Comparison of extended right hemicolectomy, left hemicolectomy and segmental colectomy for splenic flexure colon cancer: a systematic review and meta-analysis

[Evidence for the extent and oncological benefits of lymphadenectomy in colon and rectal cancer : A narrative review based on meta-analyses]

BACKGROUND

Lymphadenectomy for rectal cancer is clearly defined by total mesorectal excision (TME). The analogous surgical strategy for the colon, the complete mesocolic excision (CME), follows the same principles of dissection in embryologically predefined planes.

METHOD

This narrative review initially identified key issues related to lymphadenectomy of rectal and colon cancer. The subsequent search was based on PubMed and focused on meta-analyses. The endpoints for rectal cancer were the benefit of high tie versus low tie and the indications for lateral pelvic lymphadenectomy. For colon cancer the evidence for CME, for the longitudinal extent of resection, for the dissection of infrapyloric and gastroepiploic lymph nodes, for the number of lymph nodes and for the sentinel lymph node technique were used as endpoints.

RESULTS

An oncological benefit of the high tie cannot be derived from the current data. Lateral pelvic lymphadenectomy should only be selectively performed after chemoradiotherapy (CRT) in cases of remaining lymph nodes with suspected metastases. In most studies CME proved to be oncologically superior, especially in stage III. The longitudinal extent of resection should be at least 10 cm in both directions if the principles of CME are observed. Infrapyloric and gastroepiploic lymph node involvement is to be expected in 0.7-22% of cases, depending on patient selection, which justifies dissection, particularly in carcinomas of both flexure and the transverse colon. The minimum number of lymph nodes to be removed cannot be clearly derived from the available studies. Precisely performed CME and an optimal pathological work-up are important. The sentinel lymph node technique cannot currently be used as a criterion for limiting the extent of resection.

CONCLUSION

Both TME and CME are reliable standards for the lymphadenectomy in colorectal carcinomas. A lymphadenectomy that goes beyond this is reserved for selected cases and is partly the subject of currently ongoing studies.

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.

Treatment Differences for Splenic Flexure Cancers in Saudi Arabia: A Cross-Sectional Study

Backgrounds Colorectal surgeons worldwide have differing opinions on the best way to handle rare cases of splenic flexure colon cancers (SFCs). Although the majority of reviews indicate no significant variation in oncological outcomes among the three different procedure types used to treat SFCs, surgeons still exhibit diversity in their practices. This study determined the treatment preferences of colorectal surgeons in Saudi Arabia. Methods A descriptive cross-sectional study evaluated the management of colorectal surgeons in handling SFC cases. We utilized a validated questionnaire developed by Manceau et al., consisting of 14 questions. Emails and phone numbers of members of the Saudi Society of Colorectal Surgery (SSCRS) were gathered. Google Forms surveys were administered from October 1-30, 2023. Results A response rate of 66% (58/88) was obtained among questioned colorectal surgeons. Their responses revealed that there was no consensus regarding the preferred procedure to treat SFCs. The most common treatment reported was segmental colectomy (SC) 21/58 (36.2%), followed by subtotal colectomy (STC) (19/58, 32.8%) and left hemicolectomy (LHC) (18/58, 31%). There was a strong consensus of 96% (56/58) of the respondents in favor of using stapler anastomosis rather than hand sewing. The frequency of performing SC, STC, and LHC in France was 70%, 13%, and 17%, respectively, compared to 36.2%, 32.8%, and 31% in Saudi Arabia, with a p-value of 0.001. The surgeons' preferred approaches to managing SFCs utilizing laparoscopic, open, or hand-aided in France versus Saudi Arabia were 63%, 31%, and 11%, respectively, compared to 84.5%, 8.6%, and 6.9%, with a p-value of 0.001. Conclusion A significant disparity exists regarding the treatment of SFCs between colorectal surgeons in France and Saudi Arabia. Furthermore, there is a lack of consensus among colorectal surgeons in Saudi Arabia regarding the surgical management of SFCs. Hence, it is imperative for the SCRSS to assemble a panel of experts to reach a consensus for the most appropriate and effective treatment of SFCs.

Short- and long-term outcomes after surgical treatment of 5918 patients with splenic flexure colon cancer by extended right colectomy, segmental colectomy and left colectomy: a systematic review and meta-analysis

BACKGROUND

Colorectal cancer is among the most common cancers in the world, and splenic flexure colon cancer accounts for about 2-5% of them. There is still no consensus on the surgical treatment of splenic flexure colon cancer (SFCC), and the extent of surgical resection and lymph node dissection for SFCC is still controversial.

AIM

To compare the postoperative and long-term oncologic outcomes of extended right colectomy (ERC), segmental colectomy (SC) and left colectomy (LC) for SFCC.

METHOD

Up to March 2024, retrospective and prospective studies of ERC, SC, and LC for SFCC were searched through databases. Pooled weighted/standardized mean difference (WMD/SMD), odds ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated using a fixed effects model or random effects model, and meta-analysis was performed using Stata.

RESULTS

This meta-analysis includes 5,918 patients from 13 studies with more lymph node harvest (OR:6.29; 95%Cl: 3.66-8.91; Z=4.69, P=0), more operation time (WMD: 22.53; 95%Cl: 18.75-26.31; Z=11.68, P=0), more blood loss (WMD:58.44; 95%Cl: 20.20-96.68; Z=2.99, P=0.003), longer hospital stay (WMD:1.74; 95%Cl: 0.20-3.29; Z=2.21, P=0.03), longer time to return to regular diet (WMD:3.17; 95%Cl: 2.05-4.30; Z=5.53, P=0), longer first flatus time (WMD:1.66; 95%Cl: 0.96-2.37; Z=4.61, P=0) in ERC versus SC. More lymph node harvest (WMD: 3.52; 95% Cl: 1.59-5.44; Z=3.58, P=0) in ERC versus LC and LC versus SC (WMD: 1.97; 95% CI: 0.53-3.41; Z=2.68, P=0.007), respectively. There is no significant difference between anastomotic leakage, postoperative ileus, total postoperative complication, severe postoperative complication, wound infection, reoperations, R0 resection, postoperative mortality, 5-year overall survival (OS), 5-year disease-free survival (DFS) in three group of patients. In LC versus SC and ERC versus LC, there is no difference between operation time, blood loss, hospital stay, return to regular diet, and first flatus.

CONCLUSION

In the included studies, SC and LC may be more advantageous, with fewer postoperative complications and faster recovery. ERC harvests more lymph nodes, but there is no significant difference in long-term OS and DFS between the three surgical approaches. Given that the included studies were retrospective, more randomized controlled trials are needed to validate this conclusion.

SF-CORNER (splenic flexure colorectal cancer): an international survey of operative approaches and outcomes for cancers of the splenic flexure

AIM

The optimum surgical approach to splenic flexure cancers (SFCs) remains uncertain. The aim of this survey was to explore the opinions of an international surgical community on the management and outcomes of SFC.

METHOD

A questionnaire was constructed comprising five sections (information about respondents; definition and prognosis of SFC; operative approach; approach in specific scenarios; outcomes) and circulated through an international dissemination committee and social media.

RESULTS

The survey received 576 responses over 4 weeks across 50 countries. There was no consensus regarding the definition of the splenic flexure, whilst the proportion of respondents who did and did not think that patients with SFC had a worse outcome was equal. The overall preferred operative approach was left hemicolectomy [203 (35.2%)], followed by segmental resection [167 (29%)], extended right hemicolectomy [126 (21.9%)] and subtotal colectomy [7 (12%)]. The stated pedicles for ligation varied between resection types and also within the same resection. One hundred and sixty-six (28.8%) respondents thought a segmental resection was associated with the worst survival and 190 (33%) thought it was associated with the best quality of life.

CONCLUSION

This survey confirms a lack of consensus across all aspects SFC treatment. The differing approaches described are likely to represent different beliefs around the variable anatomy of this region and the associated lymphatic drainage. Future studies are required to address such inconsistencies and identify the optimum surgical strategy, whilst also incorporating quality-of-life metrics and patient-reported outcomes. A one-size-fits-all approach is probably not appropriate with SFC, and a more bespoke approach is required.

Comparative Efficacy and Long-Term Oncological Safety of Extended Right Hemicolectomy Versus Left Colectomy for Splenic Flexure Adenocarcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Splenic flexure adenocarcinoma poses unique challenges in surgical management due to its location and lymphatic drainage. This study compared the efficacy and oncological safety of extended right hemicolectomy (ERC) and left colectomy (LC) for treating this condition.

METHODS

This study followed the PRISMA and AMSTAR 2 guidelines. Key outcomes included postoperative mortality, morbidity, severe complications, operative results, pathological findings (R0 resection, lymph nodes), and oncological results (overall survival and disease-free survival at 3 and 5 years).

RESULTS

Twelve non-randomised studies were included involving 1710 patients (713 ERC group, 997 LC group). The analysis showed that ERC was associated with more lymph nodes and a lower conversion rate. However, there were no significant differences between ERC and LC in terms of mortality, morbidity, severe complications, anastomotic leak, wound infection, ileus, reoperation, R0 resection, hospital stay, and overall and disease-free survival rates.

CONCLUSIONS

ERC and LC are comparable in terms of postoperative and long-term oncological outcomes for splenic flexure adenocarcinoma, with ERC potentially producing a higher lymph node harvest rate and a lower conversion rate. ERC could be suggested for a better stage of the disease and when the surgical team considers the laparoscopic approach.

Tata Memorial Centre Evidence Based Management of Colorectal cancer

This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.

Association of hemicolectomy with survival in stage II colorectal cancer: a retrospective cohort study

To compare the oncological survival outcomes of partial colectomy (PC) and hemicolectomy (HC) in patients with stage II colon cancer. A total of 18,795 patients with stage II colon cancer who underwent hemicolectomy (n = 12,022) or partial colectomy (n = 6773) from 2010 to 2019 were included in the the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and cancer-specific survival (CSS) were compared between the two groups, and the threshold of harvested lymph nodes was determined. The results showed that age, gender, race, tumor site, scope of regional lymph nodes, postoperative chemotherapy, postoperative radiotherapy, harvested lymph nodes, and tumor size were significantly different between the PC and HC groups (all P < 0.05). The OS rate was slightly lower in hemicolectomy patients than in partial colectomy patients (69.9% vs. 74.5%, respectively, P < 0.001), but CSS was similar between the two groups (87.9% vs. 88.1%, respectively, P = 0.32). After propensity score matching (PSM) was performed, the OS and CSS rates in the two groups were significantly different (CSS 84.3% vs. 88.0%, P < 0.001; OS 62.2% vs. 72.5%, P < 0.001). The survminer R package determined that the optimum threshold for the harvested lymph node count in stage II colon cancer patients was 16. CSS was significantly different between patients with ≥ 12 lymph nodes harvested and patients with ≥ 16 lymph nodes harvested (P = 0.043). Univariate and multivariate Cox regression and survival analyses of stage II colon cancer patients showed that the survival benefit of stage II colon cancer patients receiving partial colectomy was superior to that of patients receiving hemicolectomy. Partial colectomy has significant oncological benefits over hemicolectomy in the treatment of stage II colon cancer patients, even in the case of pT4b or tumor deposits. Removal of 16 lymph nodes during colectomy for stage II colon cancer correlated with improved survival, and this threshold was more effective than the standard threshold of 12 lymph nodes in distinguishing between patients with good and poor prognoses.

Surgical management strategies for colorectal malignancies of the splenic flexure - A systematic review and network meta-analysis

BACKGROUND

Extended right hemicolectomy (ERHC) or left hemicolectomy (LHC) are accepted as the standard-of-care for colonic tumours of the splenic flexure. Lymphatic drainage at this site is poorly defined and subject to significant heterogeneity. Nevertheless, emerging evidence demonstrates the potential oncological safety of segmental splenic flexure colectomy (SFC).

AIM

To perform a systematic review and network meta-analysis (NMA) to compare outcomes following ERHC, LHC and SFC for splenic flexure tumours (SFTs).

METHODS

A systematic review was performed as per PRISMA guidelines. NMA was performed using R Shiny and Netmeta packages.

RESULTS

A total of 13 studies, involving 6176 patients (ERHC n = 785; LHC n = 1527; SFC n = 3864) were included in the NMA. There was no difference in overall survival (OS) (SFC vs LHC Hazard Ratio [HR] 1.0, 95% Credible Interval [CrI] 0.76,1.34; SFC vs ERHC HR 1.18, 95% CrI 0.85,1.58) between the groups. SFC had a shorter operation time (Mean 176.37 min; Mean Difference [MD] SFC vs LHC 20.34 min 95% CrI 10.9, 29.97; SFC vs ERHC MD 22.19 95% CrI 11.09, 33.29) but also had a lower average lymph node yield (LNY) compared with ERHC (MD 7.15, 95% CrI 5.71, 8.60). ERHC had a significantly higher incidence of post-operative ileus (Odds Ratio [OR] 3.47, 95% CrI 1.11, 10.84). There was also no difference observed for minimally invasive approaches, anastomotic leak rate, perioperative mortality, reoperation rates or length of stay.

CONCLUSIONS

While SFC may allow for reduced operative duration and improved bowel function postoperatively. SFC, LHC, ERHC are all acceptable approaches for curative resection of cancers of the splenic flexure, with no difference in OS observed. Thus, surgeon preference and candidate-specific factors will likely determine the management of SFTs.

Splenic flexure cancer survival: a 25-year experience and implications for complete mesocolic excision (CME) and central vascular ligation (CVL)

BACKGROUND

The management of splenic flexure cancers (SFCs) in the era of complete mesocolic excision (CME) and central vascular ligation (CVL) is challenging because of its variable lymphatic drainage. This study aimed to compare survival outcomes for SFCs and non-SFCs, and better understand the clinicopathological characteristics which may define a distinct SFC phenotype.

METHODS

An observational cohort study at Concord Hospital, Sydney was conducted with patients who underwent resection for colon adenocarcinoma (1995-2019). Clinicopathological data were extracted from a prospective database. Overall survival (OS) and disease-free survival (DFS) estimates and their associations to clinicopathological variables were investigated with Kaplan-Meier and Cox regression analyses.

RESULTS

Of 2149 patients with colon cancer, 129 (6%) had an SFC. The overall 5-year OS and DFS rates were 63.6% (95% CI 62.5-64.7) and 59.4% (95% CI 58.3-60.5), respectively. SFCs were not associated with OS (P = 0.6) or DFS (P = 0.5). SFCs were more likely to present urgently (P < 0.001) with obstruction (P < 0.001) or perforation (P = 0.03), and more likely to require an open operation (P < 0.001). These characteristics were associated with poorer survival outcomes. No differences were noted between SFCs and non-SFCs with respect to tumour stage (P = 0.3).

CONCLUSION

SFCs have a distinct phenotype, the individual characteristics of which are associated with poorer survival. However, the survivals of SFCs and non-SFCs are similar, possibly because the most important determinant of outcome, tumour stage, is no different between the groups. This may have implications for the surgical approach to SFCs with respect to standardization of CME and CVL surgery for these cancers.

Standardization of the Definition and Surgical Management of Splenic Flexure Carcinoma by an International Expert Consensus Using the Delphi Technique: Room for Improvement?

BACKGROUND

Surgical management of splenic flexure carcinoma remains controversial.

OBJECTIVE

This study aimed to establish an expert international consensus on splenic flexure carcinoma management.

DESIGN

A 3-round online-based Delphi study was conducted between September 2020 and April 2021.

SETTING

The first round included 18 experts from 12 different countries. For the second and third rounds, each expert in the first round was asked to invite 2 more colorectal surgeons (n = 47). Out of 47 invited experts, 89% (n = 42) participated in the second and third rounds of the consensus.

INTERVENTIONS

A total of 35 questions were created and sent via the online questionnaire tool.

MAIN OUTCOME MEASURES

Levels of recommendation based on voting concordance were graded as follows: more than 75% agreement was defined as strong, between 50% and 75% as moderate, and below 50% as weak.

RESULTS

There was moderate consensus on the definition of splenic flexure (55%) as 10 cm from either side where the distal transverse colon turns into the proximal descending colon. Also, experts recommended an abdominopelvic CT scan plus intraoperative exploration (moderate consensus, 72%) for tumor localization and cancer registry. Segmental colectomy was the preferred technique for the management of splenic flexure carcinoma in the elective setting (72%). Moderate consensus was achieved on the technique of complete mesocolic excision and central vascular ligation principles for splenic flexure carcinoma (74%). Only strong consensus was achieved on the surgical approach for minimally invasive surgery (88%).

LIMITATIONS

Subjective decisions are based on individual expert clinical experience and not evidence based.

CONCLUSIONS

This is the first internationally conducted Delphi consensus study regarding splenic flexure carcinoma. The definition of splenic flexure remains ambiguous. To more effectively compare oncologic outcomes among different cancer registries, guidelines need to be developed to standardize each domain and avoid arbitrary definitions. See Video Abstract at http://links.lww.com/DCR/C143 .

ESTANDARIZACIN DE LA DEFINICIN Y MANEJO QUIRRGICO DEL CARCINOMA DE NGULO ESPLNICO ESTABLECIDO POR UN CONSENSO INTERNACIONAL DE EXPERTOS UTILIZANDO LA TCNICA DELPHI ESPACIO PARA MEJORAR

ANTECEDENTES:El tratamiento quirúrgico del cáncer de ángulo esplénico sigue siendo controvertido.OBJETIVO:Establecer un consenso internacional de expertos sobre el manejo del cáncer del ángulo esplénico.DISEÑO:Se condujo un estudio Delphi en línea de 3 rondas entre septiembre de 2020 y febrero de 2021.ESCENARIO:La primera ronda incluyó a 18 expertos de 12 países distintos. Para la segunda y tercera rondas, a cada experto de la primera ronda se le pidió que invitara a 2 cirujanos colorrectales más de su región (n = 47). De los 47 expertos invitados, el 89% (n = 42) participó en la segunda y tercera ronda del consenso.INTERVENCIONES:Se crearon y enviaron un total de 35 preguntas a través de la herramienta de cuestionario en línea.PRINCIPALES MEDIDAS DE RESULTADO:Los niveles de recomendación basados en la concordancia de votos fueron jerarquizados de la siguiente manera: más del 75% de acuerdo se definió como fuerte, entre 50 y 75% como moderado y por debajo del 50% como débil.RESULTADOS:Hubo un consenso moderado sobre la definición de ángulo esplénico (55%) como 10 cm desde cualquier lado donde el colon transverso distal se convierte en el colon descendente proximal. Así también, los expertos recomendaron la tomografía computarizada abdominopélvica más la exploración intraoperatoria (consenso moderado, 72%) para la localización del tumor y el registro del ángulo esplénico. La colectomía segmentaria fue la técnica preferida para el tratamiento del cáncer de ángulo esplénico en el caso de ser electivo (72%). Se logró un consenso moderado sobre la técnica de escisión completa del mesocolon y los principios de ligadura vascular a nivel central para el cáncer de ángulo esplénico (74%). Solo se logró un fuerte consenso sobre el abordaje quirúrgico para la cirugía mínimamente invasiva (88%).LIMITACIONES:Decisiones subjetivas basadas en la experiencia clínica de expertos individuales y no basadas en evidencia.CONCLUSIONES:Este es el primer estudio internacional de consenso Delphi realizado sobre el cáncer de ángulo esplénico. Si bien encontramos un consenso moderado sobre las modalidades de diagnóstico preoperatorio y el manejo quirúrgico, la definición de ángulo esplénico sigue siendo ambigua. Para comparar de manera más efectiva los resultados oncológicos entre diferentes registros de cáncer, se deben desarrollar pautas para estandarizar cada dominio y evitar definiciones arbitrarias. Consulte Video Resumen en http://links.lww.com/DCR/C143 . (Traducción-Dr. Osvaldo Gauto ).

Impact of primary tumor resection on the survival of patients with unresectable colon cancer liver metastasis at different colonic subsites: a propensity score matching analysis

OBJECTIVE

To investigate the effect of primary tumor resection (PTR) on the prognosis of patients with unresectable colon cancer liver metastasis (UCCLM) at seven colonic subsites using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Propensity score matching (PSM) was performed to balance selection bias using all available variables that could be of potential relevance. After matching, the groups were redefined in a 1:1 ratio using the nearest method. Cancer-specific survival (CSS) was compared among the patients of PTR and non-PTR groups. Cox regression models were used to identify the prognostic factors for CSS.

RESULTS

CSS was significantly different between all groups. Cox regression analysis showed that PTR was an independent prognostic factor for all groups. After PSM, PTR significantly prolonged CSS for all groups. Subgroup analysis showed that PTR did not improve the prognosis of N2 stage patients in the cecum, ascending colon, and descending colon groups; T1 + T2 stage patients in the hepatic flexure group; and patients with a tumor size ≤5 cm in the splenic flexure group. Segmental colectomy could prolong CSS of patients in the cecum, ascending colon, transverse colon, splenic flexure, and sigmoid colon groups, while extended colectomy could prolong CSS of patients in the hepatic flexure and descending colon groups.

CONCLUSION

At different colonic subsites, UCCLM patients had different CSS. PTR could improve their prognosis, however, N stage, T stage, and tumor size are important reference indicators. In addition to patients in the hepatic flexure and descending colon groups, we suggested that patients in other groups should choose segmental colectomy.

Laparoscopic Welti's Maneuver: A Single-Center Experience

Purpose: Left hemicolectomy is the standard surgical operation for a variety of colonic diseases, both benign and malignant. When colonic resection is extended, relocation of the small bowel loops can be difficult. Several techniques have been described to reposition the small intestine. Welti's technique consists in the passage of the entire small bowel to the left side of the abdomen, below the descending colon that is positioned on the right side. Methods: We retrospectively evaluated 23 patients who underwent extended left hemicolectomy and reconstruction according to the Welti's technique at our hospital. We assessed the recovery of intestinal function and the length of hospital stay; in the mid-term follow-up we searched for episodes of acute or chronic intestinal obstruction. Results: Median operative time was 215 minutes; median resumption of gas and stool emission were, respectively, 3 days (interquartile range [IQR]: 2-6) and 4 days (IQR: 2-9) after surgery. Median hospital stay was 8 (IQR: 5-37) day. After a median follow-up of 15 months (IQR: 3-132) we did not observe any episode of acute or chronic bowel obstruction. Conclusions: Welti's technique is safe and does not cause a delay in resumption of bowel functions or a delayed hospital discharge; it is a useful technique that the colorectal surgeon can use when needed.

Multidisciplinary Treatment Strategy for Early Colon Cancer: A Review-An English Version

Treatment for early colon cancer has progressed rapidly, with endoscopic resection and minimally invasive surgery. It is important to select patients without risk of lymph node metastasis before deciding on endoscopic resection for early colon cancer treatment. Pathological risk factors include histologic grade of cancer cell differentiation, lymphovascular invasion, perineural invasion, tumor budding, and deep submucosal invasion. These risk factors for predicting lymph node metastasis are crucial for determining the treatment strategy of endoscopic excision and radical resection for early colon cancer. A multidisciplinary approach is emphasized to establish a treatment strategy for early colon cancer to minimize the risk of complications and obtain excellent oncologic outcomes by selecting an appropriate treatment optimized for the patient's stage and condition. Therefore, we aimed to review the optimal multidisciplinary treatment strategies, including endoscopy and surgery, for early colon cancer.

Surgical Treatment of SplenicFlexure Colon Cancer: Analysisof Short-Term and Long-Term Outcomes of Three DifferentSurgical Procedures

BACKGROUND

The aim of this study was to compare the short- and long-term outcomes of splenic flexure colectomy (SFC), left hemicolectomy (LHC) and extended left hemicolectomy (ELHC) for splenic flexure colon cancer.

METHODS

Between January 2011 and December 2018, 117 patients with splenic flexure cancer were enrolled in the study. We retrospectively compared the postoperative, pathological and long-term outcomes of patients with splenic flexure cancer.

RESULTS

Of the 117 patients, 73 (62.4%) underwent SFC, 22 (18.8%) underwent LHC, and 22 (18.8%) underwent ELHC. No statistically significant differences were found among the groups regarding postoperative complications, pathological data or recurrence. No metastatic lymph nodes at the root of the inferior mesenteric artery (IMA) were observed; lymph node metastasis appeared at the root of the middle colic artery (MCA), but in a low proportion of cases (4.4%). Looking at long-term prognosis, no differences were observed among the three groups regarding both 5-year overall survival (94.0% vs 90.2% vs 94.1%) and disease-free survival (88.2% vs 90.2% vs 83.0%).

CONCLUSION

Our retrospective review suggests that splenic flexure colectomy in minimally invasive surgery is a safe and effective treatment option for splenic flexure colon cancer. The rate of metastatic lymph nodes at the root of the central artery and gastroepiploic arcade node was relatively low.

Is Laparoscopic Complete Mesocolic Excision and Central Vascular Ligation Really Necessary for All Patients With Right-Sided Colon Cancer?

Colon cancer treatment is on the way to evolution over several decades. The minimally invasive surgery has improved postoperative short-term outcomes. Adjuvant chemotherapy has prolonged the survival of advanced colon cancer patients. Hohenberger proposed the noble concept of complete mesocolic excision (CME) which consists of 3 components: plane surgery, sufficient longitudinal bowel resection, and central vascular ligation (CVL). Mesocolic plane surgery shares the same surgical principle of total mesorectal excision, which is maintaining the intact mesothelial envelope. However, there remain debates about the extent of bowel resection and the level of CVL for maximizing lymph node dissection. There is no solid clinical evidence for the oncological necessity and benefit of extended radical dissection in right hemicolectomy. CME with CVL based on open surgery has been adopted in laparoscopic surgery. So, it is also necessary to look at how the CME could be transformed and successfully implanted in the laparoscopic era. Recent rapid advances in surgical technology and cancer biology are preparing for fundamental changes in cancer surgery. In this study, we reviewed the history, oncological necessity, and compatibility of CME for the right hemicolectomy in the laparoscopic era and outline the new perspectives on the evolution of cancer surgery.

Primary tumor resection improves prognosis of unresectable carcinomas of the transverse colon including flexures with liver metastasis: a preliminary population-based analysis

PURPOSE

Studies on unresectable colorectal cancer liver metastasis(CRLM) rarely analyze the prognosis of the patients from the point of colonic subsites. We aimed to evaluate the effect of primary tumor resection (PTR) and different scope of colectomy on the prognosis of patients with unresectable transverse colon cancer liver metastasis (UTCLM), hepatic flexure cancer liver metastasis (UHFLM), and splenic flexure cancer liver metastasis (USFLM).

PATIENTS AND METHODS

The patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. Cox proportional hazards regression models were used to identify prognostic factors of overall survival (OS) and cause-specific survival (CSS). Kaplan-Meier analyses and log-rank tests were conducted to assess the effectiveness of PTR on survival.

RESULTS

In total, this study included a cohort of 1960 patients: 556 cases of UHFLM, 1008 cases of UTCLM, and 396 cases of USFLM. The median survival time of whole patients was 11.0 months, ranging from 7.0 months for UHFLM patients to 15.0 months for USFLM patients. USFLM patients had the best OS and CSS, followed by UTCLM patients. UHFLM patients had the worst OS and CSS (All P < 0.001). PTR could improve the OS and CSS of UTCLM, UHFLM, and USFLM (All P < 0.001). Subgroups analysis revealed that USFLM patients with tumor size≤5 cm and negative CEA had not demonstrated an improved OS and CSS after PTR. Multivariate analysis showed that PTR and perioperative chemotherapy were common independent prognostic factors for UHFLM, UTCLM, and USFLM patients. There was no difference between segmental colon resection and larger colon resection on CSS of UHFLM, UTCLM, and USFLM patients.

CONCLUSIONS

We confirmed the different survival of patients with UTCLM, UHFLM, and USFLM, and for the first time, we proved that PTR could provide survival benefits for patients with unresectable CRLM from the perspective of colonic subsites of transverse colon, hepatic flexure, and splenic flexure. Besides, PTR may not improve the prognosis of USFLM patients with CEA- negative or tumor size≤5 cm. For oncologic outcomes, we concluded that segmental colon resection seemed an effective surgical procedure for UTCLM, UHFLM, and USFLM.

Emergency surgery for splenic flexure cancer: results of the SFC Study Group database

BACKGROUND

The effectiveness of surgical treatment for splenic flexure carcinomas (SFCs) in emergency settings remains unexplored. This study aims to compare the perioperative and long-term outcomes of different alternatives for emergency SFC resection.

METHOD

This multicenter retrospective study was based on the SFC Study Group database. For the present analysis, SFC patients were selected if they had received emergency surgical resection with curative intent between 2000 and 2018. Extended right colectomy (ERC), left colectomy (LC), and segmental left colectomy (SLC) were evaluated and compared.

RESULTS

The study sample was composed of 90 SFC patients who underwent emergency ERC (n = 55, 61.1%), LC (n = 18, 20%), or SLC (n = 17, 18.9%). Bowel obstruction was the most frequent indication for surgery (n = 75, 83.3%), and an open approach was chosen in 81.1% of the patients. A higher incidence of postoperative complications was observed in the ERC group (70.9%) than in the LC (44.4%) and SLC groups (47.1%), with a significant procedure-related difference for severe postoperative complications (Dindo-Clavien ≥ III; adjusted odds ratio for ERC vs. LC:7.23; 95% CI 1.51-34.66; p = 0.013). Anastomotic leakage occurred in 8 (11.2%) patients, with no differences between the groups (p = 0.902). R0 resection was achieved in 98.9% of the procedures, and ≥ 12 lymph nodes were retrieved in 92.2% of patients. Overall and disease-free survival rates at 5 years were similar between the groups and were significantly associated with stage pT4 and the presence of synchronous metastases.

CONCLUSION

In the emergency setting, ERC and open surgery are the most frequently performed procedures. ERC is associated with increased odds of severe postoperative complications when compared to more conservative SFC resections. Nonetheless, all the alternatives seem to provide similar pathologic and long-term outcomes, supporting the oncological safety of more conservative resections for emergency SFCs.

Subtotal colectomy, extended right hemicolectomy, left hemicolectomy, or splenic flexure colectomy for splenic flexure tumors: a network meta-analysis

AIM

To perform a network meta-analysis of the current literature to evaluate the short-term and long-term outcomes of four operations for splenic flexure tumors.

METHODS

An electronic literature search of PubMed, Baidu Scholar, EMBASE, and Cochrane Central Register of Controlled Trials databases was performed up to August 2020. A Bayesian network meta-analysis was utilized to compare the outcomes involved in subtotal colectomy (STC), extended right hemicolectomy (ERHC), standard left hemicolectomy (LHC), and splenic flexure colectomy (SFC) by using R software.

RESULTS

A total of 10 non-randomized studies were included in this meta-analysis. There was no statistically significant difference among these 4 surgical techniques in terms of the utilization rate of minimally invasive surgery, reoperative surgery, anastomotic dehiscence, mortality, the proportion of patients with the number of lymph nodes harvested ≥ 12, local recurrence, distant recurrence and overall survival. Although ERHC was associated with a higher risk of postoperative ileus (ERHC vs SFC, OR = 6.4, 95% CI 1.4-45.0, P = 0.019), it has an advantage of a higher rate of primary anastomosis (ERHC vs LHC, OR = 4.2, 95% CI 1.3-18.0, P = 0.019) and a non-significant trend for lower anastomotic dehiscence when compared with more restrict resections.

CONCLUSION

SFC, LHC, ERHC and STC for the curative resection of splenic flexure tumors provide similar survival. An individualized surgical plan considering both long-term and short-term outcomes is necessary to select the appropriate operations.