Vascular anatomy of the splenic flexure: a review of the literature

Splenic flexure adenocarcinoma: A national cohort analysis of extent of surgical resection and outcomes

AIM

The optimal extent of resection for splenic flexure adenocarcinoma remains debated. These tumours straddle the left- and right-sided vasculature with lymphatic drainage in a watershed area; current guidelines recommend either segmental or extended colectomy. We analysed surgical management of splenic flexure tumours and compared outcomes between approaches.

METHOD

The Surveillance, Epidemiology and End Results database was searched for adults with Stage I-III splenic flexure adenocarcinoma, 2004-2019.

RESULTS

Of 5238 patients, 55% underwent extended colectomy. Compared to segmental colectomy, these patients were more likely to have advanced stage. On multivariable analysis, age ≤ 65 years remained independently associated with extended colectomy. Although fewer nodes were examined in segmental colectomy (median 14 vs. 16, p < 0.001), the number of positive nodes (both, median 0 [interquartile ratio 0-2], p = 0.20) and the lymph node ratio were similar between cohorts. Surgical approach was not significantly associated with increased positive nodal yield in adjusted analyses. Five-year overall and disease-specific survival were 73% and 84% for segmental and 72% and 83% for extended colectomy (p > 0.4); these remained comparable after adjustment.

CONCLUSIONS

Nationally, we observed similar rates of segmental and extended colectomy for splenic flexure adenocarcinoma. Extended colectomy was not more common in Stage III disease, indicating lack of stage migration, and was not associated with better oncological outcomes. These observations support current practice involving either approach, which should be tailored to patient-related factors and preferences, while considering technical aspects and quality of life.

Modified Rosi-Cahill technique after left extended colectomy for splenic flexure advanced tumors

Advanced splenic flexure tumors are uncommon and have a higher risk of relapse. To ensure that the resection includes the entire area of lymphatic drainage with a complete mesocolic excision (CME), a left extended colectomy is needed. In peritoneal carcinomatosis, there is often extensive involvement of the sigma and splenic flexure of the colon. In many instances, total colectomies are chosen for these patients, even when a significant portion of the colon could be preserved. The potential impact on quality of life after splenic flexure colon resection is discussed, as well as the importance of anatomical knowledge and expertise in performing this type of surgery. Overall, this work presents a modified technique that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer. Creating a tension-free anastomosis after extended left-sided colorectal resection is challenging. There is a negative impact on quality of life when an ileorectal anastomosis is created. The colorectal anastomosis performed after modified Rosi-Cahill or Deloyers' technique allows reduced small bowel bacterial overgrowth, achieves better water and sodium absorption, and altogether permits improved stool consistency. There are potential advantages of the Rosi-Cahill technique over other popular options such as Deloyers' procedure as there is no torsion of the ileocolic vessels and no mesenteric windows. A video was recorded showing a potential pitfall during Deloyers' technique resulting in the creation of a mesenteric window. The proper rotation of the colon during the modified Rosi-Cahill procedure was also filmed. Overall, this work presents a modified technique for reconstruction after left extended colectomy that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer.

Unveiling the hidden: identification and management of overlooked blood vessels in laparoscopic left hemicolectomy for splenic flexure cancer

BACKGROUND

During laparoscopic left hemicolectomy procedures, a previously overlooked consistently thick blood vessel within the gastrocolic ligament near the splenic hilum may contribute to post-operative bleeding complications. The purpose of this study was to investigate the identification and management of the previously overlooked blood vessel.

METHODS

This is a retrospective descriptive study of patients undergoing laparoscopic left colectomy for splenic fexure cancer conducted at a national gastrointestinal surgery centre in China. Consecutive patients with splenic fexure cancer who underwent laparoscopic left colectomy using our"five-step process"(n = 34) between January 2021 and July 2023 were included.

RESULTS

The vessels can be effectively exposed using the aforementioned "five-step process." It was observed that the overlooked vessels consistently present in all patients were identified as the omental branch of the left gastroepiploic artery and vein.

CONCLUSION

We have identified the origin of previously overlooked blood vessels and recommended a safe method for their management. This may offer advantages to colorectal surgeons performing laparoscopic left colectomy for splenic flexure cancer.

A case of MCA arising from ICA: a case report

BACKGROUND

Complete mesocolic excision (CME) and central vascular detachment are very important procedures in surgery for colorectal cancer. Preoperative and intraoperative assessments of the anatomy of major colorectal vessels are necessary to avoid massive bleeding, especially in endoscopic surgery. A case with a rare anomaly in which the middle colic artery (MCA) and ileocolic artery (ICA) had a common trunk is reported.

CASE PRESENTATION

The patient was a 73-year-old woman diagnosed with ascending colon cancer on colonoscopy. Preoperative abdominal contrast-enhanced computed tomography confirmed that the MCA and ICA had a common trunk. She underwent laparoscopic ileocecal resection for the ascending colon cancer with D3 lymph node dissection. Intraoperative indocyanine green fluorescence imaging was conducted. After confirming vessel bifurcation, the ICA was dissected at the distal end of the MCA bifurcation. The patient has been followed as an outpatient, with no signs of recurrence as of 2 years postoperatively.

CONCLUSION

A case of an ascending colon cancer with a unique vascular bifurcation pattern was presented. Preoperative and intraoperative evaluations of the major colorectal vessels are very important for preventing perioperative and postoperative complications.

Two Types of Variational Arteries' Courses From the Superior Mesenteric Artery to Supply the Splenic Flexure: Gross Anatomical Study

BACKGROUND

Complete mesocolic excision with central vascular ligation is a standard method for managing colon cancer. However, there is no consensus on its procedure, especially for cancer in the splenic flexure of the transverse colon. This is because various types of variational arteries are distributed to the region, and their running course below and near the pancreas leads to difficulty in ligating the artery.

OBJECTIVE

To clarify the arterial distribution to the splenic flexure of the transverse colon using cadavers.

DESIGN

The arteries in the transverse mesocolon distributed to the colon were dissected in cadavers, and their route was quantitatively visualized using drawing software.

SETTINGS

This study was conducted at the Department of Anatomy, Tokyo Medical University.

PATIENTS

Sixty cadavers donated to Tokyo Medical University in 2017-2021 were used.

MAIN OUTCOME MEASURES

The arterial courses to the splenic flexure of the transverse colon in the mesocolon and their patterns were evaluated.

RESULTS

We found 34 variational arteries distributed to the splenic flexure of the transverse colon. Most originated from the superior mesenteric artery and the middle colic artery, with their typical course below the pancreas. We identified another arterial course, crossing the mesocolon away from the pancreas toward the splenic flexure of the transverse colon. Furthermore, the origin of these arteries was not behind the pancreas and can be found in the caudal region of the pancreas.

LIMITATIONS

We cannot discuss how the arteries within the transverse mesocolon are observed by CT examination.

CONCLUSIONS

This study showed 2 types of arterial courses (below the pancreas and within the mesocolon) toward the splenic flexure of the transverse colon for the first time. In the latter case, the complete mesocolic excision with central vascular ligation is likely performed more easily than in the former. See Video Abstract.

DOS TIPOS DE RECORRIDO VARIACIONAL DE LA ARTERIA DESDE LA ARTERIA MESENTRICA SUPERIOR PARA IRRIGAR EL NGULO ESPLNICO ESTUDIO ANATMICO MACROSCPICO

ANTECEDENTES:La escisión mesocólica completa con ligadura vascular central es un método estándar para el cáncer de colon. Sin embargo, no hay consenso sobre su procedimiento, especialmente para el cáncer en el ángulo esplénico del colon transverso. Esto se debe a que varios tipos de arterias variacionales se distribuyen en la región, y su recorrido por debajo y cerca del páncreas dificulta la ligadura de la arteria.OBJETIVO:Este estudio tuvo como objetivo aclarar la distribución arterial al SF del colon transverso utilizando cadáveres.DISEÑO:Las arterias en el mesocolon transverso distribuidas al colon fueron disecadas en cadáveres, y su ruta fue visualizada cuantitativamente utilizando un software de dibujo.AJUSTES:Este estudio se realizó en el Departamento de Anatomía de la Universidad Médica de Tokio.PACIENTES:Se utilizaron sesenta cadáveres donados a la Universidad Médica de Tokio en 2017-2021.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los cursos arteriales al ángulo esplénico del colon transverso en el mesocolon y sus patrones.RESULTADOS:Encontramos 34 arterias variacionales distribuidas al ángulo esplénico del colon transverso. La mayoría se originaron en la arteria mesentérica superior y la arteria cólica media, con su trayecto típico por debajo del páncreas. Identificamos otro curso arterial, cruzando el mesocolon alejándose del páncreas hacia el ángulo esplénico del colon transverso. Además, el origen de estas arterias no estaba detrás del páncreas y se pueden encontrar en la región caudal del páncreas.LIMITACIONES:No podemos discutir cómo se observan las arterias dentro del mesocolon transverso mediante un examen de tomografía computarizada.CONCLUSIONES:Este estudio mostró por primera vez dos tipos de trayectos arteriales (por debajo del páncreas y dentro del mesocolon) hacia el ángulo esplénico del colon transverso. En el último caso, es probable que la escisión mesocólica completa con ligadura vascular central se realice más fácilmente que en el primero. (Traducción-Dr. Aurian Garcia Gonzalez ).

Laparoscopic Resection of Transverse Colon Cancer with an Anomaly of the Middle Colic Artery Originating from the Splenic Artery: A Case Report

Introduction

We encountered a colon cancer case with a very rare anomaly of the middle colic artery (MCA) originating from the splenic artery (SA).

Case Presentation

A woman was referred to our hospital for transverse colon cancer. Three-dimensional computed tomography (3D-CT) angiography showed an anomalous MCA originating from the SA rather than from the superior mesenteric artery (SMA) as is typical. Laparoscopic left hemicolectomy with D3 lymph node dissection was performed. The lymph nodes around the SMA were dissected from the caudal view, confirming the absence of a typical MCA. An anomalous SA-originating MCA was identified just below the pancreas, where it was clipped and ligated; subsequently, total mesenteric excision was achieved.

Conclusion

As D3 lymph node dissection for transverse colon cancer is technically difficult, 3D-CT angiography is useful for identifying vascular anomalies preoperatively, thereby avoiding intraoperative injury. This is the first case report of laparoscopic colectomy associated with a SA-originating MCA anomaly.

Drainage pattern of the splenic flexure vein and its accompanying arteries using three-dimensional computed tomography angiography: a single-centre study of 600 patients

AIM

The splenic flexure has variable vascular anatomy, and the details of the venous forms are not known. In this study, we report the flow pattern of the splenic flexure vein (SFV) and the positional relationship between the SFV and arteries such as the accessory middle colic artery (AMCA).

METHODS

This was a single-centre study using preoperative enhanced CT colonography images of 600 colorectal surgery patients. CT images were reconstructed into 3D angiography. SFV was defined as a vein flowing centrally from the marginal vein of the splenic flexure visible on CT. AMCA was defined as the artery feeding the left side of the transverse colon, separate from the left branch of the middle colic artery.

RESULTS

The SFV returned to the inferior mesenteric vein (IMV) in 494 cases (82.3%), the superior mesenteric vein in 51 cases (8.5%) and the splenic vein in seven cases (1.2%). The AMCA was present in 244 cases (40.7%). The AMCA branched from the superior mesenteric artery or its branches in 227 cases (93.0% of cases with existing AMCA). In the 552 cases in which the SFV returned to the IMV, superior mesenteric vein or splenic vein, the left colic artery was the most frequent artery accompanying the SFV (42.2%), followed by the AMCA (38.1%) and the left branch of the middle colic artery (14.3%).

CONCLUSIONS

The most common flow pattern of the vein in the splenic flexure is from the SFV to IMV. The SFV is frequently accompanied by the left colic artery or AMCA.

Collateral circulation develops in stenosis of the celiac trunk and superior mesenteric artery

PURPOSE

Mesenteric circulation is provided by the celiac trunk (CT), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The collateral circulation between CT and SMA and between SMA and IMA plays a protective role against intestinal ischemia in case of narrowing or occlusion of the mesenteric vessels. In our study, it is aimed to determine the CT and SMA stenosis rates in patients with CT and SMA stenosis from angiography images, the occurrence of the collateral variations, and the frequency of these variations.

METHODS

A total of 408 non-selective or selective CT and SMA angiographic images were taken of 215 patients (130 males, 85 females) who were admitted to Akdeniz University Hospital with symptoms of chronic mesenteric ischemia (CMI) were included. The angiography images were analyzed in regards to CT and SMA stenosis rates, and the collateral variations between mesenteric vessels.

RESULTS

Stenosis of CT was observed in 14 patients, whereas the stenosis of the SMA was observed in 12 patients. The most common collateral vessel in these patients was the gastroduodenal artery. Both stenoses of CT and SMA were found in 9 patients. The Riolan arch was the most common type of collateral vessel in these patients.

CONCLUSION

It was observed that mesenteric circulation was mainly provided by gastroduodenal artery in patients with isolated CT or SMA stenosis or occlusion while in patients with stenosis or occlusion of both CT and SMA, mesenteric circulation was mainly provided by the Riolan arch. A significant increase was observed in the prominence of collateral vessels in patients with stenosis of more than 70%.

Timing of real-time indocyanine green fluorescence visualization for lymph node dissection during laparoscopic colon cancer surgery

PURPOSE

Although numerous studies have highlighted the potential value of indocyanine green (ICG) imaging in lymph node dissection of cancer surgery, its efficacy and optimal method remain to be clarified. This study aimed to investigate how lymphatic flow observation via ICG fluorescence could contribute to colon cancer surgery.

METHODS

From October 2018 to March 2021, a total of 56 patients with colon cancer who underwent laparoscopic complete mesocolic excision with intraoperative ICG imaging were analyzed. Lymphatic flow was examined at the following time points following ICG injection: within 5 min, 30-60 min, and over 60 min. We also evaluated the distribution of ICG fluorescence per each vascular pedicle.

RESULTS

Lymphatic flow was observed within 5 min following ICG injection in 6 cases (10.7%), and at 30-60 min following ICG injection in 43 cases (76.8%). ICG-stained vascular pedicles were variable especially in hepatic flexural, transverse, and splenic flexural colon cancer. Lymph node metastases were observed in 14 cases. Although metastatic lymph nodes were present only in the area along the ICG-stained vascular pedicles in 12 of the 14 cases, two patients exhibited lymph node metastasis in areas along the ICG-unstained vascular pedicles. ICG fluorescence was observed outside the standard range of lymph node dissection in 9 cases (20.9%: 9/43). Although addition of the proposed resection areas was made in 8 of these 9 cases, there was no pathologically positive lymph node.

CONCLUSION

Real-time ICG fluorescence imaging of lymph nodes may improve the performance of laparoscopic colon cancer surgery, although its oncological benefit is not yet clear.

Does the level of inferior mesenteric artery ligation affect short-term and long-term outcomes of patients with sigmoid colon cancer or rectal cancer? A single-center retrospective study

Background

For sigmoid colon or rectal cancer, a definite consensus regarding the optimal level ligating the inferior mesenteric artery (IMA) has not been reached. We performed this study to determine whether the ligation level significantly affected short-term and long-term outcomes of patients with sigmoid colon or rectal cancer after curative laparoscopic surgery.

Methods

Medical records of patients with sigmoid colon or rectal cancer who had undergone curative laparoscopic surgery between January 2008 and December 2014 at the Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine were reviewed. Then, the high tie group (HTG) was compared with the low tie group (LTG) in terms of short-term and long-term outcomes.

Results

Five-hundred ninety patients were included. No significant differences between two groups regarding baseline characteristics existed. HTG had a significantly higher risk of anastomotic fistula than LTG (21/283 vs 11/307, P = 0.040). Additionally, high ligation was proven by multivariate logistic regression analysis to be an independent factor for anastomotic fistula (P = 0.038, OR = 2.232, 95% CI: 1.047–4.758). Furthermore, LT resulted in better preserved urinary function. However, LTG was not significantly different from HTG regarding operative time (P = 0.075), blood transfusion (P = 1.000), estimated blood loss (P = 0.239), 30-day mortality (P = 1.000), ICU stay (P = 0.674), postoperative hospital stay (days) (P = 0.636), bowel obstruction (P = 0.659), ileus (P = 0.637), surgical site infection (SSI) (P = 0.121), number of retrieved lymph nodes (P = 0.501), and number of metastatic lymph nodes (P = 0.131). Subsequently, it was revealed that level of IMA ligation did not significantly influence overall survival (OS) (P = 0.474) and relapse-free survival (RFS) (P = 0.722). Additionally, it was revealed that ligation level did not significantly affect OS (P = 0.460) and RFS (P = 0.979) of patients with stage 1 cancer, which was also observed among patients with stage 2 or stage 3 cancer. Ultimately, ligation level was not an independent predictive factor for either OS or RFS.

Conclusions

HT resulted in a significantly higher incidence of anastomotic fistula and worse preservation of urinary function. Level of IMA ligation did not significantly affect long-term outcomes of patients with sigmoid colon or rectal cancer after curative laparoscopic surgery.

Comparison of laparoscopic and open colectomy for splenic flexure colon cancer: a systematic review and meta-analysis

PURPOSE

This study examined the short- and long-term outcomes of laparoscopic and open splenic flexure colon cancer (SFCC) surgery.

METHOD

Systematic literature searches were performed in PubMed and Ovid to compare laparoscopic and open colectomy for SFCC. The last search was conducted on November 7, 2021. Surgical and survival outcomes were collected and analyzed. This meta-analysis was performed using Review Manager Software (v 5.3).

RESULTS

This study included seven publications with 2397 patients published between 2011 and 2021. A significant difference in operative time was seen in the laparoscopic group (P = 0.01, WMD = 50.13, 95%CI [10.32, 89.94], I² = 97%); loss of blood estimated (P < 0.001, WMD =  -101.88, 95%CI [-161.65, -42.11], I² = 82%) and the incidence of overall complications (P < 0.001, OR = 0.53, 95%CI [0.38, 0.75], I² = 0%) of laparoscopic procedure were greatly decreased. There were similar results as compared in the two groups in terms of lymph node harvesting (P = 0.71, WMD = 0.49, 95%CI [-2.13, 3.12], I² = 93%) and the distance of proximal (P = 0.50, WMD =  -1.09, 95%CI [-4.26, 2.08], I² = 96%) or distal (P = 0.18, WMD = 2.44, 95%CI [-1.13, 6.01], I² = 97%) resection margin. In addition, no significant differences were observed on overall/disease-free survival over 3/5 years between the two procedures. An analysis of subgroups that used propensity matching scores produced similar results.

CONCLUSION

The laparoscopic procedure is clinically safe and feasible for SFCC. It shows the advantages in decreasing intraoperative blood loss and overall complications, and the long-term survival outcomes would not be affected. Randomized clinical trials with a larger sample size are warranted in the future for further investigation.