Bowel Motility After Injury to the Superior Mesenteric Plexus During D3 Extended Mesenterectomy

Thorsen, Yngve; Štimec, Bojan; Lindstrøm, Jonas Christoffer; Nesgaard, Jens Marius; Øresland, Tom; Ignjatović, Dejan

doi:10.1016/j.jss.2019.02.004

Cited by 11 publications

(11 citation statements)

References 22 publications

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“…of the D3-patients had one or more JA [1][2][3][4][5] arising proximal to the root of the middle colic artery (cranial to the D3 area). The regression analysis revealed significantly lower scores for DAS, stool frequency, stool consistency, and stool urgency in patients with at least one artery proximal to the D3 area when compared to the patients without such an artery (see Table 4 DAS questions and scoring: Stool frequency: 0: 0-1 stool/day, 1: 2 stools/day, 2: 3 stools/day, 3: 4 or more stools/day; Bowel consistency: 0: all stools formed, 1: stools formed and loose, 2: stools loose, 3: watery stools; bowel urgency: 0: no urgency, 1: somewhat urgent, 2: urgent 3: very urgent; abdominal discomfort: 0: no discomfort, 1: mild-moderate, 2: somewhat severe, 3: very severe discomfort.…”

Section: First Interviewmentioning

confidence: 99%

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The effect of vascular anatomy and gender on bowel function after right colectomy with extended D3-mesenterectomy

Thorsen¹,

Štimec²,

Lindstrøm³

et al. 2019

Ann. Laparosc. Endosc. Surg

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Background: Extended D3-mesenterectomy for right-sided colon cancer, removes all tissue around the superior mesenteric vessels beneath pancreas leading to transection of superior mesenteric plexus. In a previous study, the denervation was associated with 0.48 more stools/day. The study aims are to examine how presence of arterial branches proximal to the dissection area, gender and prolonged observation time after surgery affect bowel function following denervation. Methods: The study compares bowel function and Quality of Life in two groups undergoing right colectomy with extended D3-mesenterectomy and traditional D2-mesenterectomy. For further comparison, the denervated group was divided into groups with and without arterial branches arising proximal to the denervation. Instruments used were Gastrointestinal Quality of Life Index (0-144; 144= best) (GIQLI), Diarrhea Assessment Scale (0-12; 0= best) (DAS) and 3 additional questions (Ability to postpone defecation, night defecation, degree of distress). A second interview with prolonged observation time was performed for patients with abnormal bowel habits, defined as a) having 4 or more stools/day or b) being much or very much bothered. Results: Eighty-three D3-patients and 61 D2-patients, comparable for age and sex with shorter follow-up in the D3-group. In the D3-group 67 patients (80.7%) had one or more arteries proximal to the denervation. Sixteen patients (19.3%) had no proximal arteries. Regression analysis (correcting for confounding factors) revealed 0.30 (P=0.012) lower consistency score (increased consistency) and 0.27 (P=0.096) fewer stools/day in the D2-than the D3-group. DAS subscores, DAS, GIQLI and GIQLI-subscales revealed no differences between the groups. Within the D3-group, the estimated differences between patients with and without proximal arteries (adjusted for age, gender and time between surgery and interview) were significant for DAS and subscores; DAS: −1.526 (P=0.012), stool frequency: −0.653 (P=0.007), stool consistency: −0.432 (P=0.054), stool urgency: −0.595 (0.009). Negative scores represent lower (better) scores in the group with proximal arteries. GIQLI scores and subscales showed no difference. When genders were compared separately, the T-test revealed significantly lower (better) DAS and subscores for D2-females than D3-females, a difference not found in the male group. When controlled for observation time and age (regression) the difference disappears. A second interview with prolonged observation time (1. interview: 15.1 months, 2. interview: 56.4 months) for patients with abnormal bowel function reveals reduced (better) Extended DAS score (DAS + additional questions) in 8 of the 10 patients interviewed. 7 had no longer abnormal bowel function. Conclusions: D3-patients without arteries proximal to the nerve transection have significantly higher (worse) DAS-scores and subscores. The allover difference between the D2 and the D3 patients is small and only significant for consistency. Normalizing of the bowel function takes longe...

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Section: First Interviewmentioning

confidence: 99%

“…Surgeons have now developed a technique to safely remove all the tissue-including the lymph nodes-around the superior mesenteric vessels up to the pancreatic notch without injuring the blood vessels (2). As a consequence of this extensive mesenterectomy, the superior mesenteric nerve plexus (SMP) at this level is transected (3).…”

Section: Introductionmentioning

confidence: 99%

The effect of vascular anatomy and gender on bowel function after right colectomy with extended D3-mesenterectomy

Thorsen¹,

Štimec²,

Lindstrøm³

et al. 2019

Ann. Laparosc. Endosc. Surg

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“…These modulations can change the absorptive and secreting functions within a few days [14]. The early improvement is probably a result of this adaptation, adjusting for the significantly reduced postoperative transit time documented in the study with the WMC [6]. Previous animal studies have shown that the ability to adapt absorptive and morphometric remains after extrinsic denervation [15,16].…”

Section: Discussion/conclusionmentioning

confidence: 67%

“…Two studies concerning bowel function (BF) and quality of life (QoL) after extended D3-mesenterectomy report excellent long-term results [4,5]. A study with wireless motility capsules (WMC) revealed a significantly reduced small bowel transit time 3 weeks after surgery [6]. The clinical correlation to this early postoperative finding is not studied.…”

Section: Introductionmentioning

confidence: 99%

Stool dynamics after extrinsic nerve injury during right colectomy with extended D3-mesenterectomy

Thorsen

Štimec

Lindstrøm

et al. 2021

Scandinavian Journal of Gastroenterology

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Introduction: To improve oncological outcome in right colon cancer surgery, an extended mesenterectomy (D3) is under evaluation. In this procedure, all tissue anterior and posterior to the superior mesenteric vessels from the middle colic to ileocolic artery origin is removed, causing injury to the superior mesenteric nerve plexus. The aim was to study the effects of this injury on bowel dynamics and quality of life (QoL). Methods: Patients undergoing right colectomy with conventional D2-and extended D3-mesenterectomy were asked to record stool number and consistency for 60 d after surgery and complete questionnaires regarding QoL and bowel function (BF) before and after recovery from surgery. We compared early postoperative stool dynamics and long-term QoL in the groups and presented graphs depicting the temporal profile of stool numbers and consistency. Results: Thirty-three patients operated with a D3-resection and 12 patients with a D2-resection participated. The results revealed significantly higher stool numbers in the D3-group until day 26, with significantly more loose-watery stools until day 40. The most pronounced difference was found on day 9 (Mean difference in the total number of stools: 2.25 stools/day, p¼.004. Mean difference in loosewatery stools/day: 2.81 p<.001). About 25% in the D2-and 69.7% in the D3-group reported having more than three stools/day in the early postoperative phase. There were no differences in long-term QoL and BF between the groups except in stool consistency (p¼.039). Discussion/conclusions: Denervation following extended D3-mesenterectomy leads to transitory reduced consistency and increased frequency. It does not affect long-term QoL or BF.

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“…Given the diversity of the postoperative bowel symptoms, the causes of bowel function problems following surgery for colon cancer are probably multifactorial. One factor that has been postulated to reduce sensory and motor functions of the colon is traction and iatrogenic injury to the colonic vascularization and/or innervation that may occur during mobilization of the colon [42,56]. This might be supported by the high number of constipation-associated symptoms that were shown in this systematic review.…”

Section: Discussionmentioning

confidence: 77%

Functional outcomes of surgery for colon cancer: A systematic review and meta-analysis

Verkuijl

Jonker

Trzpis

et al. 2021

European Journal of Surgical Oncology

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Introduction: As survival rates of colon cancer increase, knowledge about functional outcomes is becoming ever more important. The primary aim of this systematic review and meta-analysis was to quantify functional outcomes after surgery for colon cancer. Secondly, we aimed to determine the effect of time to follow-up and type of colectomy on postoperative functional outcomes. Materials and methods: A systematic literature search was performed to identify studies reporting bowel function following surgery for colon cancer. Outcome parameters were bowel function scores and/or prevalence of bowel symptoms. Additionally, the effect of time to follow-up and type of resection was analyzed. Results: In total 26 studies were included, describing bowel function between 3 to 178 months following right hemicolectomy (n ¼ 4207), left hemicolectomy/sigmoid colon resection (n ¼ 4211), and subtotal/ total colectomy (n ¼ 161). In 16 studies (61.5%) a bowel function score was used. Pooled prevalence for liquid and solid stool incontinence was 24.1% and 6.9%, respectively. The most prevalent constipationassociated symptoms were incomplete evacuation and obstructive, difficult emptying (33.3% and 31.4%, respectively). Major Low Anterior Resection Syndrome was present in 21.1%. No differences between time to follow-up or type of colectomy were found. Conclusion: Bowel function problems following surgery for colon cancer are common, show no improvement over time and do not depend on the type of colectomy. Apart from fecal incontinence, constipation-associated symptoms are also highly prevalent. Therefore, more attention should be paid to all possible aspects of bowel dysfunction following surgery for colon cancer and targeted treatment should commence promptly.

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Bowel Motility After Injury to the Superior Mesenteric Plexus During D3 Extended Mesenterectomy

Cited by 11 publications

References 22 publications

The effect of vascular anatomy and gender on bowel function after right colectomy with extended D3-mesenterectomy

The effect of vascular anatomy and gender on bowel function after right colectomy with extended D3-mesenterectomy

Stool dynamics after extrinsic nerve injury during right colectomy with extended D3-mesenterectomy

Functional outcomes of surgery for colon cancer: A systematic review and meta-analysis

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