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Asian J Endosc Surg ISSN 1758-5902

C A S E R E P O RT

Laparoscopic right hemicolectomy for metachronous ascending colon cancer with preservation of an ileal conduit constructed after previous radical cystectomy for bladder cancer Kae Okoshi,1,2 Suguru Hasegawa,2 Teppei Murakami,2 Masahiro Yamada,2 Koya Hida,2 Kenji Kawada2 & Yoshiharu Sakai2 Department of Surgery, 1 Japan Baptist Hospital and 2 Graduate School of Medicine, Kyoto University, Kyoto, Japan

Keywords Ascending colon cancer; ileal conduit; right hemicolectomy Correspondence Kae Okoshi, Department of Surgery, Japan Baptist Hospital, 47 Yamonomoto-cho, Kitashirakawa, Sakyo-ku, Kyoto 606-8273, Japan. Tel: +81 (0)75 781 5191 Fax: +81 (0)75 701 9996 Email: [email protected] Received 10 November 2014; revised 21 December 2014; accepted 30 December 2014 DOI:10.1111/ases.12173

Abstract A 79-year-old woman who had undergone laparoscopic radical cystectomy and ileal conduit construction for bladder cancer 4 years earlier presented to our hospital with anemia. We diagnosed advanced ascending colon cancer (cT4bN2M1) and documented tumor regression after six courses of folinic acid, 5-fluorouracil, and oxaliplatin therapy. We then performed laparoscopic right hemicolectomy. Intraoperatively, we found that the right colic artery was the feeding artery of the tumor, whereas the ileocolic artery, which was the main feeder of the conduit, was not. We performed lymph node dissection along the surgical trunk with central vascular ligation of the right colic artery and the right branch of the middle colic artery while preserving the ileal conduit and its blood supply (ileocolic artery and ileal branches). The postoperative course was uneventful, and the patient remains well and cancer-free 2 years after colonic surgery. We believe that this is the first report of laparoscopic right colectomy in a patient with an ileal conduit.

Introduction Ileal conduit construction is the gold standard urinary diversion technique after radical cystectomy (1). However, the presence of an ileal conduit can make a second surgical procedure difficult. We herein describe a laparoscopic right hemicolectomy for treatment of metachronous ascending cancer in a patient with a history of laparoscopic total cystectomy with ileal conduit diversion for bladder cancer. To the best of our knowledge, this is the first report of laparoscopic right colectomy in a patient with an ileal conduit.

Case Presentation A 79-year-old woman with a BMI of 15.3 kg/m2 presented at our hospital (Kyoto University Hospital, Kyoto, Japan) with anemia. Four years earlier, she had undergone laparoscopic radical cystectomy with ileal conduit construction and right oophorectomy for bladder cancer.

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The patient was diagnosed with advanced colon cancer in the ascending colon near the hepatic flexure. Histopathological examination of a colonoscopic biopsy specimen revealed well-differentiated adenocarcinoma. Initial CT showed a 73-mm tumor widely invading the right abdominal wall, regional lymph node enlargement, and multiple nodules suggesting peritoneal dissemination (Figure 1a). There was no evidence of metastasis to distant organs other than the peritoneum (cT4bN2M1: stage IV, Japanese classification [7th]) (2). Threedimensional CT angiography showed that the right colic artery (RCA) was the main feeding artery of the tumor (Figure 2). We considered that the patient had a high-risk disease and that radical surgery would be difficult; our multidisciplinary team accordingly recommended systemic chemotherapy. After six courses of folinic acid, 5-fluorouracil, and oxaliplatin therapy, abdominal CT showed that the main tumor had responded well and that the lesions suspected to represent peritoneal

Asian J Endosc Surg 8 (2015) 188–192 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

Right colectomy preserving ileal conduit

K Okoshi et al.

Figure 1 CT findings. (a) Contrast-enhanced CT before treatment with systematic chemotherapy showed a large tumor, regional lymph node enlargement, and multiple peritoneal nodules. (b) Substantial reduction in tumor size and no visible nodules were present after chemotherapy.

Figure 2 Three-dimensional CT angiography. The main feeding artery of the tumor was the RCA. ICA, ileocolic artery; MCA, middle colic artery; RCA, right colic artery.

dissemination were no longer visible (Figure 1b). Thus, after urological consultation, we planned to perform laparoscopic right hemicolectomy with ileal conduit preservation. Laparoscopic surgery was performed with the patient under general anesthesia and in the lithotomy position. Five ports were placed: a 12-mm trocar to the left of the umbilicus for the laparoscope, with care taken to avoid injuring the ileal conduit; a 5-mm trocar in the left upper quadrant; a 12-mm trocar in the left lower quadrant; and 5-mm trocars in the right lower abdominal quadrant and in the suprapubic region (Figure 3a). The patient was then placed in a Trendelenburg and left semi-lateral position.

Neither ascites nor peritoneal seeding was found. An approximately 15-cm ileal segment, 5 cm proximal to the ileocecal junction, had been used as a conduit. The ileocolic artery (ICA) was identified as the conduit’s feeding artery (Figures 3b,4). The tumor was located in the ascending colon near the hepatic flexure. Because the main feeding artery was identified as the RCA, we decided to preserve the ICA to maintain the blood supply to the ileal conduit. We used a medial approach and opened a mesenteric window below the ileocolic vascular pedicle, after which the cecal branch of the ICA was divided, with particular care taken to preserve the ICA and its ileal branch. The ventral aspect of the superior

Asian J Endosc Surg 8 (2015) 188–192 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

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Right colectomy preserving ileal conduit

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RCA

Tumor

ICA *

5 Urostoma **

12 (scope) 12

5 5

Previous anastomosis

Ileal conduit

a

***

b

Figure 3 Surgical illustrations. (a) Placement of the five ports. (b) First, the cecal branch of the ICA was divided (*). Second, the ileum was divided at the ileocecal junction (just to the distal side of the previous anastomosis) (**). Third, the terminal ileum, including the previous anastomosis, was mobilized for anastomosis and resected (***). Fourth, a functional end-to-end ileocolic extracorporeal anastomosis was performed between the ileum (***) and the transverse colon.

Figure 4 The ileal branch of the ICA was identified as the feeding artery of the ileal conduit. ICA, ileocolic artery.

mesenteric vein was exposed, as were superior mesenteric artery, RCA, the middle colic artery and vein subsequently. The gastrocolic venous trunk and right gastroepiploic vein and its pancreatic branch were then identified. The RCA, right branch of the middle colic artery, and middle colic vein were ligated at their origins (Figure 5). Lymph node dissection was performed along the surgical trunk, after which the right colon was thoroughly mobilized from the duodenum, pancreas, and retroperitoneum via a medial-to-lateral approach. The ileum was then divided at the ileocecal junction (just to the distal side of the anastomosis) with a linear stapler to facilitate exposure and mobilization of the ileocecal region from the retroperitoneum (Figure 6). The transverse mesocolon was dissected, and the transverse colon was divided with a linear stapler (Figure 5), after which the specimen was extracted by elongating the incision to the left of the umbilicus. Finally, dense adhesions around the ileal conduit and ileal anastomosis were carefully released. The terminal ileum, including the previous anastomosis, was mobilized without damaging the ileal conduit, and the ileum was divided again just proximal to the previous anastomosis (Figure 3b). A functional end-to-end ileocolic extracorporeal anastomosis

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between the ileum and transverse colon was then performed. The operative time was 292 min, and the estimated blood loss was 152 mL. Pathologic examination showed moderately differentiated adenocarcinoma (pT3 pN0 (0/41) M0, Japanese classification [7th]) (2). The patient had an uneventful postoperative course. She received no adjuvant chemotherapy and is doing well with no evidence of cancer recurrence 2 years after colonic surgery. Written informed consent was obtained from this patient for publication of this case report and any accompanying images. The patient’s anonymity has been preserved.

Discussion Laparoscopic colorectal surgery for treatment of advanced or complicated cases is becoming increasingly more widespread (3–5). We performed laparoscopic right hemicolectomy for metachronous ascending colon cancer in a patient with a history of laparoscopic total cystectomy with ileal conduit diversion for bladder cancer; the hemicolectomy was completed with ileal conduit preservation. To the best of our knowledge, this

Asian J Endosc Surg 8 (2015) 188–192 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

Right colectomy preserving ileal conduit

K Okoshi et al.

Right branch of MCAwas ligated. Accessory RCV was ligated.

Tumor

MCV was ligated at the origin.

RCA was ligated at the origin. ICA and ICV were preserved.

Cecal branches of ICA and ICV were ligated.

Figure 5 Preserved and ligated vessels. ICA, ileocolic artery; ICV, ileocolic vein; MCA, middle colic artery; MCV, middle colic vein; RCA, right colic artery; RCV, right colic vein.

Figure 6 The ileal conduit and previous anastomosis. ICA, ileocolic artery.

is the first report of laparoscopic right colectomy in a patient with an ileal conduit. Several technical aspects are important for safe performance of this type of surgery. First, port placement should minimize interference with the conduit. To ensure this, the ports for the scope and assistant were not placed in our standard locations (6). Second, the blood supply to the ileal conduit should be carefully preserved. The ICA is usually divided proximally in patients with right-sided colonic cancer. However, ICA division may threaten the blood supply to the conduit. In the present case, the tumor was fortunately located in the ascending colon near the hepatic flexure and the relevant feeding artery was the RCA; therefore, we could preserve the ICA and its small intestinal branch. Yasuno et al. reported that lymph node spread along the bowel does not extend

beyond 5 cm from the tumor (7); thus, ileocecal junction preservation is feasible in patients with cancers near the hepatic flexure. When the tumor is located in the cecum or ascending colon near Bauhin’s valve, the ICA should be ligated and the ileal conduit should be recreated. Three-dimensional CT angiography seems useful for such cases in which the artery locations have great surgical importance. Third, because the normal mesenteric anatomy had been disrupted by the previous surgery, wider than usual exposure of the surgical field was essential for safe performance of laparoscopic surgery. Our patient had dense adhesions between the ileal conduit and previous ileal anastomosis. Before dissecting this area, we divided the ileum at the ileocecal junction to achieve better exposure and a greater understanding of the complex anatomy.

Asian J Endosc Surg 8 (2015) 188–192 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

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Right colectomy preserving ileal conduit

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In conclusion, we have reported a case of laparoscopic right hemicolectomy for metachronous ascending colon cancer in a patient with a history of laparoscopic total cystectomy and ileal conduit construction.

Acknowledgments There are no conflicts of interest to declare.

References 1. Lee RK, Abol-Enein H, Artibani W et al. Urinary diversion after radical cystectomy for bladder cancer: Options, patient selection, and outcomes. BJU Int 2014; 113: 11–23. 2. Japanese Society for Cancer of the Colon and Rectum. General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus, 7th edn. Tokyo: Kanehara-Shuppan, 2006.

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3. Zheng MH, Ma JJ, Zhang T et al. Laparoscopic sphincterpreserving surgery for low rectal tumor using prolapsing technique. Asian J Endosc Surg. 2010; 3: 14–17. 4. Ida S, Oki E, Ando K et al. Pure laparoscopic right-sided hepatectomy in the semi-prone position for synchronous colorectal cancer with liver metastases. Asian J Endosc Surg. 2014; 7: 133–137. 5. Mukai T, Akiyoshi T, Ueno M et al. Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer. Asian J Endosc Surg. 2013; 6: 314–317. 6. Hasegawa S, Kawamura J, Nagayama S et al. Medially approached radical lymph node dissection along the surgical trunk for advanced right-sided colon cancers. Surg Endosc 2007; 21: 1657. 7. Yasuno M, Mori T, Takahashi K. Our new propose for the length of the bowel to be resected in the colorectal cancer operation-The study of the bowel habits after the right hemicolectomy and the low anterior resection. Jpn J Gastroenterol Surg 1997; 30: 2112–2116.

Asian J Endosc Surg 8 (2015) 188–192 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

Laparoscopic right hemicolectomy for metachronous ascending colon cancer with preservation of an ileal conduit constructed after previous radical cystectomy for bladder cancer.

A 79-year-old woman who had undergone laparoscopic radical cystectomy and ileal conduit construction for bladder cancer 4 years earlier presented to o...
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