BackgroundDistribution of regional lymph nodes (LNs) is decisive for the lymphadenectomy boundary in radical resection of a right-sided colon cancer (RCC). Currently, the data of LNs in central area remains ambiguous and scarce. Herein we aim to provide a more detailed anatomical research on LNs surrounding the superior mesenteric vessels for RCC and investigated the metastasis rate.MethodsCarbon Nanoparticles (CNs) or Indocyanine Green (ICG) were used as dye and we laparoscopically observed the stained LNs distribution pattern and analyzed the harvested LNs combined with pathology report. Lastly, 137 RCC patients who received a “superior mesenteric artery (SMA)-oriented” hemicolectomy from September 2016 to September 2020 were included to calculate the probability of LNs metastasis in our target area.Results20 patients diagnosed as RCC (mean age 55.55 years, 13 male) were included. 13 patients underwent CNs injection and 7 patients consented to the ICG, while 4 cases suffered from imaging failure. The unequal number of the regional LNs located between SMV and SMA was detected in 17 cases (85%), posterior to SMV area in 6 cases (30%), and anterior to SMA in 11 cases (55%), respectively. The presence of LNs posterior to SMV was associated with the crossing pattern of ileocolic artery (²= 5.38, p= 0.020). The probability of LNs metastasis in the above areas (target areas) was 2.19% (3/137). No dyed LNs occurred when the SMA sheath was exposed. What’s more, the number of total harvested LNs in patients with dye injection was significant more than dye-free RCC patients (22.44±13.78 vs 43.20±22.70, p<0.01). ConclusionRight-hemi colon-draining lymphatic vessels anteriorly/posteriorly traversed the SMV and arrived at the surface of SMA near the middle colonic artery (MCA) level, which highlights the potential need of CME to place the internal border anterior to SMA and the removal of mesenteric tissue in our target area on lymphatic resection.

Laparoscopic resection results in improved operative and postoperative outcomes compared with open surgery according to the results of the present meta-analysis. It may be a safe and feasible option for nonductal adenocarcinomatous pancreatic tumor patients in pancreatic body and tail. However, randomized controlled trials should be undertaken to confirm the relevance of these findings.

A 56-year-old male patient was admitted to our hospital presenting with a 3-month history of epigastric pain, jaundice and weight loss of 5 kg. Abdominal magnetic resonance imaging and computed tomography (CT) scan revealed situs inversus totalis (SIT), a mass in the pancreatic head and obstructed common bile duct and dilated pancreatic duct. The patient's electrocardiogram and chest X-ray showed dextrocardia. Laboratory examination showed that serum alpha fetoprotein, carcinoembryonic antigen, CA-125 and CA19-9 were within normal limits. According to the above symptoms and examinations, the patient was diagnosed as pancreatic head carcinoma with SIT. Because of severe jaundice, percutaneous transhepatic cholangial drainage (PTCD) was carried out and about 500 mL of yellow liquid can be drained daily. Three-dimensional (3D) angiography with multidetector-row computed tomography (MD-CT) showed multiple anomalies: the common hepatic artery (CHA) originating from the superior mesenteric artery; splenic artery originating from the abdominal aorta; a lack of celiac trunk originating from the abdominal aorta; and the pancreatic head neoplasm invading part of variant CHA. Due to anatomical variations with SIT and obstructive jaundice, an endoscopic retrograde cholangiopancreatography (ERCP) was attempted but it was unsuccessful in cannulating the inverted ampulla of Vater.Abdominal laparotomy confirmed SIT with a complete mirrorimage transposition of the abdominal viscera. Dilated common biliary duct (1.2 cm in diameter), a pancreatic head mass (3.5 cm in size) with swollen lymph nodes around the hepatoduodenal ligament and pancreatic were discovered. The exploration again confirmed the multiple vascular variants (Fig. 1). The hepatic artery was in the middle of the portal vein (right) and the common biliary duct (left).After laparotomy, a pancreaticoduodenectomy (PD), partial resection of the CHA and transplant artery revascularization, was performed with an end-to-side pancreaticojejunotomy, an end-to-side choledochojenunostomy and a side-to-side gastrojejunostomy with a modified Child's procedure. A 2-cm proximal jejunum artery was removed to revascularize to the resected part of CHA (Fig. 2). Post-operative 3-and 6-day colour Doppler ultrasound of abdominal blood vessels revealed that CHA was in peak blood flow with an about 19.8-34.5 cm/s velocity without occlusion or stenosis. Pathology showed chronic cholecystitis, moderately and poorly differentiated pancreatic head ductal adenocarcinoma and lymph node metastasis rate of 1/42 within T3N1M0 stage (the 7th Edition of American Joint Committee on Cancer Stage III). The patient was discharged without operative complications 10 days after surgery. One-year post-operative assessment revealed the return of normal liver function. Abdominal 3D angiography and MD-CT showed normal transplanted and revascularized CHA and without tumour recurrence and metastasis.SIT is a congenital malformation of the visceral organs where the anatomical structure of the thoracic and abdomina...

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Background According to previous guidelines, the lymph nodes around the right side of the superior mesenteric artery (SMA) should be dissected and removed en bloc. However, due to the technical challenge and the risk of complications, most surgeons perform the dissection along the axis of the superior mesenteric vein (SMV). Herein, we described an ‘artery-first’ approach for laparoscopic radical extended right hemicolectomy with complete mesocolic excision (CME). Methods A total of 22 cases were collected from January to October 2016. The right side of the SMA and SMV were exposed and separated, and the No. 203, No. 213 and No. 223 lymph nodes were dissected en bloc. Toldt’s fascia was dissected and expanded laterally to the ascending colon, cranial to the pancreas head. The caudal root of the mesentery and lateral attachments of the ascending colon were completely mobilized. Results There were 9 male and 13 female patients, with a mean age of 63.1 (range, 39–83) years and the mean body mass index was 24.6 (range, 18.3–37.7) kg/m 2 . The mean operative time was 192.5 (range, 145–240) minutes and the mean intra-operative blood loss was 55.0 (range, 10–300) ml. The mean number of harvested lymph nodes was 27.0 (range, 13–55) and the time to flatus and hospital stay were 35.0 (range, 26–120) hours and 7.5 (range, 5–20) days, respectively. Minor complications occurred in two patients and no post-operative death was observed. Conclusions The preliminary results suggest that the reported approach may be a feasible and safe procedure that is more in accordance with the principles of CME.