Laparoscopic surgery for colorectal cancer with persistent descending mesocolon

A 50-year-old man presented with a 2-month history of melena. Colonoscopy and computed tomography (CT) showed sigmoid colon cancer and synchronous liver metastasis. CT-colonography showed PDM and a primary tumor at the distal side of the sigmoid colon (Fig. 1a). After systemic chemotherapy (Panitumumab and FOLFOX), he underwent laparoscopic sigmoidectomy with the double-stapling technique (DST) anastomosis and synchronous liver resection. The sigmoid colon located at the right side of the abdomen adhered to the abdominal wall, and the adhesion was dissected laparoscopically. In this case, the root of the inferior mesenteric artery (IMA) was cut for lymph node dissection (Fig. 1b). The left colonic artery (LCA) and inferior mesenteric vein (IMV) next to the IMA were then also cut. The operation time was 835 min and the volume of bleeding was 285 ml. Two months after surgery, the patient developed abdominal distension and pain. Colonoscopy showed stenosis of the reconstructed colon (Fig. 1c), and CT showed colonic dilatation caused by stenosis at the oral side of the anastomosis (Fig. 1d–f). No findings of local recurrence were seen. The clip on the LCA was located close to the marginal artery (Fig. 1e), and contrast enhancement at the distal side of the reconstructed colon was weak. Therefore, the main cause of the stenosis seemed to be an impaired arterial blood flow of the reconstructed colon. Although the patient was admitted to our hospital and fasted, his complaint and colonic dilatation prolonged. Because he had obstructive colitis caused by severe colonic stenosis, he underwent colostomy at the transverse colon to improve the colonic dilatation 4 months after colectomy. One year after primary surgery, he experienced recurrence in his liver. He underwent second liver resection and has been treated with systemic chemotherapy, and is still alive for 24 months after primary surgery.

A 77-year-old man who had difficulty defecating was diagnosed with rectal cancer by colonoscopy. CT-colonography showed PDM and a primary tumor at the middle rectum (Fig. 2a). Preoperative CT-angiography showed that the LCA branched from the IMA (Fig. 2b). He underwent laparoscopic low anterior resection with D3 lymph node dissection and the DST anastomosis preserving pelvic autonomic nerves. The sigmoid colon located at the right side of the abdomen adhered to the abdominal wall. In addition, the mesocolon and the mesentery of the ileum were adhered. These adhesions were dissected initially. In laparoscopic low anterior resection, the superior rectal artery (SRA) was cut while preserving the LCA (Fig. 2c). Intraoperative infrared ray (IR) imaging using indocyanine green (ICG) performed prior to the DST anastomosis showed good blood flow of the reconstructed colon (Fig. 2d). The anastomosis was located at 5 cm from the anal verge. The operation time was 333 min and the volume of bleeding was 10 ml. The preserved LCA was identified on postoperative CT-angiography (Fig. 2e). He had no postoperative complications. Pathological examination showed pT3N2bM0 pStage IIIC (TNM classification eighth edition) with a negative resection margin. He experienced an early recurrence in his liver and lung 1 month after surgery and has been treated with oxaliplatin-based systemic chemotherapy without any anastomotic complication. He is still alive for 13 months after surgery.