Laparoscopic colonic resection for splenic flexure cancer: our experience

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.

Surgical site infection after intracorporeal and extracorporeal anastomosis in laparoscopic left colectomy for colon cancer: a multicenter propensity score-matched cohort study

BACKGROUND

Intracorporeal anastomosis (IA) is associated with reduced surgical site infection (SSI) and other postoperative complications in laparoscopic right colectomy (LRC). However, evidence is inadequate for IA in laparoscopic left colectomy (LLC). This study aimed to determine the effect of IA and extracorporeal anastomosis (EA) on SSI and other short-term postoperative complications in LLC.

METHODS

In this retrospective multicenter propensity score-matched (PSM) cohort study, we enrolled consecutive patients who underwent LLC with IA (TLLC/IA) and laparoscopic-assisted left colectomy with EA (LALC/EA) at two medical centers between January 2015 and September 2021. Propensity score matching with a 1:2 ratio was employed. The primary outcome was SSI occurrence. Secondary outcomes were operating time, intraoperative hemorrhage, other postoperative complications, and pathological outcomes.

RESULTS

Overall, 574 and 99 patients received LALC/EA and TLLC/IA, respectively. After PSM, 84 patients with TLLC/IA were matched with 141 patients with LALC/EA. Thirty patients (13.3%) patients experienced SSI (17.0% in LALC/EA vs 7.1% in TLLC/IA). IA was associated with a reduced risk of overall SSI and superficial/deep SSI compared with EA after PSM, with OR of 0.375 (95% CI, 0.147-0.959, P = 0.041). and 0.148 (95% CI, 0.034-0.648, P = 0.011), respectively. Multivariate analysis of unmatched patients indicated similar results. In the analysis of secondary outcomes, LALC/EA may have a shorter operating time (absolute mean difference - 13.41 [95% CI, - 23.76 to - 3.06], P = 0.002) and a higher risk of intraoperative hemorrhage (absolute risk difference 4.96 [95% CI, - 0.09 to 9.89], P = 0.048).

CONCLUSIONS

IA in LLC is associated with a reduced risk of overall SSI and superficial/deep SSI. However, it may require a longer operating time.

Surgical management of splenic flexure cancer: is there an optimal technique? A bi-national registry analysis

BACKGROUND

Splenic flexure tumours (SFC) are uncommon and present at more advanced disease stages. The optimal surgical technique for SFC remains controversial. We sought to compare the short-term outcomes of a left hemicolectomy (LHC) versus an extended resection (subtotal colectomy, STC) for SFCs.

METHODS

A retrospective analysis using the Binational Colorectal Cancer Audit (BCCA) registry was performed. All patients with SFC who underwent elective or emergency surgery for a SFC between 2010 and 2021 were included. Primary outcomes included short-term inpatient complications. Secondary outcomes included survival outcomes.

RESULTS

Six hundred and ninety-nine patients underwent resections for SFCs. A LHC was more common, performed in 64.1%. Patients having a LHC were significantly older, with proportionally more LHCs done laparoscopically. Overall grade III/IV complications were similar between both operations. Prolonged ileus and return to theatre were significantly higher in patients undergoing a STC. On multivariate analysis, anastomotic leak and overall grade III/IV complications were not independently associated with the type of operation. There was no difference in medial survival based on type of operation. Higher tumour stage (Stage III/IV) were independently associated with worse survival.

CONCLUSION

Segmental and extended resections are both oncologically sound procedures for SFCs. Segmental resections are associated with lower rates of prolonged ileus.

The impact of laparoscopic, open, extended right, and left colectomy on clinical outcomes of splenic flexure colon cancer: A meta-analysis

BACKGROUND

Surgical intervention is the recommended line for the management of colon cancer. The aim of this study was to evaluate the impact of different surgical techniques (laparoscopic, open, extended right, and left colectomy) on clinical outcomes such as mortality, postoperative complications, operation and hospitalization time, and oncological factors.

METHODS

A total of 15 studies have been included in the current study. The outcomes of these studies were analyzed using a random-effect model and it was used to calculate the mean difference with 95% confidence intervals to quantify the impact of open, laparoscopic, extended right, and left colectomy. Inclusion criteria included studies in which subjects undergo splenic flexure colon cancer surgery with 2 comparable different surgical techniques.

RESULTS

Laparoscopic splenic flexure colon cancer surgery showed a significant beneficial impact on the length of hospital stay (P < .001), the volume of blood loss during surgery (P < .001), postoperative complications (P < .001), and time to an oral diet (P < .001). On the other hand, there was no significance regarding anastomotic leakage, infection of the surgical site, and operation time. Regarding the comparison between extended right colectomy (ERC) and lift colectomy (LC), analysis findings showed a significant (P = .001) higher efficacy of ERC in harvested number of lymph nodes compared with LC. On the other hand, there was no significant difference for the rest of the parameters. The neoadjuvant therapy as an influencing factor on postoperative outcome showed a beneficial impact regarding the overall survival rate.

CONCLUSION

Laparoscopic splenic flexure colon cancer surgery showed a significant beneficial impact compared with open surgery as proved by clinical outcomes. On the other hand, ERC and LC resulted in similar findings except for harvested lymph nodes, results were in favor of ERC.

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.

Short and long-term oncologic outcomes of patients with colon cancer of the splenic flexure

BACKGROUND

There is currently no consensus on surgical management of splenic flexure adenocarcinoma (SFA).

METHODS

Patients undergoing surgical resection for SFA between 1993 and 2015 were identified. Postoperative outcomes were compared between patients who underwent segmental (SR) vs. anatomical resection (AR).

RESULTS

One-hundred and thirteen patients underwent SR and 89 underwent AR. More patients in the SR group had open resections, but there were otherwise no differences in demographics or surgical characteristics between the two groups. There were no differences in overall (p = 0.29) or recurrence-free(p = 0.37) survival. On multivariable analysis, increased age (HR 1.04, 1.01-1.07, p = 0.005), higher American Society of Anesthesiology classification (HR 3.1, 1.7-5.71, p < 0.001), and higher tumor stage (HR 8.84, 3.76-20.82, p < 0.001) were predictive of mortality.

CONCLUSIONS

Short and long-term outcomes after SR and AR for SFA are not different, making SR a viable option for SFA surgical management.

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 extended right hemicolectomy versus laparoscopic transverse colectomy for mid-transverse colon cancer: a multicenter retrospective study from Kanagawa Yokohama Colorectal Cancer (KYCC) study group

PURPOSE

The laparoscopic surgery approach for mid-transverse colon cancer (MTC) varies depending on tumor characteristics and the guidelines implemented by each surgeon; the optimal surgical procedure for MTC has not been established. This study aimed to compare the surgical outcomes of laparoscopic extended right hemicolectomy (Lap-ERHC) and laparoscopic transverse colectomy (Lap-TC) for MTC.

METHODS

This was a multicenter, retrospective study. We surveyed eight hospitals, by questionnaire, on MTC surgery policies and retrospectively compared the short- and long-term surgical outcomes for patients with MTC who underwent Lap-ERHC or Lap-TC between January 2008 and December 2019.

RESULTS

A total of 129 patients were enrolled, of whom 35 underwent Lap-ERHC and 94 underwent Lap-TC. There were no significant differences in tumor progression between the two groups. Operation time was significantly longer (202 min vs. 185 min, p = 0.026). We observed a higher complication rate (≥ grade 3) in the Lap-ERHC group than in the Lap-TC group (11.4% vs. 3.2%, p = 0.086). Three patients (8.6%) who underwent Lap-ERHC developed anastomotic leakage; none of the patients who underwent Lap-TC had this complication (p = 0.018). The 3-year overall survival rates (stage I: 100% vs. 91.9%, p = 0.64; stage II: 100% vs. 95.5%, p = 0.46; stage III: 100% vs. 88.2%, p = 0.91, respectively) were similar between the two groups.

CONCLUSION

Lap-ERHC for MTC has the same long-term outcomes as Lap-TC. However, Lap-ERHC for MTC has a higher complication rate. Therefore, Lap-TC may be recommended for patients with MTC.

TRIAL REGISTRATION

UMIN000042674.

A Comparison between Different Management Surgical Approaches in the Treatment of Splenic Flexure Colon Cancer

Background There are many surgical approaches which described extent of resection of the colon for adequate surgical management of splenic flexure cancer, but up till now there is no established surgical procedure, this is because the presence of double lymphatic drainage of the mesenteric vessels. Segmental resection of the colon for the management of splenic flexure cancer was a recently accepted surgical procedure.

Objective In the present study, we aimed to compare three surgical management techniques to clarify the best management approach of Egyptian patients with splenic flexure cancer regarding operative, clinical, and oncological outcomes: segmental resection, and extended left or right hemicolectomy,.

Materials and Methods In the present study, we included 90 patients with splenic flexure cancer. Cases were divided into 3 groups. Each group included 30 patients in order to compare three surgical techniques: segmental resection, extended left hemicolectomy, and extended right hemicolectomy.

Results We have found no statistically significant differences between the three included groups regarding operative findings, postoperative complications, local recurrence, distant recurrence, disease progression, recurrence-free survival rate, progression-free survival rate, and overall survival rate. The operative time was longer, and the number of lymph nodes was higher in the extended right hemicolectomy group (p < 0.001).

Conclusion We have shown that segmental resection of the splenic flexure is surgically and clinically suitable for the adequate management of operable cases of carcinoma of the splenic flexure.

What Is the Optimal Elective Colectomy for Splenic Flexure Cancer: End of the Debate? A Multicenter Study From the GRECCAR Group With a Propensity Score Analysis

BACKGROUND

The optimal elective colectomy in patients with splenic flexure tumor is debated.

OBJECTIVE

This study aimed to compare splenic flexure colectomy, left hemicolectomy, and subtotal colectomy for perioperative, histological, and survival outcomes in this setting.

DESIGN

This is a multicenter retrospective cohort study.

SETTING

Patients diagnosed with nonmetastatic splenic flexure tumor who underwent elective colectomy were included.

PATIENTS

Between 2006 and 2014, 313 consecutive patients were operated on in 15 French Research Group of Rectal Cancer Surgery centers.

INTERVENTIONS

Propensity score weighting was performed to compare short- and long-term outcomes.

MAIN OUTCOME MEASURES

The primary end point was disease-free survival. Secondary end points included overall survival, quality of surgical resection, overall postoperative morbidity, surgical postoperative morbidity, and rate of anastomotic leakage.

RESULTS

The most performed surgery was splenic flexure colectomy (59%), followed by subtotal colectomy (23%) and left hemicolectomy (18%). Subtotal colectomy was more often performed by laparotomy compared with splenic flexure colectomy and left hemicolectomy (93% vs 61% vs 56%, p < 0.0001), and was associated with a longer operative time (260 minutes (120-460) vs 180 minutes (68-440) vs 217 minutes (149-480), p < 0.0001). Postoperative morbidity was similar between the 3 groups, but the median length of hospital stay was significantly longer after subtotal colectomy (13 days (5-56) vs 10 (4-175) vs 9 (4-55), p = 0.0007). The median number of harvested lymph nodes was significantly higher after subtotal colectomy compared with splenic flexure colectomy and left hemicolectomy (24 (8-90) vs 15 (1-81) vs 16 (3-52), p < 0.0001). The rate of stage III disease and the number of patients treated by adjuvant chemotherapy were similar between the 3 groups. There was no difference in terms of disease-free survival and overall survival between the 3 procedures.

LIMITATIONS

The study was limited by its retrospective design.

CONCLUSIONS

In the elective setting, splenic flexure colectomy is safe and oncologically adequate for patients with nonmetastatic splenic flexure tumor. However, given the oncological clearance after splenic flexure colectomy, it seems that the debate is not completely closed. See Video Abstract at http://links.lww.com/DCR/B703.

CUL ES LA COLECTOMA ELECTIVA PTIMA PARA EL CNCER DE NGULO ESPLNICO FIN DEL DEBATE UN ESTUDIO MULTICNTRICO DEL GRUPO GRECCAR CON UN ANLISIS DE PUNTAJE DE PROPENSIN

ANTECEDENTES:La colectomía electiva óptima en pacientes con tumores del ángulo esplénico continua en debate.OBJETIVO:Comparar la colectomía de ángulo esplénico, hemicolectomía izquierda y colectomía subtotal para los resultados perioperatorios, histológicos y de supervivencia en este escenario.DISEÑO:Estudio de cohorte retrospectivo multicéntrico.ESCENARIO:Se incluyeron pacientes diagnosticados de tumores del ángulo esplénico no metastásicos que se sometieron a colectomía electiva.PACIENTES:Entre 2006 y 2014, 313 pacientes consecutivos fueron intervenidos en 15 centros GRECCAR.INTERVENCIONES:Se realizó una ponderación del puntaje de propensión para comparar los resultados a corto y largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la supervivencia libre de enfermedad. Los criterios de valoración secundarios incluyeron la supervivencia general, la calidad de la resección quirúrgica, la morbilidad posoperatoria general, la morbilidad posoperatoria quirúrgica y la tasa de fuga anastomótica.RESULTADOS:La cirugía más realizada fue la colectomía del ángulo esplénico (59%), seguida de la colectomía subtotal (23%) y la hemicolectomía izquierda (18%). La colectomía subtotal se realizó con mayor frecuencia mediante laparotomía en comparación con la colectomía de ángulo esplénico y la hemicolectomía izquierda (93% frente a 61% frente a 56%, p <0.0001), y se asoció con un tiempo quirúrgico más prolongado (260 min [120-460] frente a 180 min [68-440] frente a 217 min [149-480], p <0.0001). La morbilidad posoperatoria fue similar entre los tres grupos, pero la duración media de la estancia hospitalaria fue significativamente más prolongada después de la colectomía subtotal (13 días [5-56] frente a 10 [4-175] frente a 9 [4-55], p = 0.0007). La mediana del número de ganglios linfáticos extraídos fue significativamente mayor después de la colectomía subtotal en comparación con la colectomía del ángulo esplénico y la hemicolectomía izquierda (24 [8-90] frente a 15 [1-81] frente a 16 [3-52], p <0.0001). La tasa de enfermedad en estadio III y el número de pacientes tratados con quimioterapia adyuvante fueron similares entre los 3 grupos. No hubo diferencias en términos de supervivencia libre de enfermedad y supervivencia general entre los 3 procedimientos.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo.CONCLUSIONES:En un escenario electivo, la colectomía del ángulo esplénico es segura y oncológicamente adecuada para pacientes con tumores del ángulo esplénico no metastásicos. Sin embargo, dado el aclaramiento oncológico tras la colectomía del ángulo esplénico, parece que el debate no está completamente cerrado. Consulte Video Resumen en http://links.lww.com/DCR/B703.

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.

Short- and long-term outcomes of laparoscopic segmental left colectomy for splenic flexure colon cancer: comparison with propensity score matching

Purpose

Splenic flexure colon cancer (SFCC) is a rare disease that accounts for 2%–8% of colorectal cancers, and the extent of surgery and resection is still debatable. There have also been few studies on the safety and feasibility of laparoscopic surgery for SFCC. The purpose of this study is to evaluate outcomes and prognoses of surgery for SFCC.

Methods

We included patients with stage 1 to 3 who had undergone laparoscopic surgery for distal transverse-to-sigmoid colon cancer at 2 hospitals from March 2004 to December 2016 and collected data by retrospective design. We defined SFCC as being cancer between distal transverse and proximal descending colon. The short- and long-term outcomes of the anterior resection (AR) group (those patients who had undergone laparoscopic AR for mid and distal descending to sigmoid colon cancer) and the left colon resection (LR) group (those who had undergone laparoscopic segmental left colectomy for SFCC) were compared using propensity score matching.

Results

The median follow-up period was 60 months. The numbers of subjects in the AR and the LR groups were 948 and 118. After 2:1 propensity score matching, 236 vs. 118 patients were selected. There was no significant difference in 5-year disease-free survival (80.7% vs. 78.6%, P = 0.607), and both the 5-year overall survival (89.2% vs. 88.2%, P = 0.563) as well as short-term outcomes showed no statistical difference in most of the variables.

Conclusion

Laparoscopic segmental left colectomy can be one option among the standard procedures for SFCC.

Surgical anatomy of the accessory middle colic artery: a meta-analysis with implications for splenic flexure cancer surgery

AIM

Surgical resection of splenic flexure cancers (SFCs) is technically demanding due to the complex regional anatomy, characterized by the presence of embryological adhesions, close proximity to the pancreas and spleen, and a highly heterogeneous arterial supply and lymphatic drainage. The accessory middle colic artery (AMCA) is increasingly being recognized as an important source of blood supply to the splenic flexure. The aim of this study is to determine the prevalence and anatomical features of the AMCA.

METHOD

A systematic search of the scientific literature was conducted on PubMed and Embase from inception to November 2020 to identify potentially eligible studies. Data were extracted and prevalence was pooled into a meta-analysis using MetaXL and Meta-Analyst software.

RESULTS

A total of 16 studies (n = 2203 patients) were included. The pooled prevalence (PP) of the AMCA was 25.4% (95% CI 18.1-33.4). Its prevalence was higher in patients without a left colic artery (LCA) (PP = 83.2%; 95% CI 70.4-93.1). The commonest origin for the AMCA was the superior mesenteric artery (PP = 87.9%; 95% CI 86.4-90.7). The AMCA shared a common trunk/gave rise to pancreatic branches in 23.1% of cases (95% CI 15.3-31.9).

CONCLUSION

The AMCA contributes to the vascularization of the splenic flexure in approximately 25% of individuals, and may be an important feeder artery to SFCs, especially in the absence of a LCA. Preoperative identification of this artery is important to ensure optimal surgery for SFC and minimize complications.

Laparoscopic complete mesocolic excision with central vascular ligation for splenic flexure colon cancer: short- and long-term outcomes

Background

Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices.

Methods

We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017.

Results

Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis.

Conclusions

Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon’s skill. The appropriate indications must be established with more case registries because our experience is limited.

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.

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.

Evaluation of vascular anatomy for colon cancer located in the splenic flexure using the preoperative three-dimensional computed tomography angiography with colonography

PURPOSE

The aim of this study is to reveal the vascular branching variation in SFC (splenic flexure cancer) patients using the preoperative three-dimensional computed tomography angiography with colonography (3D-CTAC).

METHODS

We retrospectively analyzed patients with SFC who underwent preoperative 3D-CTAC between January 2014 and December 2019.

RESULTS

Among 1256 colorectal cancer (CRC) patients, 96 (7.6%) manifested SFC. The arterial branching from the superior mesenteric artery (SMA) was classified into five patterns, as follows: (type 1A) the left branch of middle colic artery (LMCA) diverged from middle colic artery (MCA) (N = 47, 49.0%); (2A) the LMCA diverged from the MCA and the accessory middle colic artery (AMCA) (N = 26, 27.1%); (3A) the LMCA independently diverged from the SMA (N = 16, 16.7%); (4A) the LMCA independently diverged from the SMA and AMCA (N = 3, 3.1%); (5A) only the AMCA and the LMCA was absent (N = 4, 4.1%). Venous drainage was classified into four patterns, as follows: (type 1V) the SFV flows into the inferior mesenteric vein (IMV) then back to the splenic vein (N = 50, 52.1%); (2V) the SFV flows into the IMV then back to the superior mesenteric vein (SMV) (N = 19, 19.8%); (type 3V) the SFV independently flows into the splenic vein (N = 3, 3.1%); (type 4V) the SFV is absent (N = 24, 25.0%).

CONCLUSION

3D-CTAC could reveal accurate preoperative tumor localization and vascular branching. These classifications should be helpful in performing accurate complete mesocolic excision and central vessel ligation for SFC.

Efficient and Safe Method for Splenic Flexure Mobilization in Laparoscopic Left Hemicolectomy: A Propensity Score-weighted Cohort Study

Supplemental Digital Content is available in the text.

Because methods of performing laparoscopic left hemicolectomy differ between surgeons, standardizing the procedure is crucial to reduce complications and secure good oncologic outcomes.

Clinical-Pathologic Characteristics and Long-term Outcomes of Left Flexure Colonic Cancer: A Retrospective Analysis of an International Multicenter Cohort

BACKGROUND

Colorectal cancer seldom presents at the splenic flexure. Small series on left flexure tumors reported a high occurrence of negative prognostic factors called into question as causes of poor prognosis. However, because of the small number of cases, no definite conclusions can be drawn.

OBJECTIVE

The aim of this study was to compare clinical-pathologic characteristics and short- and long-term outcomes of left flexure tumors with other colonic locations.

DESIGN

This was a retrospective analysis of consecutive patients who underwent surgery for tumors at the splenic flexure. Each tumor was paired in a 1 to 1 fashion with a right-sided and sigmoid tumor.

SETTINGS

The study was conducted in 10 international centers.

PATIENTS

A total of 641 patients with left flexure tumors were included in the study.

MAIN OUTCOME MEASURES

Overall survival and cancer-specific survival were measured.

RESULTS

Left flexure tumors presented more frequently with stenosis (30.5%; p < 0.001), with lesions infiltrating beyond the serosa (21.9%; p = 0.001) and with a high rate of mucinous histology (8.8%; p = 0.001). Looking at long-term prognosis, no differences were observed among the 3 groups, both considering overall and cancer-specific survival. However, left flexure tumors recurred more frequently as peritoneal carcinomatosis (20.6%; p < 0.001).

LIMITATIONS

This study was limited because of its retrospective nature.

CONCLUSIONS

Although left flexure tumors display several negative prognostic factors, they are not characterized by a worse prognosis compared with other colon cancer locations. See Video Abstract at http://links.lww.com/DCR/B395. CARACTERÍSTICAS CLÍNICO-PATOLÓGICAS Y RESULTADOS A LARGO PLAZO DEL CÁNCER DE COLON DE ÁNGULO IZQUIERDO: UN ANÁLISIS RETROSPECTIVO DE UNA COHORTE MULTICÉNTRICA INTERNACIONAL: El cáncer colorrectal rara vez se presenta en el ángulo esplénico. Pequeñas series sobre tumores de ángulo izquierdo informaron una alta incidencia de factores pronósticos negativos cuestionados como causas de mal pronóstico. Sin embargo, debido al pequeño número de casos, no se pueden sacar conclusiones definitivas.El objetivo de este estudio fue comparar las características clínico-patológicas, los resultados a corto y largo plazo de los tumores de ángulo izquierdo con otras ubicaciones de colon.Análisis retrospectivo de pacientes consecutivos que se sometieron a cirugía por tumores en el ángulo esplénico. Cada tumor se emparejó de forma individual con un tumor del lado derecho y sigmoide.El estudio se realizó en 10 centros internacionales.Se incluyeron en el estudio un total de 641 pacientes con tumores del ángulo izquierdo.Supervivencia general y específica del cáncerLos tumores de ángulo izquierda se presentaron con mayor frecuencia con estenosis (30.5%, p <0.001), con lesiones infiltradas más allá de la serosa (21.9%, p = 0.001), y con una alta tasa de histología mucinosa (8.8%, p = 0.001). En cuanto al pronóstico a largo plazo, no se observaron diferencias entre los tres grupos, considerando la supervivencia general y específica del cáncer. Sin embargo, los tumores de ángulo izquierdo recurrieron con mayor frecuencia como carcinomatosis peritoneal (20,6%; p <0,001).Este estudio fue limitado debido a su naturaleza retrospectiva.Aunque los tumores de ángulo izquierdo muestran varios factores pronósticos negativos, no se caracterizan por un peor pronóstico en comparación con otras ubicaciones de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B395.

Laparoscopic Colectomy for Splenic Flexure Cancer Approached from Four Directions

Background: Standardized protocols for laparoscopic surgery of splenic flexure cancer (SFC) have not been established yet. We described a standardized laparoscopic procedure for SFCs and examined its safety and feasibility. Methods: Laparoscopic colectomy for SFC was performed as follows. The sigmoid colon was mobilized to the descending mesocolon through the medial approach. After confirming the base of the inferior mesenteric artery, the left colic artery was dissected and resected at the base. Further dissection was carried out between the mesentery of the colon and the renal fascia until it exceeded the upper pole of the left kidney and the splenic flexure. The next dissection reached the white line at the lateral side and the sigmoid-descending colon junction. After making an incision at the greater omentum and gastrocolic ligament from the center of the transverse colon to the splenic flexure, the transverse mesocolon base was dissected from the inside splenic flexure for complete mobilization. This was performed by approaching from four directions toward the splenic flexure. Intestinal resection and anastomosis are performed. Results: This procedure was performed in 70 patients with splenic flexure colon cancer (mean age 70 years). The mean operative time was 190 minutes, and the mean blood loss was 2.0 mL. No notable perioperative or postoperative complications were noted. Conclusions: Safe mobilization of the splenic flexure can be achieved by approaching from four directions, and standardization of left colectomy can facilitate complete mesenteric excision.

Colonic splenic flexure carcinoma: is laparoscopic segmental resection a safe enough oncological approach?

BACKGROUND

The surgical approach to the colonic splenic flexure cancer (SFC) is yet to be technically standardized. The aim of this study has been to retrospectively evaluate the oncologic long-term results of our cases comparing our data with other authors' experiences.

METHODS

Clinical data of patients with SFC operated on at our institute were retrospectively analyzed. The laparoscopic approach was used in the whole series, with limited resection distally and proximally to splenic flexure and the origin ligation of left colic artery and left branch of middle colic artery. Data on the oncological long-term safety were compared to our laparoscopic series of extended right colectomy for proximal two-third transverse colon cancer and high anterior resections for sigmoid-high rectal cancer and to the main evidences in the literature, found after a comprehensive review.

RESULTS

From March 2008 to May 2018, we completed 53 laparoscopic splenic flexure resections (26 female and 27 male, age 71.5 ± 15.4 years). The conversion rate was 3.8%. Most of the cases were stage II (pT3 73.5%, the mean number of lymph nodes harvested was 19.1, with positivity for malignancy in 45.3%). During the FU (43.5 months), 2 patients dropped out. Out of the 51 residual cases, 37 were alive (72.5%) and 14 are deceased (27.5%).

DISCUSSION

Compared to the literature, our survival rate does not show significant differences. The other oncological outcomes seem to be comparable with the data evaluated.

CONCLUSIONS

More extended resections seem not to confer an increase of the overall survival rate.

Key clinical applications for indocyanine green fluorescence imaging in minimally invasive colorectal surgery

Near-infrared indocyanine green (ICG) fluorescence imaging has gained solid acceptance over the last years, and rightly so, as this technology has so much to offer, especially in the field of minimally invasive surgery. Firm evidence from ongoing and future studies will hopefully transform many of the applications of ICG fluorescence into the standard of care for our patients. This review examines the current status of ICG fluorescence for assessment of bowel perfusion, lymphatic mapping as well as intraoperative localisation of ureter in light of the published academic literature in English.

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.

Laparoscopic segmental left colectomy for splenic flexure carcinoma: a single institution experience

BACKGROUND

There is ongoing debate regarding surgical treatment of splenic flexure cancer. The main points of controversy include the appropriate extent of colon resection, either to the right or to the left, and the appropriate extent of lymph-node dissection. The aim of this study was to review our experience in laparoscopic treatment of splenic flexure cancer cases and to compare our data to the recent literature.

METHODS

Consecutive patients, operated on for splenic flexure colon carcinoma at a single institution between April 2005 and January 2013, were included in the study. Exclusion criteria were a previous history of colorectal cancer, recurrent colonic cancer, emergency cases with an obstructive tumor or a perforated tumor with peritonitis, synchronous cancer, palliative surgery, and a past history of colorectal resection. Patients underwent laparoscopic segmental left colectomy with ligation of the left branch of the middle colic and of the left colic artery. Patient characteristics, operative and postoperative outcomes, and long-term technical, functional, and oncological results from a prospectively maintained database were retrospectively analyzed. After hospital discharge, standardized follow-up was performed at 1 month postoperatively, then every 3 months during the first 2 years, and every 6 months thereafter, for a total of 5 years.

RESULTS

A total of 28 consecutive patients (16 males) with a median age of 71.8 years (range 42.5-88.8 years) were included. Ninety-day mortality was 3.5% and surgical morbidity was 21.5% with anastomotic leak rate of 10.7%. All survivors experienced good or very good functional results. During a median follow-up period of 50.9 months, eight patients (28.5%) presented with a recurrence. The 5-year overall and disease-free survival rates were 46.3% and 39.2%, respectively.

CONCLUSIONS

Segmental left colectomy for splenic flexure carcinoma is associated with reasonably low morbidity and very good functional results. However, survival rates are low.

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.

Distribution of lymph node metastasis and the extent of lymph node dissection in descending colon cancer patients

BACKGROUND

The optimal extent of lymph node dissection in patients with descending colon cancer is still debatable. We designed this study to evaluate the distribution of lymph node metastasis and the appropriate extent of lymph node dissection in descending colon cancer patients.

METHODS

We retrospectively reviewed the medical records of 118 descending colon cancer patients without distant metastasis, who underwent curative resection between January 2004 and December 2014. The distribution of lymph node metastasis was evaluated, and prognostic factors were analysed.

RESULTS

The median follow-up period was 52 months (range 1-125 months). Twenty-six (22.0%) patients underwent high ligation of the inferior mesenteric artery (IMA), whereas 92 (78.0%) patients underwent ligation of the left colic artery, saving the IMA. Lymph nodes at the origin of the IMA showed no metastasis in any of the 26 patients who underwent high ligation of the IMA. After propensity score matching, 3-year disease-free survival (80.4% versus 92.9%, P = 0.471) and 5-year overall survival (81.8% versus 90.9%, P = 0.875) were not significantly different according to the type of IMA ligation.

CONCLUSION

In patients with descending colon cancer, there was no lymph node metastasis at the origin of the IMA, and ligation of the IMA showed no prognostic benefit.

Treatment of splenic flexure colon cancer: a comparison of three different surgical procedures: Experience of a high volume cancer center

Extended right or left hemicolectomy are the most common surgical treatments for splenic flexure colon cancer. Extended resection (including distal pancreasectomy and/or splenectomy), has been often indicated for the treatment for the splenic flexure cancer, because the lymphatic drainage at this site is poorly defined and assumed as heterogeneous. Between January 2006 and May 2016, 103 patients with splenic flexure colon cancer were enrolled in the study. We evaluated the clinicopathological findings and outcomes of all patients and associated them to the different surgical treatment. Out of 103 selected cases an extended right hemicolectomy was performed in 22 (21.4%) patients, an extended left hemicolectomy in 24 (23.3%) patients, a segmental resection of the splenic flexure in 57 (55.3%) patients; the combined resection of adjacent organs showing tumor adherence was carried out in 11 (10.7%) patients. The tumor infiltrated near organs (T4) in 5 patients. No significant differences in complications were found among the three groups. In all groups no differences were found in the total number of harvested lymphnodes. After a median follow-up of 42 months, 30 recurrences and 19 deaths occurred (12 for tumor progression). There was no difference in overall and progression free survival among the three different surgical treatments. According to our results, the partial resection of splenic flexure was not associated with a worse prognosis and it was leading for a satisfactory oncological outcome. It is our opinion that the extended surgery is seldomly indicated to cure splenic flexure cancer.

Laparoscopic resection of splenic flexure colon cancers: a retrospective multi-center study with 117 cases

The objective is to investigate the short- and long-term outcomes of laparoscopic resections of splenic flexure colon cancers in three Italian high-volume centers. The laparoscopic resection of splenic flexure colon cancers is a challenging procedure and has not been completely standardized, mainly due to the technical difficulty, the arduous identification of major blood vessels, and the problems associated with anastomosis construction. In this retrospective cohort observational study, a consecutive series of patients treated in three Italian high-volume centers with elective laparoscopic resection of the splenic flexure for cancer is analyzed. The observational period was from January 2008 to August 2017. Patient demographics and clinical features, operative data, and short- and long-term outcomes were prospectively recorded in a specific database and were retrospectively analyzed. During the observation period, 117 patients were selected. Conversion to open surgery was necessary in 15 patients (12.8%). Of 102 complete laparoscopic procedures, multi-visceral resection was performed in 13 cases (12.7%). Postoperative surgical complications occurred in 13 patients (12.7%), with 3 cases of anastomotic leak (2.9%) and 3 cases of re-operation (2.9%). The postoperative mortality in this population was null. The 5-year overall survival rate was 84.3%, and the 5-year disease-free survival rate was 87.8%. Laparoscopic resection of the splenic flexure is feasible and safe in high-volume centers. Compared to the results of other laparoscopic colonic resections, the short- and long-term outcomes are similar, but the conversion rate is higher.

Is Segmental Colon Resection an Alternative Treatment for Splenic Flexure Cancer?

Background: Optimal elective surgery for splenic flexure cancer is unclear. Three types of surgical treatment methods are commonly used, subtotal colectomy (STC), left hemicolectomy (LHC), and segmental colon resection (SCR), but consensus is lacking as to which is the optimal method. Materials and Methods: We retrospectively compared clinicopathological and operative results, morbidity, mortality, and long-term survival in patients with splenic flexure cancer who underwent surgery between 1998 and 2018. Results: The study included 124 patients in the study. Following retrospective evaluation of the database, patients were classified into one of three groups according to the surgical approach: (1) STC (n: 41), (2) LHC (n: 55), and (3) SCR (n: 28). No statistically significant differences were found between groups regarding operative results, hospital stay, pathological data, mortality, recurrence, or long-term survival outcomes. Conclusion: Our results suggest that surgical procedures such as STC and LHC have no statistically significant clinical benefits over less aggressive approaches such as SCR. We thus conclude that SCR seems both a safe and effective alternative for splenic flexure tumors.

Robotic left colectomy with complete mesocolectomy for splenic flexure and descending colon cancer, compared with a laparoscopic procedure

BACKGROUND

Its relatively low incidence and its surgical complexity mean that a standardized technique for left colectomy has not yet been established for splenic flexure and descending colon cancer (SF-DCC).

METHODS

Seventy-three patients (robot-assisted left colectomy with complete mesocolectomy [R-LCCM], n = 20; laparoscopic left colectomy with complete mesocolectomy [L-LCCM], n = 53) with SF-DCC were enrolled at the Asan Medical Center (Seoul, Korea).

RESULTS

R-LCCM conveniently enables dexterous dissection for the multi-directional approaches during left mesocolic mobilization. A conversion to open surgery was required in two patients of the L-LCCM group, but not in the R-LCCM group. A positive circumferential resection margin was exclusively identified in two patients in the L-LCCM group. Mean lymph node harvest was 21 with no difference between the two groups.

CONCLUSIONS

Although R-LCCM provided few remarkable advantages over L-LCCM, it could be considered as an efficient approach in patients with SF-DCC.

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.

Lymphatic Drainage of the Splenic Flexure Defined by Intraoperative Scintigraphic Mapping

BACKGROUND

The optimal surgical management of splenic flexure cancer is debated, partly because of an incomplete understanding of the lymphatic drainage of this region.

OBJECTIVE

This study aimed to evaluate the normal lymphatic drainage of the human splenic flexure using laparoscopic scintigraphic mapping.

DESIGN

This was a clinical trial.

SETTINGS

The study was conducted at a single tertiary care center.

PATIENTS

Thirty consecutive patients undergoing elective colorectal resections without splenic flexure pathology were recruited.

INTERVENTION

Technetium-99m was injected subserosally at the splenic flexure.

MAIN OUTCOME MEASURES

Lymphatic scintigraphic mapping was undertaken at 15, 30, and 60 minutes using a laparoscopic gamma probe at the left branch of the middle colic, left colic, inferior mesenteric, and ileocolic (control) lymphovascular pedicles.

RESULTS

Lymphatic drainage at 60 minutes was strongly dominant in the direction of the left colic pedicle (96% of patients), with a median gamma count of 284 (interquartile range, 113-413), versus the left branch of the middle colic count of 31 (interquartile range, 15-49; p < 0.0001). This equated to a median 9.2-times greater flow to the left colic versus the middle colic. Counts at the left colic were greater than all of the other mapped sites at 15, 30, and 60 minutes (p < 0.001), whereas middle colic and inferior mesenteric artery counts were equivalent. The protocol increased operative duration by 20 to 30 minutes without complications.

LIMITATIONS

These results report lymphatic drainage from patients with normal splenic flexures, and caution is necessary when extrapolating to patients with splenic flexure cancers.

CONCLUSIONS

The lymphatic drainage of the normal splenic flexure is preferentially directed toward the left colic in the high majority of cases. Retrieving these nodes should be prioritized in splenic flexure cancer resections, with important secondary emphasis on left middle colic nodes, supporting segmental (left hemicolectomy) resection as the procedure of choice. Additional development of colonic sentinel node mapping using these techniques may contribute to individualized surgical therapy morbidity. See Video Abstract at http://links.lww.com/DCR/A495.

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.

Anatomical and embryological perspectives in laparoscopic complete mesocoloic excision of splenic flexure cancers

BACKGROUND

Laparoscopic complete mesocoloic excision (CME) with central vascular ligation for splenic flexure cancer is technically challenging because of its anatomical complexity. Although embryological and anatomical consideration should be helpful to perform CME in colorectal cancer surgery, such studies on the splenic flexure are lacking.

METHODS

The splenic flexure is located embryologically between the terminal portion of the midgut and the beginning of the hindgut, and is supplied by the superior mesenteric and inferior mesenteric arteries. The mesentery of the transverse and descending colon originally is a continuous sheet, although they rotate and partially fuse to each other during development. Our surgical strategy was excision of the transverse and descending mesocolon with ligation of the left colic artery and left branch of the middle colic artery, and extraction of the specimen in an intact package wrapped by the embryological planes.

RESULTS

We performed laparoscopic surgery according to our surgical strategy in 17 patients with splenic flexure colon cancer. There were no conversions to open surgery or serious intraoperative complications. Two patients had pathological stage (pStage) I, 5 pStage II, 9 pStage III, and 1 pStage IV disease. No patient had recurrence except for 1 with pStage IV cancer, with a median follow-up of 16 months.

CONCLUSIONS

Our laparoscopic CME technique is feasible for treatment of splenic flexure cancer. Knowledge of anatomy based on embryology is essential to perform this surgery.

Long-term oncologic outcomes of laparoscopic surgery for splenic flexure colon cancer are comparable to conventional open surgery

Purpose

Few studies about laparoscopic surgery for splenic flexure colon cancer have been published. This study aims to compare the short- and long-term outcomes of laparoscopic surgery for splenic flexure colon cancer with those of conventional open surgery.

Methods

From January 2004 to December 2010, 51 consecutive patients who underwent curative resection for stages I–III splenic flexure colon cancer were enrolled. Thirty-three patients underwent laparoscopy-assisted colectomy, while 18 patients underwent conventional open colectomy. Short- and long-term outcomes of the 2 groups were compared.

Results

There were no differences in baseline characteristics, intra- and postoperative complications. The laparoscopy group showed longer operation time (median [interquartile range, IQR]: 295.0 [255.0–362.5] minutes vs. 180.0 [168.8–206.3] minutes, P < 0.001). In the laparoscopy group, return of bowel function was faster (median [IQR]: 3 [2–4] vs. 4 [3–5], P = 0.007) and postoperative hospital stay was shorter (median [IQR]: 9 [8–11] vs. 10.5 [9–19], P = 0.026). There were no statistically significant differences in overall survival rate (84.3% vs. 76.0%, P = 0.560) or disease-free survival rate (93.8% vs. 74.5%, P = 0.078) between the 2 groups.

Conclusion

Laparoscopic surgery for splenic flexure colon cancer has better short-term outcomes than open surgery, as well as acceptable long-term outcomes. Laparoscopic surgery can be a safe and feasible alternative to conventional open surgery for splenic flexure colon cancer.

Evaluation of lymph flow patterns in splenic flexural colon cancers using laparoscopic real-time indocyanine green fluorescence imaging

PURPOSE

The treatment of splenic flexural colon cancer is not standardized because the lymphatic drainage is variable. The aim of this study is to evaluate the lymph flow at the splenic flexure.

METHODS

From July 2013 to January 2016, consecutive patients of the splenic flexural colon cancer with a preoperative diagnosis of N0 who underwent laparoscopic surgery were enrolled. Primary outcome is frequency of the direction of lymph flow from splenic flexure. We injected indocyanine green (2.5 mg) into the submucosal layer around the tumor and observed lymph flow using the laparoscopic near-infrared camera system in 30 min after injection.

RESULTS

Thirty-one patients were enrolled in this study. The lymph flow was visualized in 31 patients (100 %) without any complications. No case exhibited lymph flow in both the left colic artery (LCA) and left branch of the middle colic artery (lt-MCA) areas. There were 19 cases (61.3 %) with lymph flow directed to the area of the root of the inferior mesenteric vein (IMV), regardless of the presence of the left accessory aberrant colic artery. Lymph node metastases were observed in six cases (19.4 %), and all of the involved lymph nodes existed in lymph flow areas determined by real-time indocyanine green fluorescence imaging.

CONCLUSIONS

The findings of the lymph flow pattern of splenic flexure suggest that lymph node dissection at the root of the IMV area is important, and it may be not necessary to ligate both the lt-MCA and LCA, at least in cases without widespread lymph node metastases.