Live surgeryJune 16, 20221:39:465 speakersAvailable in: EN / IT
Clinical Round: left colon cancer – ICG-guided strategy and organ preservation
Clinical case of left colon adenocarcinoma in a 46-year-old patient: multidisciplinary discussion on ICG-guided surgical strategy, vascular ligation and lymphadenectomy.
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Clinical case
Adenocarcinoma del colon sinistro (discendente/sigma) con linfonodi sospetti; lesione sincrona piatta del colon destro
Patient framing as discussed at case introduction
SexMaschio
Age46 anni
StagecT3N1 → pT3N1b (3/25 linfonodi positivi); lesione destra successivamente trattata
DiagnosisAdenocarcinoma del colon sinistro (discendente/sigma) con linfonodi sospetti; lesione sincrona piatta del colon destro
Clinical historySportivo, fumatore, anemico (Hb 8) per sanguinamento occulto. In terapia con antidepressivi, figlio unico, vive con la madre. Lavora come rappresentante in ambito medico.
NotesBiopsie iniziali con displasia di alto grado e caratteri dubbi per infiltrazione; lesione stenosante non transitabile alla colonoscopia; cisti epatiche bilobari. Proteine MMR conservate.
Overview
Third clinical round of the Permanent School on ICG Surgery dedicated to colorectal surgery. After a brief introduction by Gian Luca Baiocchi on the two main applications of indocyanine green in the left colon – assessment of anastomotic perfusion and lymph node navigation – and an overview of the debate between high and low ligation of the inferior mesenteric artery, the case of a 46-year-old man, an athlete, with anemia from occult bleeding and an endoscopic diagnosis of a non-traversable stenosing neoplasm at the descending colon/splenic flexure is presented. Initial biopsies show only high-grade dysplasia with features suspicious for infiltration, while CT and CT colonography confirm an advanced neoplastic picture with suspicious lymphadenopathies and additional colonic polyps, including a flat lesion of the right colon.
The discussion involves residents from the Pavia school (Alberto Ficarelli and Benedetta Sargenti) and the Salerno school (Paolo Amoretti and Maria Rachele Barbieri), as well as senior surgeons Raffaele De Luca (Bari) and Edoardo Saladino. Pre-operative decision-making issues are addressed (whether to repeat the biopsy, hepatic workup, neoadjuvant chemotherapy, genetic counseling for Lynch syndrome, bowel preparation, choice of minimally invasive approach) along with intra-operative ones, focusing on the choice between standard left hemicolectomy and conservative segmental resection guided by ICG lymph node mapping, with preservation of the left colic and superior rectal arteries and side-to-side mechanical intracorporeal anastomosis.
Particularly innovative is Edoardo Saladino's contribution on preoperative intravenous ICG injection (2021 Chinese protocol) combined with intraoperative three-dimensional reconstruction with image fusion. The case concludes with a T3N1b histological outcome, adjuvant therapy and subsequent right hemicolectomy for the synchronous lesion, in line with the organ-sparing philosophy. Finally, Alessandro Puzziello contributes reflections on ICG applications in liver surgery and synchronous metastases.
Topics
ICG lymph node mapping in the left colon
Anastomotic perfusion assessment
High vs low ligation of the inferior mesenteric artery
Preoperative intravenous ICG injection
Intraoperative 3D reconstruction with image fusion
Verde di indocianina (ICG)Stryker NovadaqSistema di imaging Stryker (1688/SPY)Suturatrici meccaniche lineariColonna laparoscopicaSistema di ricostruzione 3D con fusione d'immagineTC addomeColon-TC
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