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He Z, Ren J, Tang X, Li W, Zhang X, Liao W, Lin J, Wang J, Ao L, Xie J, Li H, Yi X, Lu X, Feng X, Diao D. Innovative pancreas-guided technique for splenic flexure mobilization in laparoscopic left hemicolectomy. Surg Endosc 2024:10.1007/s00464-024-11009-0. [PMID: 39060624 DOI: 10.1007/s00464-024-11009-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 06/22/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE Splenic flexure mobilization (SFM) is a major challenge in laparoscopic left hemicolectomy. This study aims to assess the safety and effectiveness of the pancreas-guided SFM technique during laparoscopic left hemicolectomy. METHODS From January 2018 to December 2023, 352 patients with left-sided colon cancer underwent laparoscopic left hemicolectomy. Based on the SFM method used, the patients were divided into the pancreas-guided group (167 cases) or the "Three Approaches Roundabout"/classic group (185 cases). Clinicopathologic characteristics and intraoperative and postoperative variables were compared between the two groups. RESULTS The two groups had no significant differences in baseline indicators (P > 0.05). All surgeries were successful without needing to convert to laparotomy, and there were no combined organ resections involving the spleen or pancreas in either group. The mean duration of surgery was significantly lower in the pancreas-guided group than in the classic group (P < 0.01). The median volume of intraoperative blood loss in the pancreas-guided group was lower than that in the classic group (P < 0.01). Through video playback, it was found that the retro-pancreatic space had been entered during operation in 8 cases (4.3%) in the classic group, while there were no such occurrences in the pancreas-guided group. This difference was statistically significant (P < 0.05). The difference in the number of lymph nodes cleared, postoperative hospital stays, and incidence of complications were not statistically significant (all P > 0.05) between the groups. CONCLUSION The pancreas-guided SFM technique is a safe and feasible option for laparoscopic left hemicolectomy. Our study's findings suggest that this approach facilitates accurate access to the correct anatomic plane, potentially improving surgical efficiency.
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Affiliation(s)
- Ziyan He
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiaqi Ren
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin Tang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenjuan Li
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xueyang Zhang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Weilin Liao
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jiaxin Lin
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jiahao Wang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lin Ao
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jiaxin Xie
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Hongming Li
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xiaojiang Yi
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - XinQuan Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - XiaoChuang Feng
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Dechang Diao
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China.
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Miftari R, Gazzetta J. Splenic Capsule Injury: A Rare Complication of Sigmoid Volvulus. Cureus 2023; 15:e41118. [PMID: 37519610 PMCID: PMC10382788 DOI: 10.7759/cureus.41118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Sigmoid volvulus can lead to life-threatening complications. We report a splenic capsule avulsion injury requiring laparotomy as a complication of sigmoid volvulus. A 73-year-old woman was admitted with abdominal distension, rigidity, and tenderness. CT abdomen revealed a splenic injury and hemoperitoneum along with possible sigmoid volvulus. The patient required an emergent exploratory laparotomy due to an acute abdomen and hemodynamic instability. A left colectomy, on-table sigmoidoscopy, hemostasis of the spleen, and temporary abdominal closure were performed. She required subsequent operations for end colostomy and abdominal closure. We establish that splenic lacerations are rare but life-threatening complications of sigmoid volvulus. Careful assessment of the spleen on abdominal imaging and clear visualization of the spleen during sigmoid volvulus surgery is recommended for early recognition and prompt management of splenic injury.
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Affiliation(s)
- Rrezane Miftari
- General Surgery, Saba University School of Medicine, The Bottom, BES
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3
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Freund MR, Kent I, Horesh N, Smith T, Emile SH, Wexner SD. Pancreatic injuries following laparoscopic splenic flexure mobilization. Int J Colorectal Dis 2022; 37:967-971. [PMID: 35178614 DOI: 10.1007/s00384-022-04112-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To call awareness to pancreatic injury occurring following laparoscopic splenic flexure mobilization (LSFM) and to discuss the mechanisms which led to such an injury. METHODS Retrospective review of patients who underwent LSFM as part of their colectomy procedure and sustained pancreatic injuries at a colorectal surgery referral center during 2014-2021. RESULTS Of 1022 (0.6%) LSFM performed during the study period, six (0.6%) patients were identified in which clinically significant injuries to the pancreas occurred. Two patients had partial transection of the tail of the pancreas and underwent laparoscopic distal pancreatectomy during the index operation. Three patients developed a post-operative pancreatic fistula after their pancreatic injury went undiagnosed during surgery and required percutaneous drainage, one of whom eventually required a distal pancreatectomy for a persistent pancreatic fistula. Another patient developed a peripancreatic fluid collection which resolved with conservative treatment. CONCLUSIONS Pancreatic injury is rare and a potentially major complication of LSFM. Anatomical misperception, retroperitoneal bleeding, a large bulky splenic flexure tumor, and a "difficult flexure" were recognized as possible mechanisms of such injury.
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Affiliation(s)
- Michael R Freund
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, United States
| | - Ilan Kent
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, United States
| | - Nir Horesh
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, United States
| | - Timothy Smith
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, United States
| | - Sameh Hany Emile
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, United States
- Colorectal Surgery Unit, Mansoura University Hospital, Mansoura, Egypt
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, United States.
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Polovinkin VV, Pryn PS. [Mobilization of splenic flexure - routine or selective (results of a single-center randomized study)]. Khirurgiia (Mosk) 2022:33-44. [PMID: 35775843 DOI: 10.17116/hirurgia202207133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate safety and effectiveness of routine splenic flexure mobilization (SFM) in surgical treatment of rectal cancer (RC). MATERIAL AND METHODS A single-center randomized study was performed between 2016 and 2019. Patients were randomized into 2 groups (SFM (+), n=156, SFM(-), n=67). Standard anterior and low anterior rectal resection was used. We used a combination of medial, lateral, and anterior approaches for SFM. Intraoperative, early and late postoperative complications, histological data, local recurrence, overall 3-year, relapse-free and cancer-specific survival were analyzed. RESULTS Surgery time was 253.2±72.8 and 252.0±78.0 min in the SFM(+) and SFM(-) groups, respectively (p=0.98). Blood loss was 53.3±53.6 and 67.0±108.8 ml, respectively (p=0.85), length of specimen - 28.6 (95% CI 27.2-29.9) and 24.0 cm (95% CI 22.2-25.7) (p<0.0001). Length of residual fragment of sigmoid colon was 5.0 (95% CI 3.9-6.1) and 9.1 cm (95% CI 7.2-11.1) (p<0.0001), respectively. The number of examined lymph nodes was 15.5 (95% CI 14.2-16.8) and 16.1 (95% CI 14.2-18.1) (p=0.52), number of affected lymph nodes - 1.5 (95% CI 0.9-2.1) and 1.5 (95% CI 0.9-2.2), respectively (p=0.38). Spleen damage was more common in the SFM (-) group (4.5% vs. 1.3%, p=0.12). Logistic regression analysis indicates that SFM does not affect the incidence of spleen damage. Severity of postoperative complications was similar (p=0.63). Anastomotic leak (AL) was more common in the SFM group (-) (17.9% vs. 9.6%, p=0.04). AL grade B was more common in the SFM(-) group (p=0.0001). Logistic regression analysis revealed the following predictors of anastomotic leakage: length of specimen and length of residual sigmoid colon. There was no significant relationship between SFM and incidence of local and systemic recurrences. Overall, cancer-specific and relapse-free 3-year survival was similar. CONCLUSION SFM is a safe procedure with various advantages. However, this approach does not improve intraoperative, early and long-term postoperative outcomes that does not allow us to recommend this approach for routine application.
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Affiliation(s)
- V V Polovinkin
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russian Federation
| | - P S Pryn
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russian Federation
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Chugh P, Eble D, He K, Sacks O, Madiedo A, Whang E, Kristo G. Evaluation of Operative Notes for Splenic Flexure Mobilization: Are the Key Aspects Being Reported? J Laparoendosc Adv Surg Tech A 2021; 32:270-276. [PMID: 33960832 DOI: 10.1089/lap.2021.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Given the importance of operative documentation, we reviewed operative notes for surgeries that required splenic flexure mobilization (SFM) to determine their accuracy. Materials and Methods: We performed a retrospective review of 51 operative notes for complete SFMs performed at a single institution from January 2015 to June 2020. Results: None of the operative notes reported a rationale for performing SFM, use of preoperative imaging to guide technical approach, reasoning for the operative method and mobilization approach used, or specific steps taken to ensure that SFM was done safely. Most reports did not include technical details, with one-third of the notes merely reporting that "the splenic flexure was mobilized." Conclusions: Increased awareness about the lack of operative documentation of the critical aspects of the SFM could stimulate initiatives to standardize the SFM method and improve the quality of operative notes for SFM.
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Affiliation(s)
- Priyanka Chugh
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.,Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts, USA
| | - Danielle Eble
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Katherine He
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olivia Sacks
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.,Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts, USA
| | - Andrea Madiedo
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.,Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts, USA
| | - Edward Whang
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gentian Kristo
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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6
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Pettke E, Leigh N, Shah A, Cekic V, Yan X, Kumara HS, Gandhi N, Whelan RL. Splenic flexure mobilization for sigmoid and low anterior resections in the minimally invasive era: How often and at what cost? Am J Surg 2020; 220:191-196. [DOI: 10.1016/j.amjsurg.2019.09.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/16/2019] [Accepted: 09/24/2019] [Indexed: 12/25/2022]
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7
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Yao L, Dolo PR, Li Z, Widjaja J, Zhu X. Intermittent Splenic Artery Occlusion Plus Gauze Compression Is a Simple and Effective Treatment for Iatrogenic Splenic Injury. Med Sci Monit 2020; 26:e922862. [PMID: 32096484 PMCID: PMC7059433 DOI: 10.12659/msm.922862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The aim of this study was to evaluate the feasibility and safety of intermittent splenic artery occlusion plus gauze compression in treating iatrogenic splenic injury. Material/Methods We retrospectively analyzed 12 iatrogenic splenic injury cases (grade I to III) treated with intermittent splenic artery occlusion plus gauze compression. The hemostatic effect was then observed after unblocking and decompression. The total operation time, gauze compression time, total blood loss, blood loss from the injured spleen, and platelet counts of each patient before and 1 week after surgery were noted. Results The average operation time was 209.58±57.11 min, and the average gauze compression time after spleen artery occlusion was 23.75±4.33 min. The average total blood loss and blood loss due to iatrogenic spleen injury were 468.33±138.22 ml and 264.17±165.72 ml, respectively. Two cases (both grade I) had successful hemostasis after 15 min of splenic artery occlusion and wound compression. Another 9 cases (all grade II) and 1 case (grade III) attained hemostasis after 25 min and 30 min, respectively, of splenic artery occlusion and wound compression. The platelet counts of all patients were within the normal range before and 1 week after surgery. No postoperative complications occurred. Conclusions Intermittent splenic artery occlusion plus gauze compression is a simple and effective treatment for iatrogenic splenic injury.
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Affiliation(s)
- Libin Yao
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - Ponnie Robertlee Dolo
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - Zhichao Li
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - Jason Widjaja
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - Xiaocheng Zhu
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
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8
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Damin DC, Betanzo LN, Ziegelmann PK. Splenic flexure mobilization in sigmoid and rectal cancer resections: a meta-analysis of surgical outcomes. ACTA ACUST UNITED AC 2019; 46:e20192171. [PMID: 31644719 DOI: 10.1590/0100-6991e-20192171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/10/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE to evaluate the influence of the splenic flexure mobilization for the main surgical outcomes of patients submitted to resection of sigmoid and rectal cancer. METHODS we searched the MEDLINE, Cochrane Central Register of Controlled Trials and LILACS, using the terms "splenic flexure mobilization", "colorectal surgery", "rectal cancer", "anterior resection", "sigmoid colon cancer", and "sigmoid resection". The main outcome was anastomotic dehiscence. Other outcomes analyzed were mortality, bleeding, infection and general complications. We estimated the effect sizes by grouping data from six case-control studies (1,433 patients) published until January 2018. RESULTS our meta-analysis showed that patients undergoing complete mobilization of the splenic flexure had a higher risk of anastomotic dehiscence (RR=2.27, 95%CI: 1.22-4.23) compared with those not submitted to this procedure. There was no difference between the groups in terms of mortality, bleeding, infection and general complications. CONCLUSION splenic flexure mobilization is associated with a higher risk of anastomotic dehiscence in resections of sigmoid and rectal cancer. This surgical maneuver should be used with caution in the surgical management of sigmoid or rectal cancers.
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Affiliation(s)
- Daniel C Damin
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Cirurgia, Programa de Pós-Graduação em Medicina (Ciências Cirúrgicas), Porto Alegre, RS, Brasil.,Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clinicas de Porto Alegre, Serviço de Coloproctologia, Porto alegre, RS, Brasil
| | - Luize N Betanzo
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Cirurgia, Programa de Pós-Graduação em Medicina (Ciências Cirúrgicas), Porto Alegre, RS, Brasil.,Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clinicas de Porto Alegre, Serviço de Coloproctologia, Porto alegre, RS, Brasil
| | - Patrícia K Ziegelmann
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Epidemiologia e Departamento de Estatística, Porto Alegre, RS, Brasil
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Puchkov DK, Khubezov DA, Puchkov KV, Ignatov IS, Ogoreltsev AY, Lukanin RV, Evsiukova MA, Li YB. [Assessment of the efficiency and safety of the modified combined approach for laparoscopic splenic flexure mobilization]. Khirurgiia (Mosk) 2019:40-47. [PMID: 31502592 DOI: 10.17116/hirurgia201908240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the efficacy and safety of the proposed modified combined approach for laparoscopic splenic flexure mobilization (SFM). MATERIAL AND METHODS A multicenter non-randomized comparative study was conducted. The main group consisted of 12 patients who underwent laparoscopic modified combined SFM from December 2018 to May 2019, the control group consisted of 12 patients who underwent laparoscopic traditional combined SFM from 2013 to 2018. The following aspects were evaluated: total duration of the operation, duration of the SFM, blood loss, rate of conversions, intraoperative complications, postoperative complications, duration of the postoperative period. RESULTS Significant differences were obtained for the average duration of the SFM. The duration of the procedure was calculated during watching a video of operation. The average duration of the SFM in the main group was 37.4±12.2 min, in the control group 59.5±19.1 min (p=0.03). The average blood loss in the main group was 52.5±12.3 ml, in the control group - 115.6±20.7 ml (p=0.02). In the main group there were no intraoperative complications, while in the comparison group 1 case of the spleen damage was noted, requiring conversion, and 1 case of the pancreas damage. These differences are not significant due to the small sample. CONCLUSION The use of the proposed modified combined approach for the laparoscopic SFM significantly reduces the duration of the operation and is accompanied by a decrease in the frequency of intraoperative complications. However, further randomized studies with a larger sample are needed.
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Affiliation(s)
- D K Puchkov
- Ryazan State Medical University Im I.P. Pavlova, Ryazan, Russia; Ryazan State Clinical Hospital, Ryazan, Russia
| | - D A Khubezov
- Ryazan State Medical University Im I.P. Pavlova, Ryazan, Russia; Ryazan State Clinical Hospital, Ryazan, Russia
| | - K V Puchkov
- Ryazan State Medical University Im I.P. Pavlova, Ryazan, Russia
| | - I S Ignatov
- Ryazan State Medical University Im I.P. Pavlova, Ryazan, Russia; Ryazan State Clinical Hospital, Ryazan, Russia
| | - A Yu Ogoreltsev
- Ryazan State Medical University Im I.P. Pavlova, Ryazan, Russia; Ryazan State Clinical Hospital, Ryazan, Russia
| | - R V Lukanin
- Ryazan State Clinical Hospital, Ryazan, Russia
| | - M A Evsiukova
- Ryazan State Medical University Im I.P. Pavlova, Ryazan, Russia; Ryazan State Clinical Hospital, Ryazan, Russia
| | - Yu B Li
- Ryazan State Medical University Im I.P. Pavlova, Ryazan, Russia
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Effect of splenic flexure mobilization performed via medial-to-lateral and superior-to-inferior approach on early clinical outcomes in elective laparoscopic resection of rectal cancer. Wideochir Inne Tech Maloinwazyjne 2019; 14:509-515. [PMID: 31908696 PMCID: PMC6939205 DOI: 10.5114/wiitm.2019.85224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/17/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Whether complete splenic flexure mobilization (SFM) is required remains a controversial issue and there are numerous approaches regarding the performance of this procedure. Aim To investigate the effect of SFM performed with a medial-to-lateral and superior-to-inferior approach on early clinical outcomes in laparoscopic resection of rectal cancer. Material and methods The SFM procedure was initiated by the ligation of the inferior mesenteric vein followed by dissection extending from the upper border of the pancreas to the splenic hilum through the gastrocolic space. The mesocolon was dissected in a superior-to-inferior and medial-to-lateral fashion and the presacral space was entered by dividing the inferior mesenteric artery. The procedure was completed by dividing all the splenocolic, phrenicocolic, gastrocolic, and pancreaticomesocolic ligaments. Results A total of 43 patients were included in the study, comprising 26 (60.5%) men and 17 (39.5%) women with a mean age of 58.2 ±13.9 (range: 30–87) years. Of the 43 patients, 21 (48.8%) underwent neoadjuvant chemotherapy and a diversion stoma was performed in 37 (86%) patients. No adjacent organ injury occurred intraoperatively. Mean operative time was 271 ±50 min and mean blood loss was 144 ±83 ml. One (2.3%) patient might have developed anastomotic leakage secondary to bevacizumab therapy postoperatively and developed no anastomotic stenosis in the follow-up period. Mean length of hospital stay was 9.3 ±4.3 days and no mortality occurred in any patient. Conclusions Splenic flexure mobilization performed via the superior-to-inferior and medial-to-lateral approach appears to be a safe and feasible procedure.
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Mouw TJ, King C, Ashcraft JH, Valentino JD, DiPasco PJ, Al-Kasspooles M. Routine splenic flexure mobilization may increase compliance with pathological quality metrics in patients undergoing low anterior resection. Colorectal Dis 2019; 21:23-29. [PMID: 30184316 DOI: 10.1111/codi.14404] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/20/2018] [Indexed: 12/29/2022]
Abstract
AIM Mandatory splenic flexure mobilization (SFM) has been debated for rectal cancers. Proponents argue that additional mobilization facilitates a tension-free anastomosis; however, this must be weighed against heightened morbidity. Little is known about the impact of specific techniques on pathology quality metrics. We aim to determine the impact of SFM on pathology quality metrics for patients undergoing rectal resections for colorectal adenocarcinoma. METHOD Patients were selected by querying the University of Kansas electronic medical records and the American College of Surgeons National Surgical Quality Improvement Program database based on Current Procedural Terminology codes. Patients were categorized as SFM or non-SFM. Primary outcomes were node yield less than 12 and margin length. RESULTS There were 146 patients who met the inclusion criteria for chart review and 7369 included from the national database. Splenic flexure mobilization was associated with wider margins (3.52 vs 2.51 cm in low anterior resection, P < 0.01) and a decreased rate of inadequate nodal staging in patients undergoing low anterior resection (3.7% vs 19.3% P < 0.01). CONCLUSIONS SFM may affect surgical quality metrics in patients undergoing resection for distal colon and rectal adenocarcinoma. Further study is warranted to determine whether these differences in quality and pathology translate into differences in oncological outcomes.
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Affiliation(s)
- T J Mouw
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - C King
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - J H Ashcraft
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - J D Valentino
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - P J DiPasco
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - M Al-Kasspooles
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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12
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Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery. Tech Coloproctol 2018; 22:767-771. [PMID: 30460619 DOI: 10.1007/s10151-018-1861-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/24/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options. METHODS All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared. RESULTS There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p = 0.005) and a lower need for splenectomy/splenorrhaphy (p = 0.03). CONCLUSIONS Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.
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13
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Splenic flexure mobilization in rectal cancer surgery: do we always need it? Updates Surg 2018; 71:505-513. [PMID: 30406931 DOI: 10.1007/s13304-018-0603-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/30/2018] [Indexed: 01/20/2023]
Abstract
Splenic flexure (SFM) in rectal cancer surgery is a crucial step which may increase the difficulty of the operation. The aim of this retrospective single-center study is to demonstrate if the selective omission of SFM during anterior rectal resection can reduce the complexity of the operation, without affecting post-operative and oncologic outcomes. Data of 112 consecutive rectal resections for cancer from March 2010 to March 2017 were analyzed and divided into two groups: SFM and No-SFM. A sub-analysis was then performed for laparoscopy and traditional cases. Post-operative and oncologic outcomes, including overall (OS) and cancer-related survival (CRS), were analyzed and compared. SFM was performed in 42% of cases and laparoscopy was used in 73.2%. Operative time resulted significantly lower in the No-SFM group (190 vs. 225 min, p = 0.01). In laparoscopy in the No-SFM group, operative time and post-operative stay were significantly lower (205.5 vs. 222.5 min, p = 0.04; 9 vs. 10 days, p = 0.01). Most of the open resections were performed without SFM (35.4% vs. 14.9%, p = 0.02). No statistical significant differences were found in OS and CRS in the two groups. We support the hypothesis that every surgeon should carry out an accurate intra-operative evaluation to perform a selective SFM. When possible, SFM can be safely avoided with no additional risks in terms of post-operative and oncologic outcomes.
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Mangano A, Gheza F, Giulianotti PC. Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results. MINERVA CHIR 2018; 73:512-519. [DOI: 10.23736/s0026-4733.18.07737-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mangano A, Fernandes E, Valle V, Bustos R, Gheza F, Giulianotti PC. Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study. MINERVA CHIR 2018; 73:451-459. [PMID: 29806761 DOI: 10.23736/s0026-4733.18.07806-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, this maneuver may increase the risk of iatrogenic spleen damage; for others this does not change the odds. Ligaments over-traction is the most frequent injury mechanism. Some documented risk factors are reported: laparotomic approach, male gender, vascular disease, cancer, diverticulitis, surgery performed in emergency-setting. The type of procedure influences the associated risk: transverse colectomy is the riskiest, followed by left colonic resection and pancolectomy. METHODS Retrospective original paper. Sample size - a total of 125 patients have been considered. 75 robotic left colonic resections (60%), 40 robotic rectal resections (32%) and 10 robotic pancolectomy (8%). Primary outcomes - 1) percentage of iatrogenic splenic injuries; 2) conversion rate. Secondary outcomes - 1) intra-/postoperative complications; 2) anastomotic leakage rate; 3) mortality. In order to avoid potential confounding factors and technical/expertise heterogeneity, all the procedures included have been performed using the same standardized operative technique and by the same experienced surgeon (P.C.G.). RESULTS We retrospectively analyzed 125 procedures. Primary outcomes - 1) iatrogenic splenic injuries: 0%; 2) conversion rate: 1.6%. Secondary outcomes - 1) intraoperative complications: 0%; 2) anastomotic leakage rate: 1 case of leakage out of 125 cases (1.3% of the left colectomy sub-sample); in this case the leakage was probably due to an infectious process rather than a vascular deficit; 3) mortality: 0%; 4) miscellanea postoperatory complications (small bowel obstructions, wound infection, pelvic collections, pneumonia and acute kidney injury) are detailed in the manuscript. CONCLUSIONS In our experience, and according to some of the literature data as well, during robotic left colonic/rectal resections the routine mobilization of the left flexure as a standard procedure is not a risk factor in terms of iatrogenic spleen injury rate. Conversely, this technique may be beneficial as it does not excessively extend the operative time, increases the surgical skills acquirement, and reduces the tension-related anastomotic ischemia. It also allows a better oncological dissection. Standard laparoscopic approach reduces the rate of spleen by almost 3.5 times in comparison to open surgery. The improved technical accuracy provided by the robotic platform may decrease the rate of splenic injury. More studies are needed on the topic to confirm our findings.
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Affiliation(s)
- Alberto Mangano
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA -
| | - Eduardo Fernandes
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Valentina Valle
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Roberto Bustos
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Federico Gheza
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Brookes AF, Macano C, Stone T, Cheetham M, Meecham L. Sex differences in the splenic flexure. Ann R Coll Surg Engl 2017; 99:456-458. [PMID: 28660812 DOI: 10.1308/rcsann.2017.0054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Anecdotally, surgeons claim splenic flexure mobilisation is more difficult in male patients. There have been no scientific studies to confirm or disprove this hypothesis. The implications in colorectal surgery could be profound. The aim of this study was to assess quantitatively whether there is an anatomical difference in the position of the splenic flexure between men and women using computed tomography (CT). METHODS Portal venous phase CT performed for preoperative assessment of colorectal malignancy was analysed using the hospital picture archiving and communication system. The splenic flexure was compared between men and women using two variables: anatomical height corresponding to the adjacent vertebral level (converted to ordinal values between 1 and 17) and distance from the midline. RESULTS In total, 100 CT images were analysed. Sex distribution was even. The mean ages of the male and female patients were 68.1 years and 66.7 years respectively (p=0.630). The mean vertebral level for men was 8.88, equating to the inferior half of the T11 vertebral body (range: 1-17 [superior half of T9 to inferior half of L2]), and 11.36 for women, equating to the inferior half of the T12 vertebral body (range: 4-16 [superior half of T10 to superior half of L2]). This difference was statistically significant (p=0.0001) and is equivalent to one whole vertebra. The mean distance from the midline was 160.8mm (range: 124-203mm) for men and 138.2mm (range: 107-185mm) for women (p<0.0001). CONCLUSIONS The splenic flexure is both higher and further from the midline in men than in women. This provides one theory as to why mobilising the splenic flexure may be more difficult in male patients.
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Affiliation(s)
| | - Caw Macano
- Heart of England NHS Foundation Trust , UK
| | - T Stone
- Shrewsbury and Telford Hospital NHS Trust , UK
| | - M Cheetham
- Shrewsbury and Telford Hospital NHS Trust , UK
| | - L Meecham
- Heart of England NHS Foundation Trust , UK
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Inadvertent Splenectomy During Resection for Colorectal Cancer Does Not Increase Long-term Mortality in a Propensity Score Model: A Nationwide Cohort Study. Dis Colon Rectum 2016; 59:1150-1159. [PMID: 27824700 DOI: 10.1097/dcr.0000000000000712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies suggest that long-term mortality is increased in patients who undergo splenectomy during surgery for colorectal cancer. The reason for this association remains unclear. OBJECTIVE The purpose of this study was to investigate the association between inadvertent splenectomy attributed to iatrogenic lesion to the spleen during colorectal cancer resections and long-term mortality in a national cohort of unselected patients. DESIGN This was a retrospective, nationwide cohort study. SETTINGS Data were collected from the database of the Danish Colorectal Cancer Group and merged with data from the National Patient Registry and the National Pathology Databank. PATIENTS Danish patients with colorectal cancer undergoing curatively intended resection between 2001 and 2011 were included in the study. MAIN OUTCOME MEASURES The primary outcome was long-term mortality for patients surviving 30 days after surgery. Secondary outcomes were 30-day mortality and risk factors for inadvertent splenectomy. Multivariable and propensity-score matched Cox regression analyses were used to adjust for potential confounding. RESULTS In total, 23,727 patients were included, of which 277 (1.2%) underwent inadvertent splenectomy. There was no association between inadvertent splenectomy and long-term mortality (adjusted HR = 1.15 (95% CI, 0.95-1.40); p = 0.16) in the propensity score-matched model, whereas 30-day mortality was significantly increased (adjusted HR = 2.31 (95% CI, 1.71-3.11); p < 0.001). Inadvertent splenectomy was most often seen during left hemicolectomy (left hemicolectomy vs right hemicolectomy: OR = 24.76 (95% CI, 15.30-40.06); p < 0.001). LIMITATIONS This study was limited by its retrospective study design and lack of detailed information on postoperative complications. CONCLUSIONS Inadvertent splenectomy during resection for colorectal cancer does not seem to increase long-term mortality. The previously reported reduced overall survival after inadvertent splenectomy may be explained by excess mortality in the immediate postoperative period.
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Meecham L, Brookes A, Macano C, Stone T, Cheetham M. Anatomical siting of the splenic flexure using computed tomography. Ann R Coll Surg Engl 2016; 99:207-209. [PMID: 27659370 DOI: 10.1308/rcsann.2016.0298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Often, left-sided colorectal surgery requires splenic flexure mobilisation (SFM) to allow a tension-free anastomosis to be carried out. This step is difficult and not without risk. We investigated a system of anatomical siting of the splenic flexure using computed tomography (CT). METHODS The Shrewsbury Splenic Flexure Siting (SSFS) system involves siting of the splenic flexure using the vertebral level (VL) as a reference point. We asked three surgical registrars (SRs) to analyse 20 CT scans of patients undergoing colonic resection to ascertain the anatomical site of the splenic flexure using the SSFS system. The distance from the centre of the vertebral body to the lateral edge (CVBL) of the splenic flexure was measured, as was the distance from the centre of the vertebral body to the inner abdominal wall (CVBI) along the same line, on axial images. RESULTS VL assessment demonstrated substantial inter-observer agreement with a kappa (κ) value of 0.742 (95% confidence interval (CI), 0.463-0.890). CVBL and CVBI demonstrated very strong inter-observer agreement (CVBL: κ = 0.905 (95% CI, 0.785-0.961); CVBI: 0.951 (0.890-0.979) (p<0.001). Overall, there was strong correlation between assessments by all three SRs across the three variables measured. CONCLUSIONS The SSFS system is an accurate method to site the splenic flexure anatomically using CT. We can use the SSFS system to develop a validated scoring system to help colorectal surgeons assess the difficulty of SFM.
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Affiliation(s)
- L Meecham
- Shrewsbury and Telford NHS Trust , UK
| | - A Brookes
- Shrewsbury and Telford NHS Trust , UK
| | | | - T Stone
- Shrewsbury and Telford NHS Trust , UK
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Saber AA, Dervishaj O, Aida SS, Christos PJ, Dakhel M. CT Scan Mapping of Splenic Flexure in Relation to Spleen and its Clinical Implications. Am Surg 2016. [DOI: 10.1177/000313481608200516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Splenic flexure mobilization is a challenging step during left colon resection. The maneuver places the spleen at risk for injury. To minimize this risk, we conducted this study for CT scan mapping of splenic flexure in relation to the spleen. One hundred and sixty CTscans of abdomen were reviewed. The level of the splenic flexure was determined in relation to hilum and lower pole of spleen. These levels were compared with patient demographics. Statistical analysis was performed using Fisher's exact test. The splenic flexure was above the hilum of the spleen in 95 patients (67.86%), at the splenic hilum level in 11 patents (7.88%), between the hilum and lower pole of the spleen in 12 (8.57%), at the lower pole of the spleen in 15 (10.7%) patients and 7 (5%) patients has a splenic flexure that lied below the lower pole of the spleen. Patient demographics showed no statistical significance in regard to splenic flexure location. Splenic flexure lies above the hilum of the spleen in majority of patients. This should be considered as part of operative strategies for left colon resection.
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Affiliation(s)
- Alan A. Saber
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
- Minimally Invasive Surgery, The Brooklyn Hospital Center, New York, New York
| | - Ornela Dervishaj
- Department of Surgery, The Brooklyn Hospital Center, New York, New York
| | - Samer S. Aida
- Department of Surgery, The Brooklyn Hospital Center, New York, New York
| | - Paul J. Christos
- Research Design and Bio statistical Core, Weill Cornell Medical College, New York, New York
| | - Mahmoud Dakhel
- Department of Radiology, The Brooklyn Hospital Center, New York, New York
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Isik O, Aytac E, Ashburn J, Ozuner G, Remzi F, Costedio M, Gorgun E. Does laparoscopy reduce splenic injuries during colorectal resections? An assessment from the ACS-NSQIP database. Surg Endosc 2014; 29:1039-44. [PMID: 25159632 DOI: 10.1007/s00464-014-3774-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 07/26/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. METHODS Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. RESULTS In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p < 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p < 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p < 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p < 0.001). CONCLUSIONS Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.
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Affiliation(s)
- Ozgen Isik
- Department of Colorectal Surgery, Digestive Disease Institute, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Stey AM, Ko CY, Hall BL, Louie R, Lawson EH, Gibbons MM, Zingmond DS, Russell MM. Are Procedures Codes in Claims Data a Reliable Indicator of Intraoperative Splenic Injury Compared with Clinical Registry Data? J Am Coll Surg 2014; 219:237-44.e1. [DOI: 10.1016/j.jamcollsurg.2014.02.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 02/24/2014] [Accepted: 02/25/2014] [Indexed: 11/16/2022]
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Steinert R, Depel M, Schmidt A, Ptok H, Meyer F, Wolff S, Otto R, Gastinger I. [Iatrogenic splenic injuries in surgery of colorectal carcinoma: impact on the oncological long-term of outcome]. Chirurg 2014; 85:812-7. [PMID: 24519612 DOI: 10.1007/s00104-013-2697-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Iatrogenic lesions of the spleen during surgery of colorectal carcinoma is considered a significant risk factor for a worse early postoperative outcome. With regard to the impact of iatrogenic splenic lesions particularly associated with splenectomy on the oncological long-term outcome, only limited valid data are available. METHODS Data obtained in a prospective multicenter observational study were analyzed. The study enrolled 45,265 patients with surgery for colorectal carcinoma in curative and palliative intentions during the study period from 01 January 2000 to 31 December 2004, with regard to the impact of iatrogenic splenic lesions on survival rates. RESULTS AND CONCLUSION Follow-up data with corresponding informed consent were obtained from 564 patients with iatrogenic splenic lesions, resulting in a follow-up rate of 99.8 %. The median follow-up period was 50.2 months. The median 5-year overall survival was 4.8 years in group I (splenic lesion with splenectomy) and in group II (splenic lesion with organ preservation) 8.0 years (p = 0.009). Between group II (splenic lesion with organ preservation) and group III (control group with no splenic lesion) there were no significant differences with regard to long-term survival. Using multivariate Cox regression analysis, iatrogenic splenic lesions with splenectomy were identified as an independent risk factor for a worse oncological long-term outcome.
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Affiliation(s)
- R Steinert
- An-Institut für Qualitätssicherung in der operativen Medizin gGmbH an der Otto-von-Guericke-Universität, Leipziger Str. 44, 39120, Magdeburg, Deutschland
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Van Koughnett JAM, Kalaskar SN, Wexner SD. Pitfalls of laparoscopic colorectal surgery and how to avoid them. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Laparoscopic surgery is commonly used for colorectal diseases. Recently, laparoscopy for colorectal carcinoma has increased in use, especially by colorectal surgeons. Laparoscopy is associated with potential pitfalls that pose challenges to the surgeon and team. The identification and management of these pitfalls may not directly parallel those during an open approach. As such, it is essential for the surgeon to have a good working knowledge of how to avoid potential problems and how to best manage them when they do occur. This review highlights common pitfalls of laparoscopic colorectal surgery, as well as offering practical approaches to their management. Technical, patient and surgeon factors are all discussed.
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Affiliation(s)
- Julie Ann M Van Koughnett
- Department of Colorectal Surgery, Cleveland Clinic FL, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
| | - Sudhir N Kalaskar
- Department of Colorectal Surgery, Cleveland Clinic FL, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic FL, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
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Mettke R, Schmidt A, Wolff S, Koch A, Ptok H, Lippert H, Gastinger I. [Spleen injuries during colorectal carcinoma surgery. Effect on the early postoperative result]. Chirurg 2013; 83:809-14. [PMID: 22434365 DOI: 10.1007/s00104-012-2277-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Unlike gastric carcinomas, the consequences of spleen damage during operative treatment of colorectal carcinoma have barely been investigated, as splenectomy is not performed on these tumor patients to extend the radicality. In this context, the only interest is in the iatrogenic intraoperative spleen lesions, which make a splenectomy necessary or require reconstructive spleen preservation. METHODOLOGY During the study period from January 2000 to the end of December 2004 the perioperative data of a prospective multicenter observational study of 46,682 Patients whose tumor had been removed with a curative or palliative intent were analyzed with respect to the early postoperative consequences of an iatrogenic spleen lesion. RESULTS Of these 46,682 Patients, 640 (1.4%) suffered an iatrogenic spleen injury during the operative therapy. The spleens of 127 Patients (0.3%) were removed and the spleens of 513 Patients (1.1%) could be left in situ following repair. In more than 80% of the cases with an iatrogenic spleen injury, the tumor was localized in the left colon and in the rectum. Logistic regression analysis showed that the decisive risk factor for this organ lesion was the mobilization of the left colonic flexure with tumor localization in the left colon and rectum. Following spleen lesion a significantly higher morbidity rate was registered (47.2% following splenectomy, 48.5% following spleen repair) compared to patients without spleen injury (36.5%). Anastomotic leaks requiring surgery were most frequently observed following splenectomy (7.9%) but this was significantly lower following spleen preservation (3.3%, p = 0.003). The total hospital mortality was 3.1%. In patients with splenectomy the hospital mortality was 11.8% and subsequent repair with organ preservation was 4.7% (p < 0.0001). CONCLUSIONS Iatrogenic spleen lesions during colorectal carcinoma surgery represent a significant risk factor for a poor early postoperative result. In particular, this concerns the high rate of anastomotic leaks and infectious septic complications. This also leads to a higher rate of total morbidity and hospital mortality. By comparison significantly worse postoperative results were found in the group of splenectomised patients compared to the group with organ preservation through repair of the injured spleen.
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Affiliation(s)
- R Mettke
- An-Institut für Qualitätssicherung in der operativen Medizin, Otto-von-Guericke Universität, Magdeburg, Germany.
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Wang JK, Tollefson MK, Kim SP, Boorjian SA, Leibovich BC, Lohse CM, Cheville JC, Thompson RH. Iatrogenic splenectomy during nephrectomy for renal tumors. Int J Urol 2013; 20:896-902. [DOI: 10.1111/iju.12065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 11/28/2012] [Indexed: 12/01/2022]
Affiliation(s)
- Jeffrey K Wang
- Department of Urology; Mayo Clinic; Rochester; Minnesota; USA
| | | | - Simon P Kim
- Department of Urology; Mayo Clinic; Rochester; Minnesota; USA
| | | | | | - Christine M Lohse
- Department of Health Sciences Research; Mayo Clinic; Rochester; Minnesota; USA
| | - John C Cheville
- Department of Anatomic Pathology; Mayo Clinic; Rochester; Minnesota; USA
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Kim HJ, Kim CH, Lim SW, Huh JW, Kim YJ, Kim HR. An extended medial to lateral approach to mobilize the splenic flexure during laparoscopic low anterior resection. Colorectal Dis 2013; 15:e93-8. [PMID: 23061515 DOI: 10.1111/codi.12056] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/11/2012] [Indexed: 12/23/2022]
Abstract
AIM The aim of this retrospective study of laparoscopic low anterior resection was to compare splenic flexure mobilization (SFM) carried out by an extended medial to lateral approach with that by a lateral approach. METHOD Records of patients with rectal cancer on a prospectively maintained database undergoing laparoscopic low anterior resection performed between January 2009 and November 2011 by a single surgeon were analysed. The extended medial to lateral approach involved continuing the medial to lateral approach upwards to enter the lesser sac over the pancreas, thus permitting detachment of the splenic flexure. RESULTS Two hundred and thirty-seven patients, including 164 undergoing a lateral SFM and 73 an extended medial to lateral SFM, were evaluated. Both patient groups had similar characteristics except for operative time (152.7 ± 32.7 min extended medial to lateral; 171.5 ± 40.8 min lateral; P < 0.001), postoperatively the interval to oral intake (3.1 ± 0.8 days extended medial to lateral; 3.7 ± 0.9 lateral; P < 0.001) and duration of hospital stay (8.2 ± 2.8 days extended medial to lateral; 10.3 ± 7.5 days lateral; P = 0.002) favoured the extended medial to lateral group. CONCLUSION An extended medial to lateral approach for SFM during laparoscopic low anterior resection of rectal cancer appears to be an improvement over the previously used lateral approach, because it may provide a shorter operation time and shorter hospital stay.
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Affiliation(s)
- H J Kim
- Division of Colorectal Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
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Different approaches for complete mobilization of the splenic flexure during laparoscopic rectal cancer resection. Int J Colorectal Dis 2012; 27:1521-9. [PMID: 22622601 DOI: 10.1007/s00384-012-1495-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Laparoscopic resection of rectal cancer has already become the standard procedure in many hospitals. The splenic flexure mobilization (SFM) is an important preparational step. Several methods are used for laparoscopic SFM; however, studies comparing different approaches are lacking. In the present study, three different approaches for SFM have been compared to each other. METHODS Between January 1998 and December 2010, 415 patients with rectal adenocarcinoma underwent laparoscopic rectal resection at one center. Of these, 303 patients received complete splenic flexure mobilization. The SFM was performed using either a medial (SFM-M; n = 41), lateral (SFM-L; n = 214), or anterior (SFM-A; n = 48) approach. RESULTS There was a significantly higher rate of intraoperative complications in the SFM-L group as compared to the SFM-M or the SFM-A group (p = 0.038). Postoperative surgical complications occurred in 5 (10.6 %) patients of the SFM-A group compared to 38 patients (17.7 %) in the SFM-L group (p = 0.002) and 5 (12.1 %) patients in the SFM-M group (p = 0.037). SFM-L was also associated with a higher frequency of overall postoperative morbidity which was mainly due to wound infection rates (p = 0.001). CONCLUSIONS The anterior approach for SFM in laparoscopic surgery seems to be associated with lower frequency of intra- and postoperative morbidity.
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Araujo SEA, Seid VE, Kim NJ, Bertoncini AB, Nahas SC, Cecconello I. Assessing the extent of colon lengthening due to splenic flexure mobilization techniques: a cadaver study. ARQUIVOS DE GASTROENTEROLOGIA 2012; 49:219-22. [DOI: 10.1590/s0004-28032012000300010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/16/2012] [Indexed: 11/22/2022]
Abstract
CONTEXT: Failure of a colorectal anastomosis represents a life-threatening complication of colorectal surgery. Splenic flexure mobilization may contribute to reduce the occurrence of anastomotic complications due to technical flaws. There are no published reports measuring the impact of splenic flexure mobilization on the length of mobilized colon viable to construct a safe colorectal anastomosis. OBJECTIVE: The aim of the present study was to determine the effect of two techniques for splenic flexure mobilization on colon lengthening during open left-sided colon surgery using a cadaver model. DESIGN: Anatomical dissections for left colectomy and colorectal anastomosis at the sacral promontory level were conducted in 20 fresh cadavers by the same team of four surgeons. The effect of partial and full splenic flexure mobilization on the extent of mobilized left colon segment was determined. SETTING: University of Sao Paulo Medical School, Sao Paulo, SP, Brazil. Tertiary medical institution and university hospital. PARTICIPANTS: A team of four surgeons operated on 20 fresh cadavers. RESULTS: The length of resected left colon enabling a tension-free colorectal anastomosis at the level of sacral promontory achieved without mobilizing the splenic flexure was 46.3 (35-81) cm. After partial mobilization of the splenic flexure, an additionally mobilized colon segment measuring 10.7 (2-30) cm was obtained. After full mobilization of the distal transverse colon, a mean 28.3 (10-65) cm segment was achieved. CONCLUSION: Splenic flexure mobilization techniques are associated to effective left colon lengthening for colorectal anastomosis. This result may contribute to decision-making during rectal surgery and low colorectal and coloanal anastomosis.
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Larkin JO, Carroll PA, McCormick PH, Mehigan BJ. Control of splenic bleeding during splenic flexure mobilisation by devascularisation of the inferior pole of the spleen. Tech Coloproctol 2012; 16:459-61. [DOI: 10.1007/s10151-012-0840-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Accepted: 04/23/2012] [Indexed: 05/26/2023]
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Gezen C, Altuntas YE, Kement M, Vural S, Civil O, Okkabaz N, Aksakal N, Oncel M. Complete versus partial mobilization of splenic flexure during laparoscopic low anterior resection for rectal tumors: a comparative study. J Laparoendosc Adv Surg Tech A 2012; 22:392-6. [PMID: 22393925 DOI: 10.1089/lap.2011.0409] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The aim of the current study is to compare the results after partial and complete splenic flexure mobilization (SFM). SUBJECTS AND METHODS The records of laparoscopic and hand-assisted laparoscopic procedures for primary rectal tumor patients were abstracted from a prospectively designed database. The phrenicocolic and splenocolic ligaments were divided via a four-trocar technique in the partial SFM group, and dissection was continued with the separation of gastrocolic and pancreaticomesocolic attachments via a five-trocar procedure in the complete SFM group. The following data were compared between the groups: Demographics, intra- and postoperative information, and pathological features. RESULTS In total, 122 cases (77 [63.1%] male, 58.2±13.2 years old) who underwent a partial (n=36, 29.5%) or a complete (n=86, 70.5%) SFM were included. Reservoir creation (48.8% versus 19.4%, P=.003) was more common and conversion (8.1% versus 22.2%, P=.039) was less frequent in the complete SFM group, but there were significantly more T4 tumors in the partial group (16.7% versus 2.3%, P=.008). Demographics, other intra- and postoperative parameters, and pathological features were identical. CONCLUSIONS In our study, complete SFM decreased conversion rates, but this finding may be related to the higher rate of T4 tumors in the partial SFM group. Complete SFM assures an increase in reservoir creation in patients receiving a low anterior resection. Because other parameters are identical, the decision for the level of SFM is better left to the surgeon in cases undergoing a low anterior resection, but complete SFM may be preferred in cases who are candidates for a reservoir formation.
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Affiliation(s)
- Cem Gezen
- General Surgery Department, Kartal Education and Research Hospital, Istanbul, Turkey.
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