Laparoscopic resection with intracorporeal anastomosis for colon carcinoma located in the splenic flexure

Minimally invasive left colectomy with total intracorporeal anastomosis versus extracorporeal anastomosis. A single center cohort study. Stage 2b IDEAL framework for evaluating surgical innovation

PURPOSE

Performing intracorporeal anastomoses in minimally invasive colon surgery appears to provide better short-term outcomes for patients with colon cancer. The aim of the study is to compare surgical aspects and short-term outcomes between intracorporeal and extracorporeal techniques in left colectomies with both laparoscopic and robotic approaches and evaluate advantages and disadvantages of intracorporeal anastomosis according to IDEAL framework (Exploration, stage 2b).

METHODS

This is a single center, ambispective cohort study comparing total intracorporeal anastomosis (TIA) and standard surgery with extracorporeal anastomosis (EA). Patients with colon cancer treated by left colectomy, sigmoidectomy and high anterior resection by total intracorporeal anastomosis between May 2020 and January 2023 without exclusion criteria were prospectively included in a standardized database. Short-term outcomes in the group undergoing TIA were compared with a historical EA cohort. The main assessment outcomes were intraoperative complications, postoperative morbidity according to the Clavien-Dindo scale and the comparison of pathological. We conducted a preliminary comparative study within the TIA group between approaches, a primary analysis between the two anastomotic techniques, and a propensity score matched analysis including only the laparoscopic approach, between both anastomotic techniques.

RESULTS

Two hundred and forty-six patients were included: 103 who underwent TIA, 35 of them with laparoscopic approach and 68 with robotic approach, and a comparison group comprising another 103 eligible consecutive patients who underwent laparoscopic EA. There were no statistically significant differences between the two groups in terms of demographic variables. No statistically significant differences were observed in anastomotic dehiscence. Intraoperative complications are fewer in the TIA group, with a higher C-Reactive Protein levels. Relevant anastomotic bleeding and the number of retrieved lymph nodes were higher in EA group. Nevertheless, no differences were observed in terms of overall morbidity.

CONCLUSION

Minimally invasive left colectomy with intracorporeal resection and anastomosis is technically feasible and safe suing either a laparoscopic or a robotic approach. Clinical data from this cohort demonstrate outcomes comparable to those achieved through the conventional EA procedure in relation to postoperative morbidity and oncological efficacy, with indications suggesting that the utilization of robotic-assisted techniques may play a contributing role in enhancing overall treatment outcomes.

Short-term and long-term outcomes of intracorporeal anastomosis in laparoscopic segmental left colectomy for splenic flexure cancer - a multicenter retrospective cohort study of 342 cases

INTRODUCTION

While intracorporeal anastomosis (IA) has been widely used in totally laparoscopic right colectomy, its application in laparoscopic segmental left colectomy for splenic flexure cancer remains underexplored, particularly in large-scale studies with long-term outcomes. This research aims to assess the technical feasibility and oncological efficacy of IA in treating colonic splenic flexure carcinoma, drawing insights from both short-term and long-term outcomes of a retrospective cohort.

MATERIALS AND METHODS

A retrospective analysis was conducted on 342 patients diagnosed with colonic splenic flexure carcinoma in three Chinese medical centers. These patients underwent laparoscopic segmental left colectomy between December 2014 and December 2019 across three medical institutions. Comprehensive data encompassing demographics, disease features, pathological characteristics, operative details, and both short-term and long-term outcomes were gathered and scrutinized. Using propensity scores, each patient from the IA cohort was paired with a counterpart from the extracorporeal anastomosis (EA) cohort.

RESULTS

IA was performed on 129 patients, while 213 underwent EA. Post-propensity score matching resulted in 129 matched pairs. After matching, many baseline characteristics were balanced. The IA cohort exhibited several advantages, including shorter incision lengths ( P <0.001) and more extensive proximal and distal resection margins ( P =0.003, P <0.001). Additionally, the IA method facilitated a more rapid postoperative recovery as indicated by quicker return of bowel movements (resumption of passing flatus [2.7 (1.0-7.0) days vs. 3.3 (2.0-8.0) days, P <0.001] and defecation [3.7 (1.0-9.0)] days vs. 4.5 (2.0-9.0) days, P <0.001]), faster discharges [6.6 (3.0-15.0) days vs. 8.3 (5.0-20.0) days, P <0.001], and decreased need for rescue analgesics ( P <0.001). The rate of postoperative complications, as rated by the Clavien-Dindo classification, remained consistent across both techniques ( P =0.087). Furthermore, the cosmetic outcome rated by Patient Scar Assessment Questionnaire and Scoring System (PSAQ) was markedly superior in the IA group ( P <0.001). Both approaches demonstrated equivalent 5-year overall (82.7% vs. 82.1%, P =0.419) and disease-free survival (80.9% vs. 78.1%, P =0.476). Subsequent stratification analysis revealed that IA achieved comparable 5-year overall (80.7% vs. 82.0%, P =0.647) and disease-free survival (78.1% vs. 76.4%, P =0.734) in patients with locally advanced colon cancer.

CONCLUSION

Employing IA for laparoscopic segmental left colectomy in cases of splenic flexure carcinoma is not only safe but also offers enhanced cosmetic results and expedited postoperative recovery. Oncologically speaking, IA in left segmental colectomy for splenic flexure carcinoma can yield therapeutic outcomes comparable to those of EA, even in patients with locally advanced colon cancer.

Short-term outcomes following intracorporeal vs. extracorporeal anastomosis after laparoscopic right and left-sided colectomy: a propensity score-matched study

BACKGROUND

To compare the short-term outcomes of patients undergoing intracorporeal anastomosis (IA) during laparoscopic colectomy to those undergoing extracorporeal anastomosis (EA).

METHODS AND MATERIALS

The study was a single-centre retrospective propensity score-matched analysis conducted. Consecutive patients who underwent elective laparoscopic colectomy without the double stapling technique between January 2018 and June 2021 were investigated. The main outcome was overall postoperative complications within 30 days after the procedure. The authors also performed a sub-analysis of the postoperative results of ileocolic anastomosis and colocolic anastomosis, respectively.

RESULTS

A total of 283 patients were initially extracted; after propensity score matching, there were 113 patients in each of the IA and EA groups. There were no differences in patient characteristics between the two groups. The IA group had a significantly longer operative time than the EA group (208 vs. 183 min, P =0.001). The rate of overall postoperative complications was significantly lower in the IA group ( n =18, 15.9%) than in the EA group ( n =34, 30.1%; P =0.02), especially in colocolic anastomosis after left-sided colectomy (IA: 23.8% vs. EA: 59.1%; P =0.03). Postoperative inflammatory marker levels were significantly higher in the IA group on postoperative day 1 but not on postoperative day 7. There was no difference in the postoperative lengths of hospital stay between the two groups, and no deaths occurred.

CONCLUSION

The data suggest that performing IA during laparoscopic colectomy can potentially reduce the risk of postoperative complications, especially in colocolic anastomosis after left-sided colectomy.

Laparoscopic and robotic intracorporeal resection and end-to-end anastomosis in left colectomy: a prospective cohort study - stage 2a IDEAL framework for evaluating surgical innovation

PURPOSE

To analyze the safety and feasibility of intracorporeal resection and anastomosis in upper rectum, sigmoid, and left colon surgery, via both laparoscopic and robotic approaches. The secondary aim was to assess possible short-term differences between laparoscopic versus robotic surgery.

METHODS

A prospective observational cohort study according to IDEAL framework exploration and assessment stage (Development, stage 2a), evaluating and comparing the laparoscopic approach and the robotic approach in left colon, sigmoid, and upper rectum surgery with intracorporeal resection and end-to-end anastomosis. Demographic, preoperative, surgical, and postoperative variables of patients undergoing laparoscopic and robotic surgery are described and compared according to the surgical technique used.

RESULTS

Between May 2020 and March 2022, seventy-nine patients were consecutively included in the study, 41 operated via laparoscopy (laparoscopic left colectomy: LLC) and 38 by robotic surgery (robotic left colectomy: RLC). There were no statistically significant differences between the two groups in terms of demographic variables. In surgical variables, the median surgical times differed significantly: 198 min (SD 48 min) for LLC vs. 246 min (SD 72 min) for RLC (p = 0.01, 95% CI: - 75.2 to - 20.5)). The only significant difference regarding postoperative complications was a higher degree of relevant morbidity in the LLC (Clavien-Dindo > II (14.6% vs. 0%, p = 0.03) and Comprehensive Complication Index (IQR 22 vs. IQR 0, p = 0.03). The pathological results were similar in both approaches.

CONCLUSION

Laparoscopic and robotic intracorporeal resection and anastomosis are feasible and safe, and obtain similar surgical, postoperative, and pathological results than described in literature. However, morbidity seems to be higher in LLC group with fewer relevant postoperative complications. The results of this study enable us to proceed to stage 2b of the IDEAL framework.

CLINICAL TRIAL REGISTRATIONS

The study is registered in Clinical trials with the registration code NCT0445693.

European multicenter propensity score match study of laparoscopic vs. open colectomy for splenic flexure carcinomas: Results from the Splenic Flexure Cancer (SFC) Study Group

AIM OF THE STUDY

This European multicenter study aims to compare the results of laparoscopic versus laparotomy approach for the resection of splenic flexure colon carcinoma (SFC).

PATIENTS AND METHODS

Patients with SFC who required curative resection by laparoscopy (LAP) or laparotomy (OPEN) between 2000 and 2018 were included. Three types of interventions were considered: extended right hemi-colectomy, left hemi-colectomy and splenic flexure resection. The LAP and OPEN groups were matched according to propensity score and compared with Chi-square, Mann-Whitney tests, and multivariate regression models. Overall survival and recurrence-free survival were assessed using the Kaplan-Meier method.

RESULTS

The study population consisted of 399 patients, including 297 operated by LAP and 102 by OPEN. Extended right hemi-colectomy was performed in 35.8% of cases, left hemi-colectomy in 32.8% and splenic flexure resection in 31.4%. After propensity score matching, the LAP (n=64) and OPEN (n=64) groups were comparable for all pre-operative variables and tumor characteristics. The LAP group showed less blood loss and a shorter interval to return of transit and feeding compared to the OPEN group, regardless of the resection technique. There were no differences between the groups in terms of overall survival and 5-year recurrence-free survival.

CONCLUSION

These results support the application of laparoscopy for the resection of SFC.

Laparoscopic versus open surgery for left flexure colon cancer: A propensity score matched analysis from an international cohort

AIM

Surgical treatment of splenic flexure cancer (SFC) still presents some debated issues, including the role of laparoscopic surgery. The literature is based on small single-centre series, while randomized controlled studies comparing open and laparoscopic treatment for colon cancer exclude SFC. This study aimed to determine the role of laparoscopic surgery in the treatment of SFC, comparing short- and long-term outcomes with open surgery.

METHOD

This was an international multicentre retrospective cohort study that analysed patients from 10 tertiary referral centres. From a cohort of 641 cases, 484 patients with Stage I-III SFC submitted to elective surgery with curative intent were selected. After 1:1 propensity score matching, 130 patients in the laparoscopic group (LapGroup) were compared with 130 patients in the open surgery group (OpenGroup).

RESULTS

After propensity score matching, the two groups were comparable for demographic and clinical parameters. OpenGroup presented a higher incidence of overall (P = 0.02) and surgery-related complications (P = 0.05) but a similar rate of severe complications (P = 0.75). Length of stay was notably shorter in the LapGroup (P = 0.001). Overall (P = 0.793) as well as cancer-specific survival (P = 0.63) did not differ between the two groups.

CONCLUSIONS

Elective laparoscopic surgery for Stage I-III SFC is feasible and associated with improved short-term postoperative outcomes compared to open surgery. Moreover, laparoscopic surgery appears to provide excellent long-term cancer outcomes.

Surgical management of splenic flexure colon cancer: a retrospective propensity-matched study comparing open and minimally invasive approaches using the national cancer database

PURPOSE

Minimally invasive resection of colon cancer at the splenic flexure can be technically challenging with concerns for a suboptimal oncologic outcome. We aimed to compare open and minimally invasive approaches following curative resection.

METHODS

The National Cancer Database was queried for patients with non-metastatic colon adenocarcinoma at the splenic flexure who underwent resection from 2010 to 2016. Cohorts were separated into open and minimally invasive approaches, and demographic and clinicopathologic variables were compared. Propensity-score matching (PSM) was utilized to balance potential confounding covariates between cohorts to elucidate the independent association between surgical approach and outcomes. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival. Secondary outcomes were analyzed by way of logistic regression or Mann-Whitney U test.

RESULTS

After matching, 842 patients were compared between approaches. Patients who underwent minimally invasive surgery had no significant difference in regional nodes ≥ 12 examined, positive margins, negative circumferential margins, unplanned 30-day readmission, or time from surgery to initiation of chemotherapy when compared to patients who underwent open surgery. Minimally invasive surgery was significantly associated with decreased odds of 30-day mortality, 90-day mortality, and decreased mortality hazard for 5-year overall survival compared to open surgery.

CONCLUSION

The optimal approach for surgical management of splenic flexure colon cancer has not been standardized given its rarity and exclusion from randomized controlled trials. Our retrospective review suggests that minimally invasive resection of splenic flexure colon cancers in carefully selected patients is associated with equivalent oncologic outcomes as well as improved short and long-term survival compared to an open approach.

Minimal invasive surgery for left colectomy adapted to the COVID-19 pandemic: laparoscopic intracorporeal resection and anastomosis, a 'don't touch the bowel' technique

AIM

The COVID-19 pandemic has forced surgeons to adapt their standard procedures. The modifications introduced are designed to favour minimally invasive surgery. The positive results obtained with intracorporeal resection and anastomosis in the right colon and rectum prompt us to adapt these procedures to the left colon. We describe a 'don't touch the bowel' technique and outline the benefits to patients of the use of less surgically aggressive techniques and also to surgeons in terms of the lower emission of aerosols that might transmit the COVID-19 infection.

METHODS

This was an observational study of intracorporeal resection and anastomosis in left colectomy. We describe the technical details of intracorporeal resection, end-to-end stapled anastomosis and extraction of the specimen through mini-laparotomy in the ideal location.

RESULTS

We present preliminary results of 17 patients with left-sided colonic pathologies, 15 neoplasia and two diverticular disease, who underwent four left hemicolectomies, six sigmoidectomies and seven high anterior resections. Median operating time was 186 min (range 120-280). No patient required conversion to extracorporeal laparoscopy or open surgery. Median hospital stay was 4.7 days (range 3-12 days). There was one case of anastomotic leak managed with conservative treatment.

CONCLUSION

Intracorporeal resection and end-to-end anastomosis with the possibility of extraction of the specimen by a mini-laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID-19 pandemic. Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis.

Extended right colectomy, left colectomy, or segmental left colectomy for splenic flexure carcinomas: a European multicenter propensity score matching analysis

BACKGROUND

The surgical resection of the splenic flexure carcinoma (SFC) is challenging and the optimal surgical procedure for SFCs remains a matter of debate. The present study aimed to compare in a multicenter European sample of patients the short- and long-term outcomes of extended right (ERC) vs. left (LC) vs. segmental left colectomy (SLC) for SFCs.

METHODS

This retrospective multicenter study analyzed the surgical and oncological outcomes of SFC patients undergoing elective curative intent surgery between 2000 and 2018. Descriptive and exploratory analyses were first conducted on the whole sample. Outcomes of the different procedures (ERC vs. LC vs. SLC) were then compared using propensity score matching for multilevel treatment. Overall (OS) and disease-free survival (DFS) were evaluated by Kaplan-Meier method.

RESULTS

From a total of 399 SFC patients, 143 (35.8%) underwent ERC, 131 (32.8%) underwent LC, and 125 (31.4%) underwent SLC. Overall, 297 (74.4%) were laparoscopic procedures. An increase in operative time, time to flatus, time to regular diet, and hospital stay was observed with the progressive extension of SFC resection. ERC was associated with significantly increased risk of postoperative ileus compared to both LC and SLC. A significantly greater number of lymph nodes were retrieved by ERC, but the objective of at least 12 retrieved lymph nodes was achieved in 85% of patients, without procedure-related differences. No differences were observed in OS or DFS between ERC, LC, and SLC.

CONCLUSION

The present study supports the resection of SFCs by colon-sparing surgical techniques, such as SLC.

Segmental Colonic Resection Is a Safe and Effective Treatment Option for Colon Cancer of the Splenic Flexure: A Nationwide Retrospective Study of the Italian Society of Surgical Oncology-Colorectal Cancer Network Collaborative Group

BACKGROUND

Global experience with splenic flexure cancer is limited because of its low incidence. Both limited (segmental) and extended resections are performed, because agreement on which is the adequate procedure has not been reached.

OBJECTIVE

The purpose of this study was to investigate whether segmental resection is as safe and effective as extended resection.

DESIGN

This nationwide retrospective cohort study included all consecutive resections of splenic flecure cancer between January 2006 and December 2016 using data from the National Colorectal Cancer Network of the Italian Society of Surgical Oncology following the guidelines set out in the STROBE statement.

SETTING

Data were obtained for 31 Italian Referral Centers for Colorectal Surgery.

PATIENTS

A total of 1304 patients were submitted to resection of the splenic flexure (n = 791, 60.7%) or extended procedures (extended right and left colectomies; n = 513, 39.3%).

MAIN OUTCOME MEASURES

We evaluated Clavien-Dindo ≥3 postoperative complications and oncological (number of lymph nodes removed, length of free proximal and distal margins, rate of R0 resections) and survival outcomes.

RESULTS

The 2 arms were well balanced in regard to sex, BMI, ASA and Eastern Cooperative Oncology Group scores, and disease stage. Limited resection was performed more frequently using a minimally invasive approach (62.1% vs 50.9%, p < 0.001) and with shorter operation times than extended procedures (165 vs 189 minutes, p < 0.001), but the same Clavien-Dindo ≥3 postoperative complications (6.44% vs 6.43%, p = 0.99), 30-day mortality (0.63% vs 0.38%), oncological outcomes, and survival rates (5-year overall survival 0.84 vs 0.83, 5-year progression-free survival 0.85 vs 0.84).

LIMITATIONS

There are limitations inherent to the retrospective nature of the study and a potential lack of consistency in treatment across centers over time. Indications as to why a specific operation was chosen were based mostly on surgeons' beliefs.

CONCLUSIONS

Segmental resection is a safe and effective treatment option for cancer of the splenic flexure. See Video Abstract at http://links.lww.com/DCR/B307. LA RESECCIÓN DE COLON SEGMENTARIA ES UNA OPCIÓN DE TRATAMIENTO SEGURA Y EFICAZ PARA EL CÁNCER DE COLON DE LA FLEXIÓN ESPLÉNICA: UN ESTUDIO RETROSPECTIVO A NIVEL NACIONAL DE LA SOCIEDAD ITALIANA DE ONCOLOGÍA QUIRÚRGICA - GRUPO COLABORATIVO RED DE CÁNCER COLORRECTAL: La experiencia global con el cáncer de flexión esplénica es limitada debido a su baja incidencia. Se realizan resecciones limitadas (segmentarias) y extendidas, ya que no se ha llegado a un acuerdo sobre cuál es el procedimiento adecuado.El propósito de este estudio fue investigar si la resección segmentaria es tan segura y efectiva como la resección extendida.Este estudio de cohorte retrospectivo a nivel nacional incluyó todas las resecciones consecutivas de cáncer de flecura esplénica entre enero de 2006 y diciembre de 2016 utilizando datos de la Red Nacional de Cáncer Colorrectal de la Sociedad Italiana de Oncología Quirúrgica siguiendo las pautas establecidas en la declaración STROBE.Se obtuvieron datos para 31 centros de referencia italianos para cirugía colorrectal.Un total de 1304 pacientes fueron sometidos a resección de la flexión esplénica (n = 791, 60.7%) o procedimientos extendidos (colectomías extendidas derecha e izquierda; n = 513, 39.3%).Evaluamos Clavien-Dindo ≥3 complicaciones postoperatorias y oncológicas (número de ganglios linfáticos extirpados, longitud de márgenes proximales y distales libres, tasa de resecciones R0) y resultados de supervivencia.Los dos brazos estaban bien equilibrados en cuanto a sexo, IMC, ASA y puntajes ECOG, y etapa de la enfermedad. La resección limitada se realizó con mayor frecuencia utilizando un enfoque mínimamente invasivo (62.1% versus 50,9%, p < 0.001) y con tiempos de operación más cortos que los procedimientos extendidos (165 min versus 189 min, p <0.001), pero el mismo Clavien-Dindo ≥3 complicaciones postoperatorias (6,44% versus 6,43%, p = 0.99), mortalidad a los 30 días (0,63% versus 0,38%), resultados oncológicos y tasas de supervivencia (5-y OS 0,84 versus 0,83, 5-PFS 0,85 versus 0,84).Existen limitaciones inherentes a la naturaleza retrospectiva del estudio y una posible falta de consistencia en el tratamiento entre centros a lo largo del tiempo. Las indicaciones de por qué se eligió una operación específica se basaron principalmente en crieterios de los cirujanos.La resección segmentaria es una opción de tratamiento segura y efectiva para el cáncer de la flexión esplénica. Consulte Video Resumen en http://links.lww.com/DCR/B307. (Traducción-Dr. Adrian Ortega).

Laparoscopic resection with complete mesocolic excision for splenic flexure cancer: long-term follow-up data from a multicenter retrospective study

BACKGROUND

Splenic flexure cancer (SFC), identified as tumors raised in the distal transverse colon and proximal descending colon, accounts for 2 to 5% of all surgically treated colorectal cancers. Despite the fact that the laparoscopic approach has become the gold standard for many colorectal procedures, it has never been extensively investigated in SFC due to lack of an agreed consensus on the appropriate operative procedure. The aim of this multicenter retrospective study is to evaluate the oncologic value of laparoscopic segmental resection with complete mesocolic excision (CME) for cancer located in the splenic flexure.

METHODS

All data of consecutive patients who had undergone laparoscopic resection with CME for SFC from January 2005 to December 2017 at five different tertiary centers were retrospectively analyzed. The Kaplan-Meier (KM) test was used to assess the overall survival (OS) and the disease-free survival (DFS) rates after surgery. Univariate Cox regression was used to explore the association between OS and other independent factors.

RESULTS

Recurrence was observed in 13 (11.6%) patients and a significant association between disease stage and recurrence (P < 0.001) was found with a higher proportion of stage IV patients in the recurrence group (46.1% vs. 7.1%). During a median follow-up of 43 months (range 12-149), 13 deaths occurred, all of them due to disease progression. KM curves for all stages showed an estimated survival rate of 51% at 148 months.

CONCLUSION

Laparoscopic segmental resection with CME appears to be an oncologically safe and effective procedure for treatment of SFC and may be considered as a standard surgical method for elective management of the disease. In the future, routine lymph node mapping could be used to confirm this hypothesis.

Intracorporeal hemi-hand-sewn technique for end-to-end anastomosis in laparoscopic left-side colectomy

BACKGROUND

Recently, complete laparoscopic procedures with intracorporeal reconstruction were performed in laparoscopic colectomies; however, they were scarcely reported in left-side colectomies because of the anatomical reasons. Since the descending colon is extensively fixed to the retroperitoneum, the dissection range required for resection cannot always be enough for a safe extracorporeal anastomosis. We devised an intracorporeal hemi-hand-sewn (IC-HHS) technique for end-to-end anastomosis in laparoscopic left-side colectomies.

MATERIALS AND METHODS

A total of 11 patients underwent IC-HHS anastomosis for the treatment of colon cancer around the sigmoid-descending (SD) junction. The posterior wall of the anastomosis was constructed with a linear stapler and subsequently, the anterior wall was sutured with an intracorporeal hand-sewn technique. Perioperative outcomes were evaluated.

RESULTS

IC-HHS reconstruction between the descending colon and sigmoid colon was performed in 11 cases. There were six males and five females with an average age of 66.5 years. The average body mass index was 26.1 kg/m². The averages of the operation time and intraoperative blood loss were 181.2 min (range, 154 to 210 min) and 13.9 ml (range 5-30 ml), respectively. There were no perioperative complications except for one patient with a superficial surgical site infection.

CONCLUSIONS

IC-HHS anastomosis was successfully performed for colon cancer around the SD junction with acceptable perioperative outcomes and there were no procedure-related complications, indicating its feasibility. IC-HHS anastomosis could eliminate unnecessary splenic flexure mobilization in left-side colectomies. IC-HHS anastomosis can be an optional reconstruction for totally laparoscopic colectomies.

Intracorporeal Versus Extracorporeal Anastomosis for Laparoscopic Resection of the Splenic Flexure Colon Cancer: A Multicenter Propensity Score Analysis

PURPOSE

The aim of this study is to compare the short and long-term outcomes of intracorporeal anastomosis (IA) versus extracorporeal anastomosis (EA) during laparoscopic resection of splenic flexure for cancer, in 3 high-volume Italian centers.

MATERIALS AND METHODS

A retrospective analysis was conducted on a multicenter database of a consecutive series of patients who underwent an elective laparoscopic resection of the splenic flexure for colon cancer in 3 high-volume centers between January 2008 and August 2017. Propensity score matching analysis was performed to overcome patients' selection bias between the 2 surgical techniques. Data on patients' demographics, operative details, short-term and long-term outcomes were prospectively recorded.

RESULTS

In total, 102 patients were selected. After propensity score match, 72 patients were compared: 36 for the IA group, 36 for the EA group. The IA group showed a significantly shorter median time to first flatus, time to first stool, time to oral feeding, and time to discharge, as well as significantly lower incidence of postoperative severe surgical complications, especially in terms of wound infections, and of incisional hernia (IH).Risk factors for IH on logistic regression were longer operative time, EA, longer incision, postoperative blood transfusions, and longer specimen.

CONCLUSIONS

The IA in laparoscopic resection of the splenic flexure is feasible and safe in terms of short-term and long-term outcomes. Major advantages are shorter time to first flatus and first stool, complete oral feeding and time to discharge, with minor incidence of severe surgical complications, such as wound infection, and lower incidence of IH.

Propensity score analysis of postoperative and oncological outcomes after surgical treatment for splenic flexure colon cancer

PURPOSE

The surgical treatment of splenic flexure colon cancer (SFCC) is somehow not yet well standardized. Postoperative and oncological results of the three surgical techniques most commonly used to treat SFCC: extended right colectomy (ERC), egmental left colectomy (SLC), and left colectomy (LC) were evaluated.

METHODS

The study included all patients with stage I-III SFCC treated by ERC, SLC, or LC between 2005 and 2016. Postoperative and long-term outcomes after the different surgical techniques were analyzed: Propensity score matching (PSM) was performed to compare the outcomes between these surgical techniques and survival analyses were performed using the Kaplan-Meier method and log-rank tests.

RESULTS

A total of 170 SFCC patients were operated; ERC was performed in 71 (41.76%), SLC in 36 (21.18%), and LC in 63 (37.06%). There were no significant differences in the short and long-term postoperative outcomes. Three comparison groups were developed so that PSM could be performed between the surgical technique cases: ERC (n = 59) vs. LC (n = 50); ERC (n = 50) vs. SLC (n = 33); and SLC (n = 32) vs. LC (n = 44). No differences in the short or long-term outcomes of these techniques were observed.

CONCLUSION

The short and long-term outcomes between ERC, SLC, and LC are similar. SLC should be considered oncologically as appropiate as the other more extensive resections.

How we do it: totally laparoscopic complete mesocolon excision for splenic flexure cancer

BACKGROUND

Splenic flexure (SF) cancer is not a common condition and its treatment is still under discussion. Although laparoscopic surgery is well accepted for the treatment of colon cancer at any stage, complete mesocolon excision (CME) with selective vascular ligation using the laparoscopic approach for SF cancer remains technically demanding and represents a real challenge for surgeons.

METHODS

We present a single-institution experience of laparoscopic CME for SF cancer. Intra-operative, pathologic, and post-operative data of patients who underwent laparoscopic SF resection were reviewed to assess the technical feasibility and oncologic safety. Technical features, histopathology, morbidity, and mortality were evaluated.

RESULTS

From February 2015 to October 2017, a minimally invasive approach was proposed to 17 patients (M/F 14/3) affected by splenic flexure cancer. In all patients, the procedure was completed by laparoscopy. The anastomosis was completed intra-corporeally in 89% of cases. The distal margin was 3.1 ± 2.6 cm and the proximal margin was 6.5 ± 3.3 cm from the tumor site. The number of mean harvested nodes was 13.9 ± 7. The mean operative time was 215.5 ± 65 min, and blood loss was 80 ± 27. In one case, a laparoscopic partial gastrectomy was associated due to tumor invasion. The mean post-operative stay was 6.7 ± 3.3 days. Readmission was necessary for two patients. No major morbidity was recorded.

CONCLUSIONS

Despite the wide spread and increasing confidence in laparoscopic colectomy, SF resection remains one of the most challenging procedures in colorectal surgery with a complex learning curve. SF resection with CME and CVL is feasible and safe for the treatment of early-stage and locally advanced SF cancer.

Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients

Although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. A multi-institutional audit was designed, including 92 patients who underwent laparoscopic left colectomy with intracorporeal anastomosis (IA) compared with 89 matched patients who underwent a laparoscopic left colectomy with extracorporeal anastomosis (EA). There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Post-surgical history and stage of disease according to AJCC/UICC TNM were also similar. IA and EA groups demonstrated similar oncologic radicality in terms of the number of lymph nodes harvested (18.5 ± 9 vs. 17.5 ± 8.4; p = 0.48). Recovery after surgery was also better in patients who underwent IA, as confirmed by the shorter time to flatus in the IA group (2.6 ± 1.1 days vs. 3.4 ± 1.2 days; p < 0.001) and higher post-operative pain expressed in the mean VAS Scale in the EA group (1.7 ± 2.1 vs. 3.5 ± 1.6; p < 0.001). Laparoscopic left colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 6.7, 95% CI 2.2-20; p = 0.001). However, when stratifying according to Clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 7.6, 95% CI 2.5-23, p = 0.001) but not for class III, IV, and V complications (OR 1.8, 95% CI 0.1-16.9; p = 0.59). Our results were consistent to hypothesize that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. Further randomized clinical trials are needed to obtain a more definitive conclusion.

A standardised and simplified technique for laparoscopic resection of the splenic flexure

The splenic flexure is an uncommon location of colorectal cancer, being involved in 2%–3% of cases. The low chance of being engaged in resecting cancer of the splenic flexure can make it difficult for surgeons to build their learning curve and to achieve a reliable experience. As the majority of colectomies are still performed by low-volume surgeons, there is growing agreement that providing local services with adequate surgical education and training could be an effective strategy to improve outcomes and global health. Arming surgeons with simplified and easy-to-learn surgical techniques could be an important step of this strategy. A novel simplified technique for laparoscopic resection of the splenic flexure is presented, which combines laparoscopic mobilisation of the right colon with extracorporeal vascular ligation and bowel anastomosis.

Surgical Treatment of Colon Cancer of the Splenic Flexure: A Systematic Review and Meta-analysis

This is a systematic review and meta-analysis on the surgical treatments of splenic flexure carcinomas (SFCs). Medline, EMBASE, and Scopus were searched from January 1990 to May 2016. Studies of at least 5 patients comparing extended right colectomy (ERC) versus left colectomy (LC) and/or laparoscopy versus open surgery for SFCs were retrieved and analyzed. Overall, 12 retrospective studies were selected, including 569 patients. ERC was performed in 23.2% of patients, whereas LC in 76.8%. Pooled data suggested that ERC and LC had similar oncologic quality of resection and postoperative outcomes. Laparoscopy was used in 50.6% of patients (conversion rate: 2.5%) and it was associated with significantly shorter time to oral diet, fewer postoperative complications, and shorter hospital stay than open surgery. In conclusion, the optimal extent of SFC surgical resection, that is, ERC or LC remains under debate. However, laparoscopy provides better postoperative outcomes and fewer postoperative complications than open surgery.

Subtotal colectomy versus left hemicolectomy for the elective treatment of splenic flexure colonic neoplasia

BACKGROUND

Optimal elective surgical treatment for splenic flexure neoplasm (SFN) is unclear. Subtotal colectomy (STC) and left hemicolectomy (LHC) are the two more common strategies used.

METHODS

Observational multicentric study comparing postoperative morbidity, mortality and long-term survival on patients with SFN electively operated by STC versus LHC between 2003 and 2014.

RESULTS

After revision of the databases, 144 patients were included (STC group, n = 68; LHC group, n = 76). No differences were found on epidemiological and surgical data. A higher global morbidity (58%vs37%, p = 0.014), surgical morbidity (50%vs33%, p = 0.037), postoperative ileus (37%vs20%, p = 0.023) and harvested lymph nodes (26vs18, p = 0.0001) were found on the STC group. No significant differences in complications according to severity, reoperation rate, hospital stay, mortality, recurrence or long-term survival were found between groups.

CONCLUSIONS

A higher surgical morbidity was found on the STC group, mainly due to mild postoperative ileus. No differences on long-term oncological results were found.

Laparoscopic extended right colectomy versus laparoscopic left colectomy for carcinoma of the splenic flexure: a matched case-control study

PURPOSE

The aim of the study was to compare the short- and long-term outcomes of laparoscopic extended right colectomy (ER) versus laparoscopic left colectomy (LC) for splenic flexure carcinomas.

METHODS

Patients with stage 0-III adenocarcinoma of the splenic flexure who underwent laparoscopy between 2000 and 2013 were identified from a prospectively maintained database. Twenty-seven patients who underwent ER were matched by age, gender, BMI, ASA score, and tumor stage with 27 patients who underwent LC.

RESULTS

The ER procedures were significantly longer than LC (235 ± 49.2 min vs. 192 ± 43.4 min, p = 0.001, respectively). Post-operatively, time to flatus and return to regular diet were observed to average 2.4 ± 0.8 days (1-4 days) and 4.6 ± 1.05 days (3-8 days), respectively, without differences between the groups. Overall, 14 complications were observed in 12 patients and 90-day mortality was nil. The length of hospitality stay was not different between ER and LC, with an overall mean of 8.3 ± 2.7 days. All procedures were classified as R0 resections, but ER was associated with a higher number of lymph nodes retrieved (21.4 ± 4.9) compared with LC (16.6 ± 5.5, p = 0.001). The 1-, 3-, and 5-year cumulative survival rates were 92.6, 85.8, and 72.8% for the ER group and 96.3, 91.9, and 75.1% for the LC group (p = 0.851). The 1-, 3-, and 5-year disease-free survival rates were 85.2, 76.7, and 67.1% for the ER group and 96.2, 75.5, and 66.7% for the LC group (p = 0.636).

CONCLUSIONS

Laparoscopic ER and LC procedures performed for splenic flexure carcinomas appear to have similar short- and long-term oncologic outcomes.

Laparoscopic colonic resection for splenic flexure cancer: our experience

Background

The treatment of colon cancer located in splenic flexure is not standardized. Laparoscopic approach is still considered a challenging procedure. This study reviews two Institutions experience in laparoscopic treatment of left colonic flexure cancer. Intraoperative, pathologic and postoperative data from patients undergoing laparoscopic splenic flexure resection were analyzed to assess oncological safety as well as early and medium-term outcomes.

Methods

From October 2005 to May 2014 laparoscopic splenic flexure resection was performed in 23 patients.

Results

Conversion rate was nihil. In 7 cases the anastomosis was performed intracorporeally. Specimen mean length was 21.2 cm, while the distance of distal and proximal resection margin from tumor site was 6.5 and 11.5 respectively. The mean number of harvested lymph nodes was 20.8. Mean operative time was 190 min and mean estimated blood loss was equal to 55 ml. As regard major postoperative complications, one case of postoperative acute pancreatitis and one case of postoperative bleeding from the anastomotic suture line were reported.

Conclusions

Although our experience is limited and appropriate indications must be set by future randomized studies, we believe that laparoscopic resection with intracorporeal anastomosis appears feasible and safe for patients affected by splenic flexure cancer.

Colon cancer in the splenic flexure: comparison of short-term outcomes of laparoscopic and open colectomy

BACKGROUND

Laparoscopic surgery for colon cancer in the splenic flexure (SF cancer) is technically demanding and has not been evaluated in randomized clinical trials. This study aimed to evaluate the safety and feasibility of laparoscopic surgery for SF cancer.

METHODS

Thirty-three patients undergoing laparoscopic surgery for SF cancer (LAC group) were retrospectively compared with 22 patients undergoing open surgery for SF cancer (OC group) between April 2003 and June 2010.

RESULTS

Left hemicolectomy was the most performed procedure in both groups (79% vs. 82%). Median operating time was significantly longer (209 vs. 178 min) and estimated blood loss was significantly lower (15 vs. 113 mL) in the LAC group than in the OC group. Conversion to open surgery was needed for 1 (3%) patient because of bleeding near the pancreas. Tumor stage was more advanced in the OC group than in the LAC group, but N stages were similar between groups. The median number of lymph nodes harvested was significantly higher in the LAC group than in the OC group (16 vs. 12). The rate of postoperative complications was significantly lower in the LAC group than in the OC group (6% vs. 36%). Time to flatus (1 vs. 3 d), time to liquid diet (2 vs. 5 d), and hospital stay (12 vs. 16 d) were significantly shorter in the LAC group than in the OC group.

CONCLUSIONS

Laparoscopic surgery for SF cancer is feasible.