Laparoscopic colonic resection for splenic flexure cancer: our experience

Splenic flexure carcinoma is a rare condition, as it represents approximately 3 to
8 % of all colon cancers. It is associated with high risk of obstruction and poor
prognosis 9]. Surgical approach selection for splenic flexure carcinoma is still under debate.
Similarly to other colon cancer sites, the resected area must encompass the mesocolon
and include major vessels ligation at the origin; the rationale is to reduce local
recurrence by complete removal of potentially involved lymph node stations. A more
accurate definition of splenic flexure cancer may regard any lesion occurring between
the distal third of the transverse colon and the first part of the descending colon
8]. The two major vessels which nourish colon splenic flexure are middle and left colic
arteries. For these reasons the resection of a carcinoma located in one of these sites
should always include lymphadenectomy up to the origin of superior and inferior mesenteric
vessels, respectively. This could ultimately be the reason why splenic flexure cancers
have never been included in randomized controlled trials, since their resection implies
some technical difficulties, including laparoscopic identification of middle and left
colic vessels and subsequent lymph node dissection. COST, COLOR, CLASICC and Barcellona
trials 3]–6] actually excluded patients with such lesions, and a future randomized clinical study
specific for this subgroup appears really unlikely. For all these reasons laparoscopic
treatment of splenic flexure carcinoma is still considered challenging, and clinical
evidence of equivalence with other colon resections is still needed. Different procedures
have been described in literature. Some Authors suggested to perform an extended right
hemicolectomy performed with laparoscopic hand-assisted approach 10]. On the contrary, several Authors recommended a left partial colectomy with ligation
at their origin of both left branch of the middle colic artery and left colic artery
11]. On the other hand, some investigators demonstrated that splenic flexure cancers
are not associated with a worse prognosis compared to other colonic tumors and that
the double lymphatic drainage does not confer a survival disadvantage, so that an
extended resection appears unnecessary 12]. As described by some Authors, the oncological effectiveness of a segmental resection
could be determined by the peculiar lymphatic spread of splenic flexure cancers: these
studies showed that the majority of positive lymph nodes among patients with splenic
flexure carcinoma are distributed along paracolic arcade and left colic artery. Nodes
along middle colic artery and its left branch resulted involved in a negligible number
of cases (0 and 4.2 %, respectively), thus not influencing the oncological outcome
13]. Therefore, a segmental resection can be effective for the treatment of splenic flexure
cancer in its earlier phases. Moreover, laparoscopic segmental splenic flexure resection
can be safely completed without identification and isolation of the middle colic vessels
11]. In fact, these Authors report that laparoscopic division of middle colic vessels
is challenging as it requires advanced skills. In our series all patients underwent
ligation at the origin of both middle colic artery left branch and left colic artery.
Nevertheless, there were no significant differences in complication or conversion
rates compared to patients who underwent laparoscopic resection of other colic segments
14]. Other main controversies making laparoscopic splenic flexure resection a a not yet
standardized procedure concern the risk of inadvertent splenectomy and the type of
intestinal anastomosis. As regard the first one theme, according to literature the
risk of accidental splenectomy is higher in splenic flexure tumors compared to other
colon cancer locations, thus leading to higher postoperative morbidity and mortality
7]. A mini-invasive approach proved to be especially suitable for splenic flexure mobilizing;
due to its fixed position, some Authors suggested the use of Da Vinci system for this
subgroup of colic cancer. Effectively, laparoscopic robot-assisted resection seems
to be a promising approach for splenic flexure cancer treatment, since it allows finer
manipulation which can decrease the risk of spleen injury 15]. Anastomosis is generally side-to-side performed. No data are available in literature
comparing extracorporeal and intracorporeal anastomosis after laparoscopic splenic
flexure resection and regarding immediately recognizable benefits for the patients
and cost-effectiveness of the procedure. The majority of series suggests extacorporeal
anastomosis; however, entirely intra-abdominal colon segments resection and anastomosis
may become the procedure of choice 16]. Some of the potential advantages of intracorporeal anastomosis are the following:
to anastomose away from the abdominal wall could reduce surgical-site infection rates;
the reduced surgical manipulation of abdominal cavity may reduce adhesions and risk
of adhesive small bowel obstruction; a smaller incision of abdominal wall for specimen
extraction could lead to clinically relevant benefits; at last, laparoscopic visualization
during the creation of the anastomosis could reduce unrecognized anastomotic twisting
17]. In our series an intracorporeal anastomosis was performed in the last 7 cases, after
the improving of the surgical skill regarding intracorporeal sutures and knotting,
using the same standardized technique of right hemicolectomy. In patients undergoing
total laparoscopic treatment operative time was longer, but we didn’t record any case
of anastomotic failure. A fast track protocol was performed in these patients, with
good outcome in term of short terms complications and with shorter hospital stay.
Preservation of inferior mesenteric and middle colic arteries could account for the
good anastomotic healing, much more than improved experience with this technique 15]. Attemping to answer to all these controversies, we believe that when laparoscopic
splenic flexure resection is performed after an adequate learning curve regarding
other colon cancer locations, and if it is performed on appropriate patient groups
with accurate preoperative diagnosis, this procedure should be considered a safe and
useful treatment 18]. Indeed, in our series too, mortality was 0 % and 30-day morbidity resulted 8.7 %.
The only major complication was a episode of postoperative acute pancreatitis involving
pancreatic tail. This event simulated an anastomotic leakage, thus relaparotomy was
necessary. Some Authors described postoperative acute pancreatitis occurring after
surgical procedures involving transverse mesocolon root separation from pancreas 14]. Regarding oncological safety, this technique requires long-term follow-up observation
to assess distant metastases and local recurrence rates; larger scale multicenter
prospective studies on laparoscopic splenic flexure resection are therefore necessary.
However, in our study a tumor-free resection margin was reported in all specimens
and tumor distance from proximal and distal margins was always adequate. Lymphadenectomy
was sufficient in all cases, too. During a mean follow-up of 33?±?17 months one patient
developed systemic recurrence with liver metastasis, while another one experienced
a local recurrence in the anastomosic area, in accordance with a previous study describing
an overall recurrence rate equal to 8.5 % 18]. Recurrent disease in these 2 cases was however related with the anatomopathological
stage of the primitive disease (pT3, N1/2).