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Laparoscopic Right Colectomy with Ileocolic Anastomosis

David W. Rattner, MD1; Joshua M. Harkins2
1Massachusetts General Hospital
2Lake Erie College of Osteopathic Medicine

Abstract

Colonic polyps are projections from the surface of the colonic mucosa. Most are asymptomatic and benign. Over time, some colonic polyps develop into cancers. Colorectal polyps are classified as non-neoplastic and neoplastic. Non-neoplastic polyps include hyperplastic, inflammatory, and hamartomatous polyps. They are typically harmless and do not become cancerous. Neoplastic polyps include adenomas and serrated polyps. They are premalignant lesions that may progress to colon cancer over time. In general, the larger the polyp, the greater the risk of cancer, especially with neoplastic polyps. Polyps are diagnosed using colonoscopy and are removed via polypectomy if they are small and pedunculated. If the polyps are too large or cannot be removed safely, they may be removed by colonic resection.

Carcinoid tumors develop from cells in the submucosa. They are slow-growing neoplasms. Carcinoid tumors of the colon are rare, comprising less than 11% of all carcinoid tumors and only 1% of colonic neoplasms. The majority of patients diagnosed with carcinoid tumors have no symptoms, and their tumors are found incidentally during endoscopy. Treatment of these tumors depends on the size, location, and presence of metastatic disease. Tumors less than 1 cm can often be excised locally either by endoscopy or for rectal lesions via a transanal approach. Carcinoid tumors larger than 2 cm require formal oncologic resection.

Here we present a middle-aged male who had an unresectable polyp in the ascending colon and a carcinoid tumor in the ileocecal valve. The patient underwent laparoscopic right colectomy with ileocolic anastomosis to remove both lesions.

Case Overview

Background

This patient underwent a laparoscopic right colectomy with ileocolic anastomosis as a curative procedure that removed both an unresectable polyp that was found in his ascending colon as well as a carcinoid tumor that was incidentally found at his ileocecal valve. In this case, the patient required surgery because the mass in his ascending colon was too large to be resected by endoscopic means, and carcinoid tumors of the ileocecal valve are also not suitable for endoscopic resection. This procedure allowed the patient to have both tumors removed in one surgery and required only one anastomotic connection between his small and large intestine, lowering the chance of postoperative complications. By doing this procedure with a laparoscopic approach the patient is able to have a shorter and easier recovery with a more cosmetic outcome. The surgeons were able to resect both of the patient’s abnormal growths because the patient’s colonic polyp was located in his ascending (right) colon, just distal to the ileocecal valve, and had a blood supply that originated from the same major blood vessel. This approach allowed the surgeon to resect both growths in the same operation and reconnect the patient’s small intestine to his remaining large intestine, eliminating the need for an ileostomy and helping the patient to retain much of his large intestine for normal functions. 

Focused History of the Patient

A middle-aged white male was found to have an unresectable polyp in his ascending colon on colonoscopy. Incidentally, on further work-up, the patient was found to have a carcinoid tumor at the ileocecal valve. Due to the nature of these two masses, a laparoscopic right colectomy with ileocolic anastomosis was performed.  

Physical Exam

Aside from the detection of occult blood on a digital rectal exam, the physical examination is usually not helpful in the diagnosis of colon cancer.

Imaging

Colon masses may be picked up on screening colonoscopies or incidentally on other abdominal imaging a patient may receive. However, when a colon mass is suspected or identified a further work-up should be performed including a CT chest, abdomen, and pelvis with both oral and IV contrast. This imaging modality allows for the estimation of the preoperative staging and helps determine the best surgical approach. This modality of imaging offers an accuracy of 73-83% for determining the T stage, a 59-71% for determining the N stage, and an 85-97% for determining the M stage of the disease.1

Natural History

Most colon cancers are asymptotic in their early stages, which is why the United States Preventive Services Task Force recommends all adults to begin screening colonoscopies at age 50 and continue them every 10 years if no pathology is found.2 A general rule of thumb is that colonic cancers located in the right (ascending) colon tend to slowly bleed leading to signs and symptoms of anemia including but not limited to fatigue, low energy, pallor, shortness of breath, and/or elevated heart rate. Colon cancers located in the left (descending) colon, sigmoid colon, or rectum tend to alter the diameter of a person’s stool as the mass narrows the lumen in which the stool passes.3 Carcinoid tumors tend to be completely asymptomatic until widespread metastasis has occurred. The neuroendocrine function of carcinoid tumors means that they produce hormones, mainly serotonin, a monoamine hormone. Since the venous blood supply from the gastrointestinal tract flows first into the liver through the portal system, excess serotonin produced from the tumor is broken down by the enzyme monoamine oxidase found in the liver and the patient remains asymptomatic. Once the carcinoid tumor has metastasized to or beyond the liver, excess serotonin can enter the circulation and leads to signs and symptoms referred to as Carcinoid Syndrome. These symptoms include diarrhea, cutaneous flushing, wheezing, and right-sided heart strain.

Colon cancers originate as either polyps or flat adenomatous lesions. The natural progression of colon cancer ranges from asymptomatic in early stages to complete obstruction and potential perforation in later stages. As a mass in the colon continues to grow it can grow into adjacent structures and/or into the lumen of the bowel leading to obstruction of bowel contents. Once enough tissue disruption has occurred due to cancer, patients may present with an acute abdomen due to perforation of the bowel.5

Options for Treatment

As stated above, small growths that arise in the colon can often be removed during the colonoscopy and be sent to pathology to confirm if the growth was cancerous or not, as well as if the mass was removed entirely. In this case, the patient’s colonic mass was too large to be removed during colonoscopy; therefore, he required surgical colonic resection. In addition, the patient was able to have his carcinoid tumor removed during the surgery before it had the chance to grow and metastasize to the rest of his body. Given the fact that this patient had both a large colonic polyp as well as a carcinoid tumor, his only option was to have his right colon and a small portion of terminal ileum removed. 

Rationale for Treatment

One goal for the treatment of this patient was to remove the two masses in question. By removing these masses in their entirety, a pathologist is able to study them in further detail and determine the extent of the patient’s disease. In addition, they are able to assess the lymph nodes that are resected within the mesentery of the specimen for any spread of the disease. The second goal of this procedure was to reconnect the patient’s small intestine to his remaining large intestine to avoid the creation of a diverting ileostomy. With the help of this, the patient was able to retain normal bowel functions including the absorptive function of the large intestine and the continence that comes with having a fully-connected gastrointestinal tract. This surgery was successful in removing the patient’s masses allowing for further analysis, which will help to determine if further treatment is necessary.5

Special Considerations

An adequate lymphadenectomy is critical for accurate staging of both adenocarcinomas and carcinoid tumors of the bowel. A minimum of 12 lymph nodes should be examined to achieve accurate staging.  In the case of carcinoid tumors, the primary lesion is often small and may even present with lymph node metastases. Hence a thorough lymphadenectomy is especially important in this patient.

Surgical Procedure

The goal of a surgical right colectomy in this patient is to remove the mass with at least 5-cm margins on both the proximal and distal ends of the mass and a 1 mm circumferential margin. In addition, the ideal resection for possible cancers is to remove 12 or more lymph nodes that are found within the mesocolon that is transected during the dissection process. To do this resection, the ileocolic vascular pedicle is identified, dissected, and transected near its origin. This allows access to the retroperitoneum. The mesentery is dissected away from the retroperitoneal tissue and duodenum and then the lesser sac is entered. This allows the division of the attachments of the hepatic flexure to occur to complete the mobilization of the entire right colon, hepatic flexure, and proximal transverse colon. After the mobilization and division of the vascular pedicle, a transversus abdominis plane nerve block is performed, and the colon is externalized through a periumbilical mini-laparotomy. The bowel is then resected, anastomosis created, and then returned to the abdomen. The procedure is completed by closing the mini-laparotomy.  

Discussion

This presentation of a colonic mass is unusual because it was located adjacent to a carcinoid tumor found at the ileocecal valve. Due to the proximity of these lesions and the fact that the colonic mass was too large to be removed by colonoscopy alone, the patient opted to undergo a right colectomy in which the ileocecal valve was also removed, and primary anastomosis was created between his remaining ileum and transverse colon. 

Large masses in the colon are presumed to be cancerous until proven otherwise and must be taken out for further pathological examination and to prevent further spread of disease. Colon cancer affects around 150,000 Americans per year, with approximately a third of patients dying as a result of the disease.6

While some advanced centers can offer endoscopic resection for low-grade tumors (i.e. carcinoma in situ in a sessile polyp),  it is not widely available, and the mainstay of treatment for patients with non-metastatic colon cancer is surgical resection. Neoadjuvant chemotherapy has no role in the primary treatment of localized colon cancers.

Many randomized clinical trials including the COLOR, CLASSIC, and COST trials have shown that laparoscopic-assisted colectomy surgery has the same outcome (69%) as open surgery (68%) in terms of 5-year survival. In addition, retrospectively it has been found that open surgery resections have a higher positive margin rate at 5.3% with a hazard ratio of 3.39, 95% CI 2.41 – 4.77.7 The usual length of hospitalization following laparoscopic right colectomy is 2-3 days. The use of enhanced recovery after surgery (ERAS) protocols has been an essential component of post-operative care, shortening hospital stay, and reducing complication rates. Most patients with node-negative colon cancer ( i.e. Stages I-II) are cured by surgery alone. Some patients with Stage II adenocarcinoma that has aggressive histologic features (such as lymphovascular invasion) may benefit from adjuvant chemotherapy. The risk/benefit ratio is such that decision making should be individualized. However, adjuvant chemotherapy is clearly indicated for those with Stage III tumors. Treatment of patients with isolated liver metastases needs to be individualized and should be discussed by a multidisciplinary tumor board to optimize treatment planning.8

Equipment

No special equipment used. 

Disclosures

Nothing to disclose. 

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

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  3. Recio-Boiles A, Cagir B. Cancer, colon. In: StatPearls [Internet}. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: http://www.ncbi.nlm.nih.gov/book/nbk470380/
  4. Ito T, Lee L, Jensen R. Carcinoid-syndrome: recent advances, current status, and controversies. Curr Opin Endocrinol Diabetes Obes. 2018 Feb; 25(1): 22-35.  https://doi.org/10.1097/med.0000000000000376
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  6. Jemal A, Siegel R, Ward E, et al. Cancer statistics. CA Cancer J Clin. 2007;57:43-46.  https://doi.org/10.3322/canjclin.57.1.43
  7. Yozgatli TK, Aytac E, Ozben V, Bayram O, Gurbuz B, Baca B, Balik E, Hamzaoglu I, Karahasanoglu T, Bugra D. Robotic complete mesocolic excision versus conventional laparoscopic hemicolectomy for right-sided colon cancer. J Laparoendosc Adv Surg Tech A. 2019 May;29(5):671-676.  https://doi.org/10.1089/lap.2018.0348
  8. Cascinu S, Poli D, Zaniboni A, Lonardi S, Labianca R, Sobrero A, Rosati G, Di Bartolomero M, Scartozzi M, Zagonel V, Pella N, Banzi M, Torri V. The prognostic impact of primary tumor location in patients with stage II and stage III colon cancer receiving adjuvant therapy. A GISCAD analysis from three large randomized trials. Eur. J. Cancer. 2019 Apr; 111:1-7. https://doi.org/10.1016/j.ejca.2019.01.020