Subtotal colectomy versus left hemicolectomy for the elective treatment of splenic flexure colonic neoplasia
Introduction
Colorectal cancer is the third cause of cancer-related death in both males and females.1 Around 4% of all colorectal lesions are located in the confluence between the transverse and descending colon.2, 3 Splenic flexure neoplasia (SFN), despite being a well-known surgical entity, is not clearly defined in the literature. It has some controversial anatomopathological features, especially a lymphatic drainage that lies between the right and left territories. Moreover, there is a scarcity of publications regarding its surgical outcomes and long-term survival.4, 5, 6, 7, 8
When SFN is diagnosed in the emergency room as an occlusive mass, most authors advocate for a subtotal colectomy (STC) as treatment of choice, although left hemicolectomy (LHC) has also been proposed.9, 10, 11, 12, 13 In the elective setting, LHC seems to be the more commonly used technique.5 However, this strategy has not been validated in terms of morbimortality and long-term survival.14, 15 It is assumed that SFN drains mainly to the inferior mesenteric artery territory and that an extended resection to the left branch of the middle colic artery is enough to obtain satisfactory oncologic results. Yet, middle colic artery is absent in around 20% of patients.16, 17 That fact could explain some published reports of ileocecal dissemination of SFN5, 18 that support the systematic STC approach. On the other hand, retrospective studies point out that STC could result in higher postoperative complications and lesser quality of life.19, 20, 21
This study aims to compare postoperative morbimortality and long-term survival outcomes of LHC versus STC as elective surgical procedures for SFN.
Section snippets
Materials and methods
We designed a multicentric retrospective study with data recorded prospectively on the databases of four colorectal surgery units between 2003 and 2014. SFN was defined as the colonic neoplasm located on the splenic flexure itself or 10 cm proximal towards the transverse colon or 10 cm distal towards the descending colon, only when clearly described on the surgical report or measurable on pre-operative imaging. Inclusion criteria were clinical and radiologic diagnosis of SFN stage III or
Results
After revision of the prospective databases, 144 patients were included: 68 in the STC group and 76 in the LHC group (Hospital Universitari Vall d’Hebron, n = 71; Corporació Sanitaria Parc Taulí, n = 39; Hospital Universitari de Bellvitge, n = 19; Hospital Universitari Josep Trueta, n = 15).
Both groups had similar distribution (Table 1) of age, gender, ASA score and POSSUM score. Laparoscopic approach was used in 32% of patients in the STC group and 38% of patients in the LHC group, with a
Discussion
This observational multicentric study compared the postoperative complications and long-term survival of two groups of patients operated electively for SFN either by a STC or a LHC. A significant increase in global and surgical postoperative morbidity was found in the STC group, although only a mild postoperative ileus seemed to account for that difference. No differences were found when complications were graded according to the Dindo-Clavien classification. No significant differences in
Conclusions
The current multicentric retrospective study aims to add some evidence on the controversy between STC and LHC for the elective surgical treatment of SFN. Our data shows a higher surgical morbidity on the STC group, mainly due to mild postoperative ileus. No differences on long-term oncological results were found. LHC could be a slightly better surgical strategy, although a prospective study is still needed.
Conflict of interests
The authors of this manuscript entitled “Subtotal colectomy versus left hemicolectomy for the elective treatment of splenic flexure colonic neoplasia” declare having no conflicts of interest that could inappropriately influence their work.
Financial support
None.
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