Congestive ischemic colitis occurring after resection of left colon cancer: 4 case series

Abstract

Background: Ischemic colitis can occur after colectomy and is sometimes difficult to treat. We report 4 cases of refractory, delayed onset, regional congestive colitis occurring on the anal side of the anastomosis after laparoscopic left hemicolectomy. Case presentation: A total of 191 patients underwent surgery for left colon cancer (transverse, descending, and sigmoid colon cancer) at our hospital from January 2012 to December 2017. During the procedures, the left colic artery (LCA) or sigmoid colic artery (SA) was dissected, the superior rectal artery (SRA) was preserved, and the inferior mesenteric vein (IMV) was dissected at the inferior margin of the pancreas. Congestive ischemic colitis due to venous return dysfunction occurred in 4 cases (2.1%), 5 to 34 months postoperatively. The patients had diarrhea and blood in the stool. On computed tomography (CT), the patients exhibited continuous intestinal edema and high-density adipose tissue from the anastomosis site to the rectum. Contrast enhancement showed dilation of the vasa recti and arteries from the inferior mesenteric artery (IMA) to the SRA. Three patients improved with long-term intestinal rest; in 1 case, the stenosis did not improve and required colorectal resection. Conclusion: Diagnoses were easy in these cases, but treatment was prolonged and surgery was necessary in 1 case. While this condition is rare, caution is warranted as it is difficult to treat.

Clinical impact of inferior mesenteric vein preservation during left hemicolectomy with low ligation of the inferior mesenteric artery for distal transverse and descending colon cancers: A comparative study based on computed tomography

“…Colonic ischemia around the anastomosis site following colorectal surgery is an unusual but serious complication ( 1 , 2 ). Several mechanisms underlie the development of colonic ischemia, including vascular factors such as arteriosclerosis, intestinal factors such as an increase in the intestinal pressure from constipation or other reasons, and factors associated with congestion due to poor blood circulation ( 3 – 5 ). A long, remnant distal stump after left hemicolectomy with low ligation of inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) ligation may cause congestive ischemic colitis due to inadequate venous circulation ( 3 ).…”

“…Several mechanisms underlie the development of colonic ischemia, including vascular factors such as arteriosclerosis, intestinal factors such as an increase in the intestinal pressure from constipation or other reasons, and factors associated with congestion due to poor blood circulation ( 3 – 5 ). A long, remnant distal stump after left hemicolectomy with low ligation of inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) ligation may cause congestive ischemic colitis due to inadequate venous circulation ( 3 ). In left hemicolectomy for left-sided colon cancer, the appropriate vascular ligation site, which includes IMV, remains controversial ( 6 – 8 ).…”

“…Colon cancers arising from distal transverse, splenic flexure, and proximal descending colons among left-sided colon cancers account for <10% of all colorectal cancer cases ( 3 , 9 – 12 ), and left hemicolectomy is performed if cancer develops in that area ( 6 – 8 , 13 ). The left colic artery is ligated to retrieve the nodes in this area and the left branch of the middle colic artery is ligated to harvest the surrounding nodes ( 14 – 18 ).…”

“…The left colic artery is ligated to retrieve the nodes in this area and the left branch of the middle colic artery is ligated to harvest the surrounding nodes ( 14 – 18 ). IMV is usually ligated at the inferior margin of the pancreas to ensure sufficient lymph node harvest ( 3 , 19 , 20 ), although studies have not yet been conducted regarding the appropriate ligation site for the IMV. IMV ligation near the root may lead to an imbalance in the venous return when the preserved IMA maintains sufficient blood supply.…”

“…IMV ligation near the root may lead to an imbalance in the venous return when the preserved IMA maintains sufficient blood supply. Four cases of congestive ischemic colitis due to venous return imbalance were reported ( 3 ). However, to date, no studies have been conducted to evaluate congestive ischemic colitis, occurring in long remnant sigmoid colon after left hemicolectomy with low ligation of IMA, and the clinical benefits of IMV preservation.…”