Surgical management of splenic flexure colonic malignancy

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
Left hemicolectomy	Proximal: Mid transverse colon; distal: Rectosigmoid colon	Left branch of middle colic; inferior mesenteric	Colorectal	Allows for concomitant resection of synchronous tumor or non-viable proximal colon (in setting of obstruction)	Technically more demanding to achieve tension free anastomosis
Segmental resection	Proximal: Transverse colon; distal: Descending colon	Left branch of middle colic; left colic	Colo-colic	(1) Avoids unnecessary resection of bowel; and (2) Shorter operative time, shorter length of stay, faster bowel recovery	Risk of inadequate oncological resection

Table 2 Summary of comparative studies analyzing the different surgical approaches for splenic flexure malignancy, mean ± SD

Ref.	Study type	Approach evaluated	MIS (%)	EM or EL setting	Operative time (minute)	LOS (days)	Postop mortality (%)	Postoperative morbidity (%)	Anastomotic leak	Reoperation	Ileus	No of LN harvested	Positive LN (%)	OS (%)	DFS (%)
Manceau et al[15]	Retrospective multi- center	SR	40	EL	180 (68-440)	10 (4-175)	2	16	8	10	NA	15 (1-81)	NA	8	82
		LH	44	EL	217 (149-480)	9 (4-55)	2	23	5	5	NA	16 (3-52)	NA	78	72
		STC	71	EL	260 (120-46)1	13 (5-56)1	3	19	11	14	NA	24 (8-90)1	NA	80	72
Odermatt et al[18]	Retrospective single center	LH	20	EM + EL	NA	11 (2-61)	3.3	NA	3.3	6.7	NA	NA	NA	60	54
		ERH	10.5	EM + EL	NA	16.5 (3-79)	7.9	NA	10.5	10.5	NA	NA	NA	49	41
Pang et al[19]	Retrospective multi- center	SR	72.8		193 ± 84.11	5.4 ± 4.5	0.7	8.9	3.7	3.7	NA	19.4 ± 9.8	NA	NA	NA
		LH	71.4	EL	213 ± 83.5	5.3 ± 4.3	0.4	8.4	4	4.8	NA	21.2 ± 12.21	NA	NA	NA
Bono et al[20]	Retrospective multi- center	SR	7	EM + EL	196.2	14.1	7	10.5	7	NA	0	13 5 ± 28	NA	No difference	No difference
		LH	14	EM + EL	215.08	14.03	3.5	14	7	NA	1.8	14.5 ± 7.23	NA
		ERH	8.3	EM + EL	211.11	14.55	0	13.9	13.9	NA	0	19.3 ± 8.01	NA
		TC	0	EM + EL	2351	11.63	4.6	9	0	NA	0	19/7 ± 7.011	NA
Martín Arévalo et al[21]	Retrospective single center	SR	8	EM + EL	152 (85-330)	NA	14	50	5.5	14	NA	17.5 (2-32)	22	87.5	87.5
		LH	9	EM + EL	180 (75-385)	NA	2	43	5	5	NA	15 (2-68)	36.5	95.5	89
		ERH/STC	17	EM + EL	180 (58-360)	NA	7	34	8.5	7	NA	17 (3-60)	38	94	96
Huang et al[22]	Retrospective single center	SR	84.9	EL	239.1 ± 62.1	9.2 ± 5.4	0	27.4	1.	0	6.8	27.5 ± 13.6	3.6	94	88.2
		LH	86.4	EL	222.7 ± 54.9	9.4 ± 4.5	0	22.7	0	0	13.6	25 ± 10.3	8	90.2	90.2
		ELH	86.4	EL	197.1 ± 42.6	8.2 ± 3.8	0	31.8	0	0	9.1	25.6 ± 11.6	4.3	94.1	83.0
Rega et al[24]	Retrospective single center	SR	17.5		105.3 ± 49.6		2	5	NA	NA	NA	21.5 ± 9.6	33	NA	NA
		LH	21		109 ± 50.8		0	4	NA	NA	NA	23.3 ± 13.9	37.5	NA	NA
		STC	14		121 ± 58.6		0	9	NA	NA	NA	28/9 ± 13	21	NA	NA
de’Angelis et al[25]	Retrospective single center	LH	100	EL	192.2 ± 43.4	8.1 ± 1.8	0	22.2	0	NA	7.4	16.6 ± 5.5	NA	75.1	66.7
		ERH	100	EL	235 ± 49.181	8.6 ± 3.4	0	22.2	3.7	NA	0	21.4 ± 4.91	NA	72.8	67.1
Beisani et al[26]	Retrospective multi- center	LH	38	EL	NA	7	5	37	7	9	20	18	11	84	16
		ERH/STC	32	EL	NA	10	6	581	7	10	371	261	7.7	85	22
El-Hendawy et al[27]	Retrospective multi- center	SR	NA	EL	105 (90-150)	7 (5-9)	5	2.5	NA	NA	NA	15 (9-20)	27.5	90	80
		LH	NA	EL	105 (100-150)	7 (5-9)	5	2.5	NA	NA	NA	20 (10-27)	40	90	80
		ERH	NA	EL	125 (100-150)1	7 (5-9)	5	2.5	NA	NA	NA	24 (10-28)1	35	87.5	80
Kohn et al[28]	Retrospective multi- center	SR	411	EM + EL	NA	5 (3-7)	3	NA	NA	NA	NA	16 (12-21)	37	76	NA
		EC	37	EM + EL	NA	5 (4-8)	3	NA	NA	NA	NA	18 (13-25)	37	75	NA
Degiuli et al[30]	Retrospective multi- center	SR	62.071	EM + EL	160 (120-210)	7 (6-10)	0.63	6.44	3.16	5.3	NA	16.85 ± 8.09	NA	84	85
		ERH + LH	50.68	EM + EL	189 (140-240)1	8 (6-10)	0.38	6.43	2.53	6.04	NA	20.08 ± 10.371	NA	83	84
Gravante et al[37]	Retrospective single center	LH	20.6	EM + EL	158 ± 411	NA	2.9	14.7	5.9	NA	0	13 (4-23)	NA	51.8	NA
		ERH	6.3	EM + EL	133 ± 50	NA	1.6	21.9	6.3	NA	4.7	16 (5-39)	NA	50.4	NA

¹Statistically significant.

SR: Segmental resection; LH: Left hemicolectomy; ERH: Extended right hemicolectomy; STC: Subtotal colectomy; ELH: Extended left hemicolectomy; EC: Extended colectomy; MIS: Minimally invasive surgery; EM: Emergency; EL: Elective; NA: Not available; LOS: Length of stay; LN: Lymph node; OS: Overall survival; DFS: Disease-free survival.