Live surgeryJune 9, 20222:35:2110 speakersAvailable in: EN / IT
Hot Topics in Lower GI Surgery: CME, IMA Ligation, Flexures and Early Rectal Cancer
ICG Permanent School session on lower GI surgery: CME in the right colon, high vs low IMA ligation, lymphadenectomy of the colonic flexures, and rectum-sparing in early cancers.
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Clinical case
Caso 1: adenoma cancerizzato del retto basso (3 cm dalla linea pettinata) post-EMR piecemeal R1, T1 SM2, G1, invasione linfovascolare presente, budding non zero. Caso 2: adenocarcinoma del retto basso T3b NX, lesione 4 cm sulla linea dentata
Patient framing as discussed at case introduction
Sexfemminile
Agegiovane adulta (caso 1) e giovane adulta (caso 2)
StageCaso 1: ypT0 dopo TEM di completamento (no neoadiuvante); Caso 2: yT2 dopo TNT con risposta clinica maggiore
DiagnosisCaso 1: adenoma cancerizzato del retto basso (3 cm dalla linea pettinata) post-EMR piecemeal R1, T1 SM2, G1, invasione linfovascolare presente, budding non zero. Caso 2: adenocarcinoma del retto basso T3b NX, lesione 4 cm sulla linea dentata
Prior treatmentCaso 1: EMR piecemeal endoscopica R1; Caso 2: chemioradioterapia 50 Gy + chemioterapia sistemica con oxaliplatino (Total Neoadjuvant Therapy)
Clinical historyCasi presentati da Baiocchi nell'ultima parte della sessione per discutere il rectum sparing
NotesEntrambe trattate con escissione locale transanale + sampling linfonodale mesorettale ICG-guidato per via laparoscopica, anziché TME radicale. Follow-up serrato; al momento della presentazione entrambe libere da malattia
Overview
Episode of the Permanent School on ICG Surgery dedicated to the "Hot Topics" of lower gastrointestinal surgery, moderated by Alberto Arezzo with an introduction by Gian Luca Baiocchi. The session is structured around four major topics, each with a speaker and a shooter/discussant: D2 vs D3/CME in right hemicolectomy (Maurizio De Giuli, discussant Gianandrea Baldazzi); high vs low ligation of the inferior mesenteric artery in left colon and rectal surgery (Simona Giuratrabocchetta from the Bianchi group, discussant Marcello Gasparrini); ICG-guided lymphadenectomy of the colonic flexures and transverse colon (Caterina Foppa for the Spinelli group, discussant Gianluigi Moretto); and finally "sparing the rectum" in early cancers and good responders after neoadjuvant therapy (Gian Luca Baiocchi, discussant Marco Catarci).
The speakers discuss the oncologic rationale of CME and central vascular ligation, the emerging evidence from the RELARC trial and the Italian national study coordinated by De Giuli, the (still investigational) role of indocyanine green in colonic lymphadenectomy, the vascular anatomical variants of the right colon and flexures, the functional implications (genitourinary, defecatory) of high IMA ligation, preservation of the left colic artery, and the use of ICG to assess anastomotic perfusion. Particularly lively is the debate on ligation of the gastroepiploic vessels in right colon CME and on the Japanese concept of lymph flow vs lymph node mapping.
In the final part, Baiocchi presents two real clinical cases of rectal sparing: a malignant adenoma with R1 margins after piecemeal EMR in a young woman, and a T3b post-TNT with major clinical response, both managed with transanal local excision combined with laparoscopic ICG-guided lymph node sampling. Limits, medico-legal risks, strict follow-up, and the need for rescue surgery are discussed, with constructive criticism from Catarci and Arezzo on whether it would be preferable to retrieve lymph nodes via a transabdominal rather than transanal approach.
Topics
D2 vs D3/CME in right hemicolectomy
Oncologic rationale of central vascular ligation
RELARC trial and Italian national study on CME
Ligation of gastroepiploic vessels: pros and cons
Vascular anatomical variability of the right colon
High vs low ligation of the inferior mesenteric artery
Left colic artery preservation and genitourinary function
ICG assessment of anastomotic perfusion
ICG-guided lymphadenectomy of the colonic flexures
Lymph flow concept vs lymph node mapping
Non-fluorescent metastatic lymph nodes: a word of caution
Rectum sparing in early cancers and after TNT
Transanal local excision + lymph node sampling
Total neoadjuvant therapy and complete clinical response
Watch and wait vs local excision after neoadjuvant therapy
Tools used
Verde di indocianina (ICG)Sistema di imaging near-infraredRobot chirurgico (Da Vinci)Ago da spinale / ago da sollevamento polipo per iniezione endoscopicaEcografo endoanale e endorettaleTEM/TAMISSuturatrici meccanicheClip vascolariBipolare e energy device
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