gerota’s fascia at the hilum and inferior renal pole, predominantly on the left. There were significant differences in fascial thickness between sides (1.30 mm on the right and 1.34 mm on the left) and a positive correlation with BMI, whereas age and sex showed no significant effects. Conclusion: Gerota’s fascia is a critical anatomical landmark in CME for right colon cancer. This study highlights the fascia’s structural integrity, unaffected by the tumor, underscoring its importance in surgical navigation.

Objective: Assess outcomes of patients with right-sided colon cancer with metastases in the D3 volume after personalized surgery. Background: Patients with central lymph node metastasis (D3-PNG) are considered to have a systemic disease with a poor prognosis. A 3-dimensional definition of the dissection volume allows the removal of all central nodes. Materials and Methods: D3-PNG includes consecutive patients from an ongoing clinical trial. Patients were stratified into residual disease negative (D3-RDN) and residual disease positive (D3-RDP) groups. D3-RDN was further stratified into 4 periods to identify a learning curve. A personalized D3 volume (defined through arterial origins and venous confluences) was removed “ en bloc” through medial-to-lateral dissection, and the D3 volume of the specimen was analyzed separately. Results: D3-PNG contained 42 (26 females, 63.1 SD 9.9 y) patients, D3-RDN:29 (17 females, 63.4 SD 10.1 y), and D3-RDP:13 (9 females, 62.2 SD 9.7 y). The mean overall survival (OS) days were D3-PNG:1230, D3-RDN:1610, and D3-RDP:460. The mean disease-free survival (DFS) was D3-PNG:1023, D3-RDN:1461, and D3-RDP:74 days. The probability of OS/DFS were D3-PNG:52.1%/50.2%, D3-RDN:72.9%/73.1%, D3-RDP: 7.7%/0%. There is a significant change in OS/DFS in the D3-RDN from 2011–2013 to 2020–2022 (both P =0.046) and from 2014–2016 to 2020–2022 ( P =0.028 and P =0.005, respectively). Conclusion: Our results indicate that surgery can achieve survival in most patients with central lymph node metastases by removing a personalized and anatomically defined D3 volume. The extent of mesenterectomy and the quality of surgery are paramount since a learning curve has demonstrated significantly improved survival over time despite the low number of patients. These results imply a place for the centralization of this patient group where feasible.

Background: Anastomotic leak rates after colorectal surgery remain high. In most left-sided colon and rectal resection surgeries, a circular stapler is utilized to create the primary bowel anastomosis. However, it remains unclear whether a relationship between circular stapler technology and anastomotic leak in left-sided colorectal surgery exists. Methods: A post-hoc analysis was conducted using a prospectively collected data set of patients from the 2017 European Society of Coloproctology snapshot audit who underwent elective left-sided resection (left hemicolectomy, sigmoid colectomy, or rectal resection) with a manual circular stapled anastomosis. Rates of anastomotic leak and unplanned intensive care unit stay in association with manual circular stapling were assessed. Patient-, disease-, geographical-, and surgeon-related factors as well as stapler brand were explored using multivariable regression models to identify predictors of adverse outcomes. Results: Across 3305 procedures, 8.0% of patients had an anastomotic leak and 2.1% had an unplanned intensive care unit stay. Independent predictors of anastomotic leak were male sex, minimal-access surgery converted to open surgery, and anastomosis height C11 (lower third rectum) (all P < 0.050). Independent predictors of unplanned intensive care unit stay were minimal-access surgery converted to open surgery and American Society of Anesthesiologists grade IV (all P < 0.050). Stapler device brand was not a predictor of anastomotic leak or unplanned intensive care unit stay in multivariable regression analysis. There were no differences in rates of anastomotic leak and unplanned intensive care unit stay according to stapler head diameter, geographical region, or surgeon experience. Conclusion: In patients undergoing left-sided bowel anastomosis, choice of manual circular stapler, in terms of manufacturer or head diameter, is not associated with rates of anastomotic leak and unplanned intensive care unit stay.

Andersen, Bjarte T. M.D.; Kazaryan, Airazat М. M.D., Ph.D.; Stimec, Bojan V. M.D., Ph.D.; Ignjatovic, Dejan M.D., Ph.D. Author Information