Cheok SHX, Jabbar SAA, Wong NW, Ngu JCY, Teo NZ. Surgical management of splenic flexure colonic malignancy. World J Gastrointest Surg 2025; 17(12): 111582 [DOI: 10.4240/wjgs.v17.i12.111582]
Corresponding Author of This Article
Nan-Zun Teo, Department of General Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore. teo.nan.zun@singhealth.com.sg
Research Domain of This Article
Surgery
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Sabrina Hui-Xian Cheok, Salman Ahmed Abdul Jabbar, Neng-Wei Wong, James Chi-Yong Ngu, Nan-Zun Teo, Department of General Surgery, Changi General Hospital, Singapore 529889, Singapore
Author contributions: Cheok SHX drafted the article; Jabbar SAA, Wong NW, Ngu JCY, and Teo NZ were involved in the concept and design of the article, critical revision, and final approval.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nan-Zun Teo, Department of General Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore. teo.nan.zun@singhealth.com.sg
Received: July 3, 2025 Revised: August 6, 2025 Accepted: October 9, 2025 Published online: December 27, 2025 Processing time: 174 Days and 19.4 Hours
Abstract
There is a lack of consensus on the optimal surgical approach for splenic flexure malignancies. Surgeons face the challenge of balancing successful oncological outcomes with the morbidity and functional effects of extended colonic resection, considering the variable ‘watershed’ vasculature and lymphatic anatomy of the splenic flexure. While there is an increasing body of evidence supporting the oncological safety of a more conservative segmental resection, most of the data stems from retrospective single center studies. This article reviews the management strategies and examines the evidence supporting various surgical approaches to splenic flexure malignancies.
Core Tip: There are several studies in current literature discussing the optimal surgical approach for splenic flexure malignancies. However, these studies are mainly retrospective and performed in single centers. The variability in the vascular and lymphatic anatomy of the splenic flexure coupled with the lack of international standardization in the terminology for oncologic resections makes management challenging. This article reviews the various management strategies in the literature and examines the evidence supporting various surgical approaches to splenic flexure malignancies.
Citation: Cheok SHX, Jabbar SAA, Wong NW, Ngu JCY, Teo NZ. Surgical management of splenic flexure colonic malignancy. World J Gastrointest Surg 2025; 17(12): 111582
Standard anatomical resection for right and left-sided colon malignancy is well established, however there is ongoing debate regarding the optimal surgical strategy for splenic flexure malignancies (SFMs)[1-3]. This ambiguity exists due to the variable lymphatic and vascular anatomy of the splenic flexure[4]. The American Society of Colon and Rectal Surgeons highlight that SFM require specific consideration regarding what constitutes an appropriate lymphadenectomy, suggesting that segmental resection (SR) is a reasonable option, although this is primarily supported by observational and retrospective single center studies[5]. The clinicopathologic characteristics of SFM differ from non-SFM with the former presenting at more advanced stages with higher risk of obstruction and distant metastases[6,7]. Furthermore, the adoption of minimally invasive techniques such as laparoscopic and, more recently, robotic surgery in the treatment of SFM should also be factored into the surgeon’s decision-making algorithm. This article aims to review the evidence and considerations for the different surgical approaches to SFM.
LITERATURE REVIEW
The protocol for this review was designed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines[8]. Three electronic databases (PubMed, EMBASE, and Cochrane) were systematically searched. A preliminary keyword search was performed on PubMed using the following search terms: “Splenic flexure tumor”, “SFM”, “splenic flexure cancer”, “surgical technique”, “colectomy” and “surgery”. A second search was performed using medical subject headings terms to generate a search strategy. After refining the search strategy using a combination of medical subject headings terms and text words, the search strategy as detailed in Supplementary Table 1 was applied. The authors included all relevant articles by performing backward reference search of included articles and published systematic review articles. The selection process is summarized in the Preferred Reporting Items for Systematic reviews and Meta-Analyses flow diagram in Figure 1.
Figure 1 Preferred Reporting Items for Systematic reviews and Meta-Analyses flow diagram.
DEFINITION OF SPLENIC FLEXURE AND RELEVANT ANATOMY
The splenic flexure is defined as the segment extending from the distal 10 cm of the transverse colon to the proximal 10 cm of the descending colon and receives collateral vascular supply between the superior mesenteric artery and the inferior mesenteric artery[9]. Griffiths[10] described a variable vascular supply of this “watershed” area, with a predominant left colic artery (LCA), via the inferior mesenteric artery, supply in 89% of cases and the left branch of the middle colic artery (MCA), via the superior mesenteric artery, in 11% of cases. Fukuoka et al[11] further demonstrated the variability of the splenic flexure’s vascular supply using computed tomography angiography and identified a variation of 6 arterial patterns.
Lymphatic drainage of the splenic flexure similarly shows variability. Watanabe et al[12] demonstrated that the pattern of lymphatic flow differed based on the location of SFM, with the distal third of the transverse colon draining preferentially along the left branch of the MCA and the proximal descending colon along the LCA. Using laparoscopic scintigraphy, Vasey et al[13] reported that lymphatic drainage is predominantly towards the left colic pedicle compared to the left branch of the middle colic pedicle (median gamma count 284, interquartile range 113-413 vs median gamma count 31, interquartile range 15-49, P < 0.0001). Watanabe et al[12] utilized indocyanine green fluorescence imaging for real time lymphatic mapping and suggested that 61.3% of cases had lymphatic flow directed to the root of the inferior mesenteric vein. Furthermore, no cases exhibited lymphatic flow to both the LCA and left branch of the MCA. Although lymphatic drainage to the splenic hilum and pancreatic tail has been demonstrated in anatomical studies, this has not been supported by majority of clinical studies. Hence, routine distal pancreatectomy or splenectomy is not indicated in resection of SFM unless in the setting of gross direct invasion or nodal metastases. Given that optimal nodal harvest directly impacts tumor staging and survival outcomes, the variable lymphatic drainage of the splenic flexure adds complexity to determining the most suitable surgical approach for SFM.
TYPES OF SURGICAL RESECTION FOR SFM
The decision on the extent of resection for colorectal malignancy requires the surgeon to consider two key factors: (1) Attaining oncologically adequate resection margins, including the en-bloc resection of surrounding structures in the presence of locoregional invasion; and (2) Removing regional lympho-vascular structures. Conventional techniques commonly utilized for the surgical resection of SFM include extended right hemicolectomy (ERH), subtotal colectomy (STC), left hemicolectomy (LH), or SR[3]. It is important to recognize that, in the current literature, there is significant variability in the definition of colectomies and what constitutes an associated oncological resection. The Board of Coloproctology of the Spanish Association of Surgeons recognized this gap and attempted to define each oncological colectomy using a Delphi consensus methodology[14]. The Board of Coloproctology of the Spanish Association of Surgeons consensus deemed that both ERH and LH would not include the splenic flexure. The consensus concluded that an ERH would only involve resection up to the distal transverse colon and a LH involves resecting the descending to sigmoid colon. Others have described LH differently as a resection from the distal third of the transverse colon to the rectum, with high ligation of the left branch of the MCA and inferior mesenteric artery[15,16]. The significant variability in definition of colectomy nomenclature makes comparison between studies difficult. For ease of discussion in this review, we will group ERH and STC cases under ERH and divide the surgical approaches into three categories: ERH, LH and SR. These three different surgical approaches and their technical considerations are summarized in Table 1. A schematic diagram illustrating the lymphovascular territories and extent of resection for the three surgical approaches can be found in Figure 2.
Figure 2 Schematic illustration of the lymphovascular territory of the different colectomies and the extent of bowel resection.
ERH: Extended right hemicolectomy; LH: Left hemicolectomy; SR: Segmental resection.
Table 1 Summary of the three surgical approaches for splenic flexure malignancy.
Type of surgical approach
Proximal and distal extent for bowel transection
Major vessels ligated
Type of bowel anastomosis
Pros of surgical approach
Cons of surgical approach
Extended right hemicolectomy
Proximal: Terminal ileum; distal: Descending colon or sigmoid colon
Ileocolic; right colic; middle colic; +/- left colic
Ileocolic
(1) High lymph node yield; and (2) Allows for concomitant resection of synchronous tumor or non-viable proximal colon (in setting of obstruction)
(1) Unnecessary resection of excess bowel length; (2) Increased risk of iatrogenic injury; and (3) Possible increased risk of adhesions due to extensive dissection
ERH is defined as a resection from the distal 10 cm of the terminal ileum, right and transverse colon up to the sigmoid colon with ileocolic anastomosis. High ligation of the ileocolic, right colic, middle colic and LCA is performed[3,15]. Many authors have suggested performing an extensive resection for SFM to improve oncologic outcomes, especially since SFM are associated with a poorer prognosis[7,17]. ERH is reported to be less challenging technically and allows for concomitant resection of synchronous right sided colonic malignancy or non-viable proximal colon in the setting of acute distal obstruction[14,17,18]. LH is defined as a resection from the mid transverse colon to the rectosigmoid junction with a colorectal anastomosis. Ligation of the left branch of the MCA and the inferior mesentery artery is performed[3,15]. Like ERH, LH is a well-established surgical approach for SFM and allows for concomitant resection of diseased colon such as extensive diverticular disease. In up to 25% of patients, LH may require additional maneuvers such as retroileal, transmesenteric or a Deloyers procedure to achieve a tension free anastomosis. Due to the level of technical expertise required for such approaches, it has been advocated that LH should be performed by colorectal specialists[18]. SR is defined as a resection between the distal transverse colon and the proximal descending colon, with high ligation of the left branch of the MCA and LCA. Subsequent colo-colic anastomosis is performed[3,15]. The proposed advantage of SR is that it avoids excessive resection of the colon, thereby improving functional outcomes. Less extensive dissection also lowers the risk of iatrogenic injuries to structures such as the ureter and para-aortic nerves. Other benefits include a shorter operative time, lower incidence of post-operative ileus, and shorter length of hospital stay. The primary concern regarding SR is its oncological adequacy and effect on survival outcomes. However, several publications have reported oncological and survival outcomes comparable to extended resections[19-21]. A summary of the published comparative studies for the different surgical approaches for SFM is detailed in Table 2.
Table 2 Summary of comparative studies analyzing the different surgical approaches for splenic flexure malignancy, mean ± SD.
There is significant heterogeneity in the reporting of intraoperative outcomes between the different surgical approaches for SFM. Martín Arévalo et al[21] compared LH, SR and ERH and found a significant increase in risk of postoperative blood transfusion for LH compared to SR (P = 0.036; odds ratio = 1.615, 95% confidence interval: 1.161-2.248) but no difference when compared to ERH. Huang et al[22] compared LH vs SR and found no difference in estimated blood loss between both approaches.
Splenic flexure mobilization is considered technically challenging due to its complex network of vessels and ligaments and its proximity to vital organs such as the spleen and pancreas[23]. Multiple studies that reported splenectomies due to uncontrolled hemorrhage did not demonstrate any statistical difference in the rates of splenic injury amongst the three different approaches[14,20,24]. None of the approaches have been associated with an increased risk of other iatrogenic injuries to structures such as the duodenum, inferior mesenteric artery, and gonadal vessels. Reported conversion rates to open surgery range from 10%-21%[14,25,26]. Technical difficulties, inadequate exposure, or visualization due to tumor fixation or invasion were the most frequently cited reasons for conversion[14]. There was no significant difference in the rate of conversion between the three approaches, but it is worthwhile noting that ERH is typically performed via upfront laparotomy in emergencies such as obstruction.
There is some evidence from current literature to suggest that SR is associated with shorter operative time. El-Hendawy et al[27] and Manceau et al[15] compared the 3 different approaches and reported longer operative time with ERH vs LH and SR (125 minutes vs 105 minutes vs 105 minutes, P < 0.001; and 260 minutes vs 217 minutes vs 180 minutes, P < 0.0001) respectively. Pang et al[19] compared LH and SR and reported significantly longer operative time with LH (213 ± 84 minutes vs 193 ± 84 minutes, P < 0.001). Operative time is dependent on multiple factors such as technical difficulty, tumor bulk, presence of adhesions, choice of open vs minimally invasive, extent of resection, and surgeon expertise. These potentially confound the comparison of operative time between the various surgical approaches.
Immediate post-operative outcomes
Post-operative morbidity rates were similar between the 3 surgical approaches. Beisani et al[26] is the only study that reported a higher risk of post operative ileus in ERH compared to LH (37% vs 20%, P = 0.023), attributing this to more extensive dissection required in ERH. This finding was not corroborated in other retrospective studies. Post operative mortality ranged from 1%-7% and showed no significant difference between the approaches[18-21]. There was no association between the rate of major complications such as anastomotic leak or reoperation and the type of surgical approach for SFM[14,18,21].
Delayed post-operative outcomes
There is a paucity of data regarding delayed post-operative outcomes. Most of the available literature focuses on long-term oncological and survival outcomes. Kohn et al[28] reported higher 30-day hospital readmission rate after extended resections such as ERH or LH compared to SR (8% vs 6%, P = 0.02). After multi-variate analysis, the study reported that longer length of stay, Charlson-Deyo score ≥ 2 and extended resection (odds ratio = 1.24, 95% confidence interval: 1.03-1.51) were associated with increased risk of unplanned 30-day readmission.
A systemic review evaluating bowel function following surgery for colon malignancy by Verkuijl et al[29] reported that fecal incontinence and constipation related symptoms were highly prevalent following surgery, however, these were not associated with the type of colectomy performed. None of the studies evaluating the different surgical approaches in SFM reported quality of life indicators such as bowel function or sexual dysfunction. Hence it is hard to determine if any of the three approaches confer a better long term functional outcome for patients with SFM.
ONCOLOGICAL AND SURVIVAL OUTCOMES
Oncological quality of resection specimen
The R0 resection, negative circumferential resection margin (CRM) and adequate lymph node harvest (> 12 lymph nodes) are well recognized histological features determining oncological outcomes after surgery for colorectal malignancy. Three studies demonstrated no difference in R0 resection rates between the different surgical approaches[15,21,25]. Manceau et al[15] reported that all patients in their series were CRM negative whilst Kohn et al[28] reported a higher rate of CRM involvement in the extended resection group vs those that underwent SR (2.1% vs 1.3%, P = 0.02). Despite a higher rate of CRM involvement, the 5-year overall survival rates between the two groups were comparable.
Understandably, lymph node harvest is expected to be higher in extended resections. This is demonstrated in many studies which show significantly higher number of lymph nodes resected with ERH compared to LH and SR[16,23-26]. Despite the higher nodal harvest associated with ERH, there was no clinical difference in the likelihood of positive lymph nodes between the three approaches[21]. This can be attributed to the fact that extended resections potentially include lymph nodes that are beyond the drainage basin of the tumor-bearing area, an argument in favor of less extensive resections.
Survival outcomes
There was no significant difference between the three surgical approaches in terms of 5-year disease-free survival and 5-year overall survival[21,22,25,27]. Degiuli et al[30] conducted a multivariate analysis and found that only age and pathologic tumor-nodes-metastasis stage III were significant predictors for disease-free survival. Age, pathologic tumor-nodes-metastasis stage II and lymphatic invasion were significant predictors for overall survival.
CHOICE OF SURGICAL APPROACH
The recent international Delphi approach towards standardizing surgical management of SFM showed a strong consensus in favor of MIS for elective resection (88% of respondents)[3]. Kohn et al[28] reported similar trends with an increase in robotic utilization for SFM from 1% in 2010 to 24% in 2020 (P < 0.01) with benefits of shorter length of stay but no difference in readmission rate between minimally invasive surgery (MIS) and open. Degiuli et al[30] demonstrated non inferiority of MIS vs open approach with respect to pathological outcome (number of lymph node retrieved > 12 and free resection margin) and short-term clinical outcomes (Clavien-Dindo complications grade < 3 and 30 day post operative mortality rate). They also found no significant difference in survival and recurrence between both groups. Although the evidence for MIS is increasing, most of the studies have only investigated MIS approach in elective cases as most advanced, emergency or locally invasive cases are still performed via the open approach. The utilization of MIS for SFM presenting in an emergency setting should be analyzed separately to determine if MIS is non inferior to the open approach and can be safely adopted for obstructed or perforated SFM.
SPECIAL CONSIDERATIONS- EMERGENCY PRESENTATION
Studies have reported that the incidence of obstruction for SFM is four times that of other colonic malignancies with a risk of almost 50%[6,7,31]. Naidu et al[32] compared clinicopathological variables and survival outcomes between SFM and non SFM and found that SFM were significantly associated with an obstructed (P < 0.001) or perforated (P = 0.03) presentation, urgent open operation (P < 0.001) or a stenosing tumor (P < 0.001). Although SFM has been associated with higher risk of colonic emergencies, the number of cases reported in the literature and consensus on its optimal management is limited. Most of the literature reports outcomes of this subset of patients alongside the elective group, without any subgroup analyses of the emergency cases. Obstructed SFM were more likely to be managed by an open approach (P < 0.001) and required a more extensive resection due to distension and viability concern of the proximal colon[18-20]. The de’Angelis et al[33] reported that ERH in the emergency SFM case was associated with a higher incidence of severe postoperative complications; while having comparable outcomes in terms of lymph node yield, disease free interval and overall survival compared to LH and SR. They proposed that a more conservative resection is feasible and oncologically safe for emergency SFM. Labiad et al[34] reports that if a Hartmann type procedure was done for emergency SFM, the rate of subsequent reversal of stoma is low and thus affects patient’s long-term quality of life.
Colonic stenting is a viable option in patients with malignant large bowel obstruction[35]. There is concern that placement of a stent at the flexure region is technically more difficult with an increased chance of technical failure or perforation[36]. Köneş et al[36] reported an 88% success rate of stenting for obstructed SFM. However, there are no other randomized studies or large scale prospective or retrospective case series in the literature supporting this approach. Although there are numerous studies evaluating the outcomes of colonic stenting vs surgery for left sided colonic malignancy, none evaluate and compare outcomes in patients with SFM. These factors should be taken into consideration and stenting should only be performed by accredited endoscopists in an experienced center.
LIMITATIONS OF STUDY
There are several limitations to our study. Given the lack of randomized controlled trials, the current data is mainly derived from retrospective studies thus making the results susceptible to confounding and bias. There is also concern regarding the external validity of the individual study findings given the potential variability in surgical technique, institutional protocol and outcome reporting between different centers. The lack of consensus of surgical definitions for colectomies may further confound the study findings and make comparison between studies difficult. Furthermore, there is a lack of long term follow up oncological data and patient reported outcome measures in the current literature.
CONCLUSION
In the emergency setting where the proximal bowel is threatened, an ERH/STC is the procedure of choice. The decision between MIS and open should be dependent on surgeon expertise and resource availability. However, in the elective setting, MIS SR should be considered given its short-term benefits and comparable oncological outcomes to more extensive resections.
Footnotes
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: Singapore
Peer-review report’s classification
Scientific Quality: Grade B, Grade C
Novelty: Grade B, Grade B
Creativity or Innovation: Grade B, Grade B
Scientific Significance: Grade B, Grade B
P-Reviewer: Rath S, MD, Researcher, India S-Editor: Zuo Q L-Editor: A P-Editor: Xu ZH
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