Abstract
Background:
Minimally invasive surgery for T4 colon cancer with adjacent organ involvement remains controversial and has traditionally been considered a relative contraindication, with such cases excluded from major randomized trials. Concerns include tumor handling, risk of peritoneal dissemination, and achieving negative circumferential resection margins. However, emerging evidence suggests comparable oncological outcomes in carefully selected patients when strict oncological principles are followed.
Case Presentation:
We present a 60-year-old female with altered bowel habits and abdominal pain. Colonoscopy revealed an ulceroproliferative growth at the rectosigmoid junction with the scope not negotiated proximally, and biopsy confirmed moderately differentiated adenocarcinoma. Baseline serum carcinoembryonic antigen (CEA) was 3.5 ng/mL. Contrast-enhanced computed tomography (CT) demonstrated a locally advanced rectosigmoid tumor with direct invasion of adjacent small bowel loops (cT4b), without evidence of bowel obstruction. Following a multidisciplinary team discussion, the patient was planned for curative minimally invasive en bloc resection. Staging laparoscopy confirmed the absence of peritoneal metastases or ascites. Intraoperatively, the tumor involved two small bowel segments, approximately 20 cm distal to the duodenojejunal flexure and 40 cm proximal to the ileocecal junction, and a laparoscopic en bloc anterior resection with segmental small bowel resections was performed to achieve an R0 resection.
Surgical Technique:
A five-port laparoscopic approach was utilized. To minimize tumor handling, a combined medial-to-lateral and lateral-to-medial dissection strategy was employed. Dense desmoplastic reaction around the tumor necessitated careful and meticulous dissection. The involved small bowel loops were deliberately left attached to the primary tumor, and no attempt was made to separate them, ensuring an oncologically sound en bloc resection. Inferior mesenteric vessel ligation, complete lymphadenectomy, and splenic flexure mobilization were performed. The specimen was extracted via a protected incision, followed by jejunal anastomosis, ileal stoma formation, and stapled colorectal anastomosis.
Results:
Histopathology confirmed a pT4bN+ adenocarcinoma with negative circumferential resection margins (R0 resection). The postoperative course was uneventful, and the patient completed adjuvant chemotherapy. Ileostomy was reversed at 3 months post-chemotherapy. At both 6- and 12-month follow-ups, she remained clinically disease free. Surveillance CEA was 2.5 ng/mL, and follow-up contrast-enhanced CT scans demonstrated no evidence of local recurrence or distant metastasis.
Conclusions:
Laparoscopic en bloc resection for selected T4 colon cancers is feasible and oncologically safe when principles such as minimal tumor handling, avoidance of tumor breach, and complete en bloc resection are strictly adhered to.
No competing financial interests exist.
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
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