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

Elsayed I. El-Hendawy Mohamed Farouk Amin Ahmed M. Fahmy Ahmed Z. Alattar Shereen Elshorbagy Ola A. Harb Ahmed Fathy Gomaa Ahmed Embaby Ahmed M. Elsayed Gamal Osman Ramadan M. Ali About the authors

Abstract

Background

There are many surgical approaches which described extent of resection of the colon for adequate surgicalmanagement of splenic flexure cancer, but up till now there is no established surgical procedure, this is because the presence of double lymphatic drainage of themesenteric 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.

Keywords:
splenic flexure cancer; surgery; segmental resection; outcome

Introduction

Splenic flexure cancer is a type of colon cancer that is located in the left corner of the colon, in the distal part of the transverse colon, or in the proximal part of the descending colon. It is considered a rare anatomical variant of colon cancer.11 Rega D, Pace U, Scala D, et al. Treatment of splenic flexure colon cancer: a comparison of three different surgical procedures: Experience of a high volume cancer center. Sci Rep 2019;9(01):10953 It is diagnosed late in advanced stage, mostly with obstructive manifestations.22 Milone M, Angelini P, Berardi G, et al. Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients. Surg Endosc 2018;32(08):3467-3473 There are many surgical approaches that describe the extent of resection of the colon for successive management of splenic flexure cancer, but there is no established surgical procedure due to double lymphatic drainage of the mesenteric vessels.33 Shaikh IA, Suttie SA, Urquhart M, Amin AI, Daniel T, Yalamarthi S. Does the outcome of colonic flexure cancers differ from the other colonic sites? Int J Colorectal Dis 2012;27(01):89-93 44 Odermatt M, Siddiqi N, Johns R, et al. Short- and long-term outcomes for patients with splenic flexure tumours treated by left versus extended right colectomy are comparable: a retrospective analysis. Surg Today 2014;44(11):2045-2051 Many authors tried to identify the best surgical approaches for the management of splenic flexure cancer, either open or laparoscopic, extracorporeal or intracorporeal anastomosis.22 Milone M, Angelini P, Berardi G, et al. Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients. Surg Endosc 2018;32(08):3467-3473 Few surgeons accept the performance of segmental resection of the colon for the management of splenic flexure cancer.55 Chong CS, Huh JW, Oh BY, et al. Operative Method for Transverse Colon Carcinoma: Transverse Colectomy Versus Extended Colectomy. Dis Colon Rectum 2016;59(07):630-639 66 van Rongen I, Damhuis RA, van der Hoeven JA, Plaisier PW. Comparison of extended hemicolectomy versus transverse colectomy in patients with cancer of the transverse colon. Acta Chir Belg 2013;113(02):107-111

There are few published reports that assessed the benefits of segmental resection in comparison with extended colectomy to detect the best approach for the surgical management of splenic flexure cancer. Rega et al.11 Rega D, Pace U, Scala D, et al. Treatment of splenic flexure colon cancer: a comparison of three different surgical procedures: Experience of a high volume cancer center. Sci Rep 2019;9(01):10953 tried in their retrospective study to detect the benefits of segmental resection and have showed similar oncological benefits from extended colectomy and segmental resection. To our knowledge, there are no prospective studies that compared the outcome of Egyptian patients with splenic flexure cancer who were managed by different surgical techniques.

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 hemi-colectomy.

Materials and Methods

In the present study, we included 90 patients with splenic flexure cancer who were managed and subsequently followed-up in the period from February 2017 to February 2020. Cases were operated in General Surgery department of the Faculty of Medicine of the Zagazig University hospitals. Cases were divided into 3 groups. Each group included 30 patients in order to compare 3 surgical techniques: segmental resection, extended left hemicolectomy, and extended right hemicolectomy.

Inclusion Criteria

Patients with proven diagnosis of splenic flexure cancer stage I to III who underwent curative resection.

Patients with complete medical files.

Patients who accepted to be included in the study.

Exclusion Criteria

Patients with distant metastases, synchronous or metachronous colon cancer, palliative or emergency resection, and patients who received preoperative therapy were excluded.

Finally, we included ninety patients with splenic flexure cancer who were divided into 3 equal groups each group included 90 patients who were managed by one of the 3 different techniques.

Preoperative Workup

Complete physical examination, colonoscopy, biopsy for histopathological confirmation of the diagnosis, computed tomography (CT) of the whole body, and assessment of serum levels of carcinoembryonic antigen.

The following patient characteristics were recorded: age, gender, year of surgery, surgical management approach, and resection type

Operative Data

The following operative data were recorded: operative time, amount of blood loss, intraoperative complications, and operative mortality.

Postoperative Data

The following postoperative data were recorded: duration hospital stay, postoperative complications, 30-day morbidity and mortality.

Histopathological Evaluation

Histopathological subtype, grade, stage, number of dissected lymph nodes, and number of lymph nodes invaded by the cancer were recorded.

We used the 7th edition of the American Joint Committee on Cancer for cancer staging.77 UICC TNM classification of malignant tumors. 7th ed. New York: John Wiley & Sons; 2009

Follow-up Data

Most patients were followed-up for 3 years for the detection of disease recurrence, distant metastases, disease progression, progression-free survival, and overall survival rate. The end of the follow-up period was in February 2020.

The follow-up was performed every 4 months in the 1st 2 years, then every 6 months in the 3rd year.

Routine follow-up included complete physical examination and evaluation of the carcinoembryonic antigen.

Colonoscopy and whole-body CT were performed annually.

In case of suspected metastasis or recurrence, positron emission tomography (PET-CT) scan, bone scan, and magnetic resonance imaging (MRI) were performed.

Local recurrence is defined by radiological and histopathological confirmation of cancer in the bowel wall or in the lymphatic drainage area in the site of the primary tumor.

Distant recurrence is defined by radiological and histopathological confirmation of cancer in the liver, the peritoneum, in nonregional lymph nodes, or in distant organs such as the lung or bone.

We calculated the progression-free survival rate from the time of surgery to the time of occurrence of recurrence of the tumor or of distant metastases. We calculated the overall survival rate from the time of surgery to the time of death of the patient.

Ethical approval was obtained from the local ethical committee of the Faculty of medicine of the Zagazig University.

Consent to be included in the present study was obtained from the included patients.

Surgical Techniques

All included patients have received antibiotics and antithrombotics as prophylactic perioperative therapies, but they have not received any mechanical preparation of the bowel.

For the group of patients who underwent extended right hemicolectomy, we have resected the ascending colon, the transverse colon, and part of the descending colon in addition to dissection of regional lymph nodes with ligation of the right colic, the ileocolic, the middle colic, and the left colic vessels at their origins. Then, we performed an ileocolic end-to-side mechanical anastomosis.

For the group of patients who underwent extended left hemicolectomy, we have resected the segment of the colon located between the colorectal junction and the left third of the transverse colon, with excision of the regional lymph nodes, and performed ligation of the left branch of the middle colic and the inferior mesenteric vessels at their origins. We have restored intestinal continuity by mechanical colorectal side-to-end anastomosis.88 Feig BW, Ching CD. The MD Anderson Surgical Oncology Handbook, Department of Surgical Oncology. (eds University of Texas MD Anderson Cancer Center) Philadelphia, P. A.: Lippicott Williams & Wilkins; 2011 99 Kim JW, Kim JY, Kang BM, Lee BH, Kim BC, Park JH. Short- and long-term outcomes of laparoscopic surgery vs open surgery for transverse colon cancer: a retrospectivemulticenter study. Onco- Targets Ther 2016;9:2203-2209

For the group of patients who underwent segmental splenic flexure resection, we have resected the colonic segment that is found between the distal part of the transverse colon and the first part of the descending colon. We have resected regional lymph nodes and ligated the left branch of the middle colic vessels, of the left colic vessels, and of the inferior mesenteric vein.1010 Sakorafas GH, Zouros E, Peros G. Applied vascular anatomy of the colon and rectum: clinical implications for the surgical oncologist. Surg Oncol 2006;15(04):243-255

We have restored intestinal continuity by mechanical colocolic side-to-end anastomosis

Usually, a mechanical side-to-end colocolic anastomosis was performed. We have resected the colon in addition to excision of the regional mesocolon.1111 West NP, Kobayashi H, Takahashi K, et al. Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol 2012;30(15):1763-1769

Patients with radiological preoperative confirmation of vascular or regional lymph nodes involvement by malignancy and patients with larger tumor size were more liable to undergo extended resection, either right or left. En-bloc resection of adjacent organs was performed in case of malignant or inflammatory involvement.1212 Otchy D, Hyman NH, Simmang C, et al; Standards Practice Task Force American Society of Colon and Rectal Surgeons. Practice parameters for colon cancer. Dis Colon Rectum 2004;47(08): 1269-1284

Statistical Analysis

IBM SPSS Statistics for Windows version 24 (IBM Corp., Armonk, NY, USA0 was used for statistical analysis of the collected data. A p-value ≤ 0.05 was considered as a statistically significant difference, and p < 0.001 was considered highly significant. Kaplan and Meier survival curves were used to assess time to death and time to recurrence of the tumor.

Results

The present study included 90 patients who underwent surgical excision of splenic flexure cancer: we performed extended right hemicolectomy in 30 (33.3%), extended left hemicolectomy in 30 (33.3%), and segmental resection of the splenic flexure in 30 (33.3%).

Preoperative Results

Demographics and basic findings about the patients are shown in Table 1.

Table 1
Correlations between the three studied surgical techniques regarding demographic and operative findings of included patients

No statistically significant differences were found between the different groups of patients regarding baseline findings.

Operative Results: Tables 1 and 2

Table 2
Correlations between the three studied surgical techniques regarding postoperative findings of included patients

The operative time was ∼ 125 (100–150) minutes in the extended right hemicolectomy group, and 105 (100–150) minutes in both the extended left hemicolectomy group and the segmental resection of the splenic flexure group (p < 0.001).

We performed multiorgan resection in 7.5% of all included patients in the extended right hemicolectomy group, in 7.5% of the extended left hemicolectomy group, and in 10.0% of the segmental resection of the splenic flexure group.

We have reported no colon perforation from the cancer or from the surgical procedures.

We have found no statistically significant differences between the three included groups regarding operative findings (Table 2).

Postoperative Results

The duration of the postoperative hospital stay was 7 (5–9) days for most patients.

The immediate postoperative period was uneventful and there were no significant differences among the studied groups regarding postoperative complications (Table 2).

Histopathological Results

Most cases were diagnosed as conventional adenocarcinoma of the colon (NOS) while of patients was diagnosed with mucoid carcinoma.

Cancer-free surgical margins were found in 114 (95.0%) patients, correct lymphadenectomy with number of dissected lymph nodes was found in all patients, and there were no significant differences among the studied groups regarding histopathological findings.

The number of dissected lymph nodes was 24 (10–28) in the extended right hemicolectomy group, 20 (10–27) in the extended left hemicolectomy group, and 15 (9–20) in the segmental resection group (Table 3).

Table 3
Correlations between the three studied surgical techniques regarding progression and survival outcome of included patients

There was a statistically significant difference in the number of dissected lymph nodes among the 3 studied groups, with a higher number of lymph nodes in the extended right hemicolectomy group (p < 0.001) (Table 2).

Oncologic and Follow-up Data: Table 3, Fig. 1

Fig. 1
Survival findings of included patients: (A) time to recurrence and recurrence-free survival rate, (B) time to death and overall survival rate.

The follow up time was of ∼ 36 months.

During the follow-up period, we have found no statistically significant differences among groups regarding local recurrence, distant recurrence, disease progression, recurrence free survival rate, progression free survival rate, and overall survival rate.

Discussion

There is no established method of management of splenic flexure cancer due to incomplete understanding of dual lymphatic drainage of this location, which is related to both the superior and the inferior mesenteric vessels.33 Shaikh IA, Suttie SA, Urquhart M, Amin AI, Daniel T, Yalamarthi S. Does the outcome of colonic flexure cancers differ from the other colonic sites? Int J Colorectal Dis 2012;27(01):89-93 44 Odermatt M, Siddiqi N, Johns R, et al. Short- and long-term outcomes for patients with splenic flexure tumours treated by left versus extended right colectomy are comparable: a retrospective analysis. Surg Today 2014;44(11):2045-2051 1313 Bourgouin S, Bège T, Lalonde N, et al. Three-dimensional determination of variability in colon anatomy: applications for numerical modeling of the intestine. J Surg Res 2012;178(01):172-180

Griffiths1414 Griffiths JD. Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl 1956;19(04):241-256 showed that the splenic flexure region is supplied by the terminal branches of the left colic artery in 89% of cases and by the middle colic branch of the superior mesenteric artery in 11%.

Nakagoe et al.1515 Nakagoe T, Sawai T, Tsuji T, et al. Surgical treatment and subsequent outcome of patients with carcinoma of the splenic flexure. Surg Today 2001;31(03):204-209 showed that most lymph nodes that proved to be positive for metastatic spread were found to be located along the left colic artery and the paracolic arcade. Vasey et al.1616 Vasey CE, Rajaratnam S, O'Grady G, Hulme-Moir M. Lymphatic Drainage of the Splenic Flexure Defined by Intraoperative Scintigraphic Mapping. Dis Colon Rectum 2018;61(04):441-446 concluded that splenic flexure lymphatic drainage was directed toward the left colic vessels in 96% of the patients. Some surgeons stated that performing extended hemicolectomy is the best method of management of splenic flexure cancer and consider segmental resection as being less radical to ensure complete removal of all lymph nodes along the branches of the superior mesenteric vessels.44 Odermatt M, Siddiqi N, Johns R, et al. Short- and long-term outcomes for patients with splenic flexure tumours treated by left versus extended right colectomy are comparable: a retrospective analysis. Surg Today 2014;44(11):2045-2051 1717 Pisani Ceretti A, Maroni N, Sacchi M, et al. Laparoscopic colonic resection for splenic flexure cancer: our experience. BMC Gastroenterol 2015;15(15):76 1818 de'Angelis N, Hain E, Disabato M, et al. Laparoscopic extended right colectomy versus laparoscopic left colectomy for carcinoma of the splenic flexure: a matched case-control study. Int J Colorectal Dis 2016;31(03):623-630 Other surgeons restricted performing segmental resection for older patients, for patients with comorbid conditions, and as a palliative measure for cases with extensive disease.1919 Shen SS, Haupt BX, Ro JY, Zhu J, Bailey HR, Schwartz MR. Number of lymph nodes examined and associated clinicopathologic factors in colorectal carcinoma. Arch Pathol Lab Med 2009;133(05): 781-786 Other authors showed that extended resection has benefits on survival and is not necessary for all cases.33 Shaikh IA, Suttie SA, Urquhart M, Amin AI, Daniel T, Yalamarthi S. Does the outcome of colonic flexure cancers differ from the other colonic sites? Int J Colorectal Dis 2012;27(01):89-93 2020 KimCW, Shin US, Yu CS, KimJC. Clinicopathologic characteristics, surgical treatment and outcomes for splenic flexure colon cancer. Cancer Res Treat 2010;42(02):69-76 Removal of at least 12 lymph nodes in surgically excised colon cancer is sufficient to ensure radicalism,2121 Dotan E, Cohen SJ. Challenges in themanagement of stage II colon cancer. Semin Oncol 2011;38(04):511-520 which is associated with complete mesocolic excision.1111 West NP, Kobayashi H, Takahashi K, et al. Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol 2012;30(15):1763-1769 2222 Weber K, Merkel S, Perrakis A, Hohenberger W. Is there a disadvantage to radical lymph node dissection in colon cancer? Int J Colorectal Dis 2013;28(02):217-226

In the present study, we assessed the oncological outcomes of patients with splenic flexure cancer managed by three different surgical approaches – segmental resection, extended left or left hemicolectomy – to detect the best surgical approach of management of this anatomical variant.

Although extended right hemicolectomy produced a higher number of dissected lymph nodes, patients with > 12 dissected lymph nodes were similar between all the 3 groups we have found no statistically significant differences among groups regarding local recurrence, distant recurrence, disease progression, recurrence free survival rate, progression free survival rate, and overall survival rate. Rega et al.11 Rega D, Pace U, Scala D, et al. Treatment of splenic flexure colon cancer: a comparison of three different surgical procedures: Experience of a high volume cancer center. Sci Rep 2019;9(01):10953 performed the first study that compared the three surgical approaches in the management of splenic flexure cancer and found nearly similar results. Our study included a large number of patients operated in more than one hospital, so its results could prove the feasibility of performing segmental resection better than extended resections, with shorter operative time and similar postoperative and long-term outcomes.

Regarding the surgical management of splenic flexure cancer, previous studies have compared only extended right colon resection with extended left colon resection, but they did not clarify long-term and follow-up oncological outcomes.1818 de'Angelis N, Hain E, Disabato M, et al. Laparoscopic extended right colectomy versus laparoscopic left colectomy for carcinoma of the splenic flexure: a matched case-control study. Int J Colorectal Dis 2016;31(03):623-630 2323 Martínez-Pérez A, Brunetti F, Vitali GC, Abdalla S, Ris F, de'Angelis N. Surgical Treatment of Colon Cancer of the Splenic Flexure: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2017;27(05):318-327 2424 Gravante G, Elshaer M, Parker R, et al. Extended right hemicolectomy and left hemicolectomy for colorectal cancers between the distal transverse and proximal descending colon. Ann R Coll Surg Engl 2016;98(05):303-307

Martínez-Pérez et al.2323 Martínez-Pérez A, Brunetti F, Vitali GC, Abdalla S, Ris F, de'Angelis N. Surgical Treatment of Colon Cancer of the Splenic Flexure: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2017;27(05):318-327 showed that the extent of the surgical procedure does not affect the resection quality or the postoperative outcomes.

With results that were nearly similar to ours, Rega et al.11 Rega D, Pace U, Scala D, et al. Treatment of splenic flexure colon cancer: a comparison of three different surgical procedures: Experience of a high volume cancer center. Sci Rep 2019;9(01):10953 showed that the number of dissected lymph nodes and the rate of negative margins were similar in the three studied groups.

The large number of dissected lymph nodes in the group of patients who were managed by extended right hemicolectomy was due to more extent of colon resection colon with least 3 colonic vascular branches, as has also been reported by other authors.2424 Gravante G, Elshaer M, Parker R, et al. Extended right hemicolectomy and left hemicolectomy for colorectal cancers between the distal transverse and proximal descending colon. Ann R Coll Surg Engl 2016;98(05):303-307

In the present study, we made multiorgan resection in included patients which is indicated to made R0 in some cases with large tumor size, we found no statistically significant differences among groups regarding the degree of organ resection. Regarding the degree and number of cases that underwent organ resection, similar results were reported by Rega et al.11 Rega D, Pace U, Scala D, et al. Treatment of splenic flexure colon cancer: a comparison of three different surgical procedures: Experience of a high volume cancer center. Sci Rep 2019;9(01):10953.

Additionally, Perrakis et al.2525 Perrakis A, Weber K, Merkel S, et al. Lymph node metastasis of carcinomas of transverse colon including flexures. Consideration of the extramesocolic lymph node stations. Int J Colorectal Dis 2014;29(10):1223-1229 showed that the rationale for performing splenectomy alone or in addition to distal pancreasectomy is the presence of large number of metastatic lymph nodes in the greater curvature of the stomach, in the head of the pancreas, or in the inferior part of the pancreas.

Regarding operative safety, we have observed no significant difference in the safety, by complication rates, or in the severity of complications among the three studied techniques.

Moreover, we found no statistically significant differences between groups regarding the survival rates of the patients who were followed-up.

Generally, for the adequate management of colon cancer sharp dissection of tissue planes and giving resected tissues having intact mesocolic fascia that surrounded tumor draining lymphatics.

Performing segmental resection of carcinoma of the splenic flexure allows the removal of the left colic, left branch of middle colic lymphatics, ensuring removal of most of lymphatic drainage of colon cancer located in the splenic flexure.

Multiorgan resection was performed in 3 (7.5%) of all included patients of the extended right hemicolectomy group, in 3 patients (7.5%) of the extended left hemicolectomy group, and in 4 patients (10.0%) of the segmental resection of the splenic flexure group.

Due to the prospective nature of the present study, we selected randomly the procedure to be performed.

Conclusion

Collectively, we showed that segmental resection of splenic flexure is surgically and clinically suitable for the adequate management of operable cases of carcinoma of the splenic flexure in Egyptian patients, and that the clinical, surgical, survival or oncological benefits of extended surgery do not surpass those of segmental resection. Moreover, segmental resection allows adequate removal of lymph drainage.

Strengths of the Present Study

One of the strengths of the present study is its prospective nature. Another is that the study was performed on a large number of Egyptian patients with cancer of the splenic flexure, which is a single anatomical subtype of colon cancer. Also, the long follow-up period, which allowed adequate reporting of the results.

References

  • 1
    Rega D, Pace U, Scala D, et al. Treatment of splenic flexure colon cancer: a comparison of three different surgical procedures: Experience of a high volume cancer center. Sci Rep 2019;9(01):10953
  • 2
    Milone M, Angelini P, Berardi G, et al. Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients. Surg Endosc 2018;32(08):3467-3473
  • 3
    Shaikh IA, Suttie SA, Urquhart M, Amin AI, Daniel T, Yalamarthi S. Does the outcome of colonic flexure cancers differ from the other colonic sites? Int J Colorectal Dis 2012;27(01):89-93
  • 4
    Odermatt M, Siddiqi N, Johns R, et al. Short- and long-term outcomes for patients with splenic flexure tumours treated by left versus extended right colectomy are comparable: a retrospective analysis. Surg Today 2014;44(11):2045-2051
  • 5
    Chong CS, Huh JW, Oh BY, et al. Operative Method for Transverse Colon Carcinoma: Transverse Colectomy Versus Extended Colectomy. Dis Colon Rectum 2016;59(07):630-639
  • 6
    van Rongen I, Damhuis RA, van der Hoeven JA, Plaisier PW. Comparison of extended hemicolectomy versus transverse colectomy in patients with cancer of the transverse colon. Acta Chir Belg 2013;113(02):107-111
  • 7
    UICC TNM classification of malignant tumors. 7th ed. New York: John Wiley & Sons; 2009
  • 8
    Feig BW, Ching CD. The MD Anderson Surgical Oncology Handbook, Department of Surgical Oncology. (eds University of Texas MD Anderson Cancer Center) Philadelphia, P. A.: Lippicott Williams & Wilkins; 2011
  • 9
    Kim JW, Kim JY, Kang BM, Lee BH, Kim BC, Park JH. Short- and long-term outcomes of laparoscopic surgery vs open surgery for transverse colon cancer: a retrospectivemulticenter study. Onco- Targets Ther 2016;9:2203-2209
  • 10
    Sakorafas GH, Zouros E, Peros G. Applied vascular anatomy of the colon and rectum: clinical implications for the surgical oncologist. Surg Oncol 2006;15(04):243-255
  • 11
    West NP, Kobayashi H, Takahashi K, et al. Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. J Clin Oncol 2012;30(15):1763-1769
  • 12
    Otchy D, Hyman NH, Simmang C, et al; Standards Practice Task Force American Society of Colon and Rectal Surgeons. Practice parameters for colon cancer. Dis Colon Rectum 2004;47(08): 1269-1284
  • 13
    Bourgouin S, Bège T, Lalonde N, et al. Three-dimensional determination of variability in colon anatomy: applications for numerical modeling of the intestine. J Surg Res 2012;178(01):172-180
  • 14
    Griffiths JD. Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl 1956;19(04):241-256
  • 15
    Nakagoe T, Sawai T, Tsuji T, et al. Surgical treatment and subsequent outcome of patients with carcinoma of the splenic flexure. Surg Today 2001;31(03):204-209
  • 16
    Vasey CE, Rajaratnam S, O'Grady G, Hulme-Moir M. Lymphatic Drainage of the Splenic Flexure Defined by Intraoperative Scintigraphic Mapping. Dis Colon Rectum 2018;61(04):441-446
  • 17
    Pisani Ceretti A, Maroni N, Sacchi M, et al. Laparoscopic colonic resection for splenic flexure cancer: our experience. BMC Gastroenterol 2015;15(15):76
  • 18
    de'Angelis N, Hain E, Disabato M, et al. Laparoscopic extended right colectomy versus laparoscopic left colectomy for carcinoma of the splenic flexure: a matched case-control study. Int J Colorectal Dis 2016;31(03):623-630
  • 19
    Shen SS, Haupt BX, Ro JY, Zhu J, Bailey HR, Schwartz MR. Number of lymph nodes examined and associated clinicopathologic factors in colorectal carcinoma. Arch Pathol Lab Med 2009;133(05): 781-786
  • 20
    KimCW, Shin US, Yu CS, KimJC. Clinicopathologic characteristics, surgical treatment and outcomes for splenic flexure colon cancer. Cancer Res Treat 2010;42(02):69-76
  • 21
    Dotan E, Cohen SJ. Challenges in themanagement of stage II colon cancer. Semin Oncol 2011;38(04):511-520
  • 22
    Weber K, Merkel S, Perrakis A, Hohenberger W. Is there a disadvantage to radical lymph node dissection in colon cancer? Int J Colorectal Dis 2013;28(02):217-226
  • 23
    Martínez-Pérez A, Brunetti F, Vitali GC, Abdalla S, Ris F, de'Angelis N. Surgical Treatment of Colon Cancer of the Splenic Flexure: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2017;27(05):318-327
  • 24
    Gravante G, Elshaer M, Parker R, et al. Extended right hemicolectomy and left hemicolectomy for colorectal cancers between the distal transverse and proximal descending colon. Ann R Coll Surg Engl 2016;98(05):303-307
  • 25
    Perrakis A, Weber K, Merkel S, et al. Lymph node metastasis of carcinomas of transverse colon including flexures. Consideration of the extramesocolic lymph node stations. Int J Colorectal Dis 2014;29(10):1223-1229

  • Strengths of the Present Study

    One of the strengths of the present study is its prospective nature. Another is that the study was performed on a large number of Egyptian patients with cancer of the splenic flexure, which is a single anatomical subtype of colon cancer. Also, the long follow-up period, which allowed adequate reporting of the results.
  • Limitations of the Present Study

    Its monocenter nature.
  • Recommendations

    We recommend performing large scale, multicenter, prospective, and randomized studies to prove our data regarding the surgical management of splenic flexure cancer.

Publication Dates

  • Publication in this collection
    03 June 2022
  • Date of issue
    Jan-Mar 2022

History

  • Received
    20 Mar 2021
  • Accepted
    06 Aug 2021
  • Published
    31 Jan 2022
Sociedade Brasileira de Coloproctologia Av. Marechal Câmara, 160/916, 20020-080 Rio de Janeiro/RJ Brasil, Tel.: (55 21) 2240-8927, Fax: (55 21) 2220-5803 - Rio de Janeiro - RJ - Brazil
E-mail: sbcp@sbcp.org.br