Inferior mesenteric arteriovenous malformation extending to splenic flexure colonic wall presenting with massive lower gastrointestinal bleeding, a case report

INTRODUCTION AND IMPORTANCE

An arteriovenous malformation (AVM) in the inferior mesenteric artery is a rare vascular pathology that accounts for 6 % of the causes of gastrointestinal bleeding. AVMs are typically classified as congenital persisting embryonic vasculature that link both systems and do not develop into arteries or veins [3], but they may also develop later in life. The majority of documented cases are iatrogenic after colon surgery.

CASE PRESENTATION

Herein we describe a 56-year-old man who presented complaining of fresh blood per rectum with passage of clots not related to defecation with no previous similar episodes, he was found to have extensive inferior mesenteric branches AVM invading the colonic splenic flexure via Computed Tomography (CT) angiography following three non-revealing upper and lower endoscopies which was later managed surgically with left hemicolectomy with primary end to end colo-colic anastomosis.

CLINICAL DISCUSSION

Although AVMs seldom manifest in multiple sites through the gastrointestinal tract, it is more prevalent in the stomach, small intestine, and ascending colon, and very unusual to affect the Inferior mesenteric artery and vein and to extend to the splenic flexure colonic wall.

CONCLUSION

Even if rare, inferior mesenteric AVMs should be suspected in a patient presenting with GI Bleeding with unrevealing endoscopies, where CT Angiography is to be considered.

Inferior mesenteric vein preserving lymphadenectomy in high left segmental colectomy for splenic flexure melanoma: A case report

INTRODUCTION AND IMPORTANCE

Surgical resection is the mainstay for management of splenic flexure cancers, with the aim of achieving adequate lymphadenectomy. Left-sided bowel resections often require ligation of the inferior mesenteric vein (IMV) for mesocolic dissection or lymphadenectomy which can result in congestive colitis on the anal side of the anastomosis secondary to poor venous outflow. Preserving the IMV may mitigate this risk but is technically difficult and can compromise oncological resection. This case report is a rare example of high left segmental resection of the splenic flexure with preservation of the IMV in a patient with splenic flexure melanoma.

CASE PRESENTATION

A non-obstructing lesion was discovered in a 73-year-old male who underwent colonoscopy following a positive faecal occult blood test. Biopsy of the lesion confirmed a melanoma. This patient had a history of cutaneous melanoma which was excised 20 years prior. A laparoscopic high left segmental colectomy was performed, and metastatic melanoma was identified in 3 of 12 regional lymph nodes. The patient recovered with no complications.

CLINICAL DISCUSSION

This patient underwent high left segmental colectomy to achieve oncological clearance while resecting minimal bowel and preserving bowel function. The IMV was spared in this surgery to prevent venous congestion. Reports of colitis following left sided colectomy have been described, whereby colitis is thought to result from a mismatch in arterial perfusion and venous drainage following IMV resection.

CONCLUSION

This case highlights the potential role of preservation of the inferior mesenteric vein in a rare case of splenic flexure melanoma.

Short and long-term oncologic outcomes of patients with colon cancer of the splenic flexure

BACKGROUND

There is currently no consensus on surgical management of splenic flexure adenocarcinoma (SFA).

METHODS

Patients undergoing surgical resection for SFA between 1993 and 2015 were identified. Postoperative outcomes were compared between patients who underwent segmental (SR) vs. anatomical resection (AR).

RESULTS

One-hundred and thirteen patients underwent SR and 89 underwent AR. More patients in the SR group had open resections, but there were otherwise no differences in demographics or surgical characteristics between the two groups. There were no differences in overall (p = 0.29) or recurrence-free(p = 0.37) survival. On multivariable analysis, increased age (HR 1.04, 1.01-1.07, p = 0.005), higher American Society of Anesthesiology classification (HR 3.1, 1.7-5.71, p < 0.001), and higher tumor stage (HR 8.84, 3.76-20.82, p < 0.001) were predictive of mortality.

CONCLUSIONS

Short and long-term outcomes after SR and AR for SFA are not different, making SR a viable option for SFA surgical management.

Associations of Polyp Characteristics in Children and Adolescents Presenting with Less Than Five Colorectal Polyps: A Full Colonoscopy Is Still Required

Background/Aims

A full colonoscopy is currently required in children and adolescents with colorectal polyps, because of their potential of neoplastic transformation and complications such as intussusception. We aimed to analyze the associations of polyp characteristics in children and adolescents with colorectal polyps. Based on these findings, we also aimed to reevaluate the necessity of conducting a full colonoscopy.

Methods

Pediatric patients <18 years of age who had undergone a colonoscopic polypectomy and those with <5 colorectal polyps were included in this multicenter, retrospective study. Baseline clinicodemographics, colonoscopic and histologic findings were investigated.

Results

A total of 91 patients were included. Multivariate logistic regression analysis showed that polyp size was the only factor associated with the presence of any polyps located proximal to the splenic flexure (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.28 to 4.28; p=0.007). Furthermore, polyp location proximal to the splenic flexure and sessile morphology were associated with the presence of any adenomatous polyp (OR, 8.51; 95% CI, 1.43 to 68.65; p=0.023; OR, 18.41; 95% CI, 3.45 to 173.81; p=0.002, respectively).

Conclusions

In children and adolescents presenting with <5 colorectal polyps, polyp size and the presence of any adenomatous polyp were positively associated with polyp location proximal to the splenic flexure. This finding supports the necessity of a full colonoscopic exam in pediatric patients with colorectal polyps for the detection of polyps before the occurrence of complications such as intussusception or neoplastic transformation.

Vascular variations encountered during laparoscopic surgery for transverse colon, splenic flexure, and descending colon cancer: a retrospective cohort study

BACKGROUND

Laparoscopic surgery for cancer located in the transverse colon or splenic flexure is difficult because of vascular variability in this region and adjacent vital organs such as the pancreas, spleen, and duodenum.

METHODS

This retrospective cohort study involved 51 patients who underwent laparoscopic surgery for colon cancer at Tokushima University Hospital from July 2015 to December 2020. Variations of the middle colic artery (MCA), left colic artery (LCA), middle colic vein (MCV), and first jejunal vein (FJV) and short-term outcomes of laparoscopic surgery in patients with each vascular variation were evaluated.

RESULTS

Variations of the MCA, LCA, MCV, and FJV were classified into four, three, five, and three patterns, respectively. The short-term outcomes of laparoscopic surgery for transverse colon cancer in patients with MCA variations and those with FJV variations were evaluated, and no significant difference was found in the operation time, blood loss, postoperative complication rate, time from surgery to start of dietary intake, or time from surgery to discharge among the different variations. Additionally, no significant differences were found in the short-term outcomes of laparoscopic surgery for descending colon cancer in patients with LCA variations.

CONCLUSION

Preoperative assessment of vascular variations may contribute to the stability of short-term outcomes of laparoscopic surgery for transverse colon, splenic flexure, and descending colon cancer.

Comparison of laparoscopic and open colectomy for splenic flexure colon cancer: a systematic review and meta-analysis

PURPOSE

This study examined the short- and long-term outcomes of laparoscopic and open splenic flexure colon cancer (SFCC) surgery.

METHOD

Systematic literature searches were performed in PubMed and Ovid to compare laparoscopic and open colectomy for SFCC. The last search was conducted on November 7, 2021. Surgical and survival outcomes were collected and analyzed. This meta-analysis was performed using Review Manager Software (v 5.3).

RESULTS

This study included seven publications with 2397 patients published between 2011 and 2021. A significant difference in operative time was seen in the laparoscopic group (P = 0.01, WMD = 50.13, 95%CI [10.32, 89.94], I² = 97%); loss of blood estimated (P < 0.001, WMD =  -101.88, 95%CI [-161.65, -42.11], I² = 82%) and the incidence of overall complications (P < 0.001, OR = 0.53, 95%CI [0.38, 0.75], I² = 0%) of laparoscopic procedure were greatly decreased. There were similar results as compared in the two groups in terms of lymph node harvesting (P = 0.71, WMD = 0.49, 95%CI [-2.13, 3.12], I² = 93%) and the distance of proximal (P = 0.50, WMD =  -1.09, 95%CI [-4.26, 2.08], I² = 96%) or distal (P = 0.18, WMD = 2.44, 95%CI [-1.13, 6.01], I² = 97%) resection margin. In addition, no significant differences were observed on overall/disease-free survival over 3/5 years between the two procedures. An analysis of subgroups that used propensity matching scores produced similar results.

CONCLUSION

The laparoscopic procedure is clinically safe and feasible for SFCC. It shows the advantages in decreasing intraoperative blood loss and overall complications, and the long-term survival outcomes would not be affected. Randomized clinical trials with a larger sample size are warranted in the future for further investigation.

Anatomical variations of the branches from left colic artery and middle colic artery at splenic flexure

BACKGROUND

Variations of the vasculature at splenic flexure by left colic artery (LCA) and middle colic artery (MCA) remain ambiguous.

OBJECTIVES

This study aim to investigate the anatomical variations of the branches from LCA and MCA at splenic flexure area.

METHODS

Using ultra-thin CT images (0.5-mm thickness), we traced LCA and MCA till their merging site with paracolic marginal arteries through maximum intensity projection (MIP) reconstruction and computed tomography angiography (3D-CTA).

RESULTS

A total of 229 cases were retrospectively enrolled. LCA ascending branch approached upwards till the distal third of the transverse colon in 37.6%, reached the splenic flexure in 37.6%, and reached the lower descending colon in 23.1%, and absent in 1.7% of the cases. Areas supplied by MCA left branch and aMCA were 33.2%, 44.5% and 22.3% in the proximal, middle and distal third of transverse colon of the cases, respectively. The accessory MCA separately originated from the superior mesenteric artery was found in 17.9% of the cases. Mutual correlation was found that, when the LCA ascending branch supplied the distal transverse colon, MCA left branch tended to feed the proximal transverse colon; when the LCA ascending branch supplied the lower part of descending colon, MCA left branch was more likely to feed the distal third of transverse colon.

CONCLUSIONS

Vasculature at splenic flexure by LCA and MCA varied at specific pattern. This study could add more anatomical details for vessel management in surgeries for left-sided colon cancer.

Short- and long-term outcomes of laparoscopic segmental left colectomy for splenic flexure colon cancer: comparison with propensity score matching

Purpose

Splenic flexure colon cancer (SFCC) is a rare disease that accounts for 2%–8% of colorectal cancers, and the extent of surgery and resection is still debatable. There have also been few studies on the safety and feasibility of laparoscopic surgery for SFCC. The purpose of this study is to evaluate outcomes and prognoses of surgery for SFCC.

Methods

We included patients with stage 1 to 3 who had undergone laparoscopic surgery for distal transverse-to-sigmoid colon cancer at 2 hospitals from March 2004 to December 2016 and collected data by retrospective design. We defined SFCC as being cancer between distal transverse and proximal descending colon. The short- and long-term outcomes of the anterior resection (AR) group (those patients who had undergone laparoscopic AR for mid and distal descending to sigmoid colon cancer) and the left colon resection (LR) group (those who had undergone laparoscopic segmental left colectomy for SFCC) were compared using propensity score matching.

Results

The median follow-up period was 60 months. The numbers of subjects in the AR and the LR groups were 948 and 118. After 2:1 propensity score matching, 236 vs. 118 patients were selected. There was no significant difference in 5-year disease-free survival (80.7% vs. 78.6%, P = 0.607), and both the 5-year overall survival (89.2% vs. 88.2%, P = 0.563) as well as short-term outcomes showed no statistical difference in most of the variables.

Conclusion

Laparoscopic segmental left colectomy can be one option among the standard procedures for SFCC.

Vascular anatomy of the splenic flexure: a review of the literature

Surgical treatment of the transverse colon is difficult because of the many variations of blood vessels. We reviewed the patterns of vascular anatomy and the definition of the vessels around the splenic flexure. We searched the PubMed database for studies on the vascular anatomy of the splenic flexure that were published from January 1990 to October 2020. After screening of full texts, 33 studies were selected. The middle colic arteries were reported to arise independently without forming a common trunk in 8.9-33.3% of cases. The left colic artery was absent in 0-7.5% of cases. The accessory middle colic artery was present in 6.7-48.9% of cases and was present in > 80% of cases without a left colic artery. The reported frequency of Riolan's arch was 7.5-27.8%. The frequency was found to vary widely across studies, partially due to the ambiguous definition of Riolan's arch. A comprehensive preoperative knowledge of the branching patterns of the middle colic artery and left colic artery and the presence of collateral arteries would be helpful in surgery for colon cancer in the splenic flexure.

Laparoscopic complete mesocolic excision with central vascular ligation for splenic flexure colon cancer: short- and long-term outcomes

Background

Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices.

Methods

We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017.

Results

Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis.

Conclusions

Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon’s skill. The appropriate indications must be established with more case registries because our experience is limited.

Primary tumor resection improves prognosis of unresectable carcinomas of the transverse colon including flexures with liver metastasis: a preliminary population-based analysis

Purpose

Studies on unresectable colorectal cancer liver metastasis(CRLM) rarely analyze the prognosis of the patients from the point of colonic subsites. We aimed to evaluate the effect of primary tumor resection (PTR) and different scope of colectomy on the prognosis of patients with unresectable transverse colon cancer liver metastasis (UTCLM), hepatic flexure cancer liver metastasis (UHFLM), and splenic flexure cancer liver metastasis (USFLM).

Patients and methods

The patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. Cox proportional hazards regression models were used to identify prognostic factors of overall survival (OS) and cause-specific survival (CSS). Kaplan-Meier analyses and log-rank tests were conducted to assess the effectiveness of PTR on survival.

Results

In total, this study included a cohort of 1960 patients: 556 cases of UHFLM, 1008 cases of UTCLM, and 396 cases of USFLM. The median survival time of whole patients was 11.0 months, ranging from 7.0 months for UHFLM patients to 15.0 months for USFLM patients. USFLM patients had the best OS and CSS, followed by UTCLM patients. UHFLM patients had the worst OS and CSS (All P < 0.001). PTR could improve the OS and CSS of UTCLM, UHFLM, and USFLM (All P < 0.001). Subgroups analysis revealed that USFLM patients with tumor size≤5 cm and negative CEA had not demonstrated an improved OS and CSS after PTR. Multivariate analysis showed that PTR and perioperative chemotherapy were common independent prognostic factors for UHFLM, UTCLM, and USFLM patients. There was no difference between segmental colon resection and larger colon resection on CSS of UHFLM, UTCLM, and USFLM patients.

Conclusions

We confirmed the different survival of patients with UTCLM, UHFLM, and USFLM, and for the first time, we proved that PTR could provide survival benefits for patients with unresectable CRLM from the perspective of colonic subsites of transverse colon, hepatic flexure, and splenic flexure. Besides, PTR may not improve the prognosis of USFLM patients with CEA- negative or tumor size≤5 cm. For oncologic outcomes, we concluded that segmental colon resection seemed an effective surgical procedure for UTCLM, UHFLM, and USFLM.

Evaluation of vascular anatomy for colon cancer located in the splenic flexure using the preoperative three-dimensional computed tomography angiography with colonography

PURPOSE

The aim of this study is to reveal the vascular branching variation in SFC (splenic flexure cancer) patients using the preoperative three-dimensional computed tomography angiography with colonography (3D-CTAC).

METHODS

We retrospectively analyzed patients with SFC who underwent preoperative 3D-CTAC between January 2014 and December 2019.

RESULTS

Among 1256 colorectal cancer (CRC) patients, 96 (7.6%) manifested SFC. The arterial branching from the superior mesenteric artery (SMA) was classified into five patterns, as follows: (type 1A) the left branch of middle colic artery (LMCA) diverged from middle colic artery (MCA) (N = 47, 49.0%); (2A) the LMCA diverged from the MCA and the accessory middle colic artery (AMCA) (N = 26, 27.1%); (3A) the LMCA independently diverged from the SMA (N = 16, 16.7%); (4A) the LMCA independently diverged from the SMA and AMCA (N = 3, 3.1%); (5A) only the AMCA and the LMCA was absent (N = 4, 4.1%). Venous drainage was classified into four patterns, as follows: (type 1V) the SFV flows into the inferior mesenteric vein (IMV) then back to the splenic vein (N = 50, 52.1%); (2V) the SFV flows into the IMV then back to the superior mesenteric vein (SMV) (N = 19, 19.8%); (type 3V) the SFV independently flows into the splenic vein (N = 3, 3.1%); (type 4V) the SFV is absent (N = 24, 25.0%).

CONCLUSION

3D-CTAC could reveal accurate preoperative tumor localization and vascular branching. These classifications should be helpful in performing accurate complete mesocolic excision and central vessel ligation for SFC.

Comparison of extended right hemicolectomy, left hemicolectomy and segmental colectomy for splenic flexure colon cancer: a systematic review and meta-analysis

AIM

The aim of this work was to compare the outcomes of extended right hemicolectomy (ERH), left hemicolectomy (LH) and segmental colectomy (SC) for the surgical management of splenic flexure tumours.

METHOD

In compliance with PRISMA statement standards, a systematic review was performed to identify all studies comparing outcomes of ERH, LH and SC for the surgical management of splenic flexure tumours. Primary outcomes included anastomotic leakage and all postoperative complications. The secondary outcomes included operative time, R0 resection, number of harvested lymph nodes, > 12 harvested lymph nodes, severe complications, postoperative mortality, paralytic ileus, wound infection, pancreatic fistula, intra-abdominal abscess, need for reoperation, length of hospital stay, 5-year overall survival and 5-year disease-free survival. The ROBINS-I tool and GRADE system were used to assess the risk of bias and certainty of evidence, respectively.

RESULTS

Analysis of 956 patients from seven observational studies showed that ERH was associated with more paralytic ileus than LH (OR 2.74, P = 0.002) and SC (OR 6.67, P < 0.0001) and the operative time was shorter in SC than in ERH (mean difference 25.48, P < 0.0001) and LH (mean difference -17.94, P = 0.0002). There were no differences between ERH, LH and SC in terms of anastomotic leakage, postoperative complications, R0 resection, severe complications, postoperative mortality, wound infection, pancreatic fistula, intra-abdominal abscess, need for reoperation, length of hospital stay, > 12 harvested lymph nodes, 5-year overall survival and 5-year disease-free survival.

CONCLUSIONS

The available evidence, limited to observational studies, suggests that there is no difference between ERH, LH and SC in terms of postoperative morbidity and mortality, lymph node yield and cancer survival. Randomized controlled trials are required for definite conclusions.

Colonic splenic flexure carcinoma: is laparoscopic segmental resection a safe enough oncological approach?

BACKGROUND

The surgical approach to the colonic splenic flexure cancer (SFC) is yet to be technically standardized. The aim of this study has been to retrospectively evaluate the oncologic long-term results of our cases comparing our data with other authors' experiences.

METHODS

Clinical data of patients with SFC operated on at our institute were retrospectively analyzed. The laparoscopic approach was used in the whole series, with limited resection distally and proximally to splenic flexure and the origin ligation of left colic artery and left branch of middle colic artery. Data on the oncological long-term safety were compared to our laparoscopic series of extended right colectomy for proximal two-third transverse colon cancer and high anterior resections for sigmoid-high rectal cancer and to the main evidences in the literature, found after a comprehensive review.

RESULTS

From March 2008 to May 2018, we completed 53 laparoscopic splenic flexure resections (26 female and 27 male, age 71.5 ± 15.4 years). The conversion rate was 3.8%. Most of the cases were stage II (pT3 73.5%, the mean number of lymph nodes harvested was 19.1, with positivity for malignancy in 45.3%). During the FU (43.5 months), 2 patients dropped out. Out of the 51 residual cases, 37 were alive (72.5%) and 14 are deceased (27.5%).

DISCUSSION

Compared to the literature, our survival rate does not show significant differences. The other oncological outcomes seem to be comparable with the data evaluated.

CONCLUSIONS

More extended resections seem not to confer an increase of the overall survival rate.

A three-dimensional computed tomography angiography study of the anatomy of the accessory middle colic artery and implications for colorectal cancer surgery

Purpose

In the present study, we focused on the accessory middle colic artery and aimed to increase the safety and curative value of colorectal cancer surgery by investigating the artery course and branching patterns.

Methods

We included 143 cases (mean age, 70.4 ± 11.2 years; 86 males) that had undergone surgery for neoplastic large intestinal lesions at the First Department of Surgery at Yamagata University Hospital between August 2015 and July 2018. We constructed three-dimensional (3D) computed tomography (CT) angiograms and fused them with reconstructions of the large intestines. We investigated the prevalence of the accessory middle colic artery, the variability of its origin, and the prevalence and anatomy of the arteries accompanying the inferior mesenteric vein at the same level as the origin of the inferior mesenteric artery.

Results

Accessory middle colic artery was observed in 48.9% (70/143) cases. This arose from the superior mesenteric artery in 47, from the inferior mesenteric artery in 21, and from the celiac artery in two cases. In 78.2% (112/143) cases, an artery accompanying the inferior mesenteric vein was present at the same level as the origin of the inferior mesenteric artery; this artery was the left colic artery in 92, the accessory middle colic artery in 11, and it divided and became the left colic artery and the accessory middle colic artery in 10 cases.

Conclusion

3D CT angiograms are useful for preoperative evaluation. Accessory middle colic arteries exist and were observed in 14.9% of cases.

A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box

AIM

The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach.

METHODS

Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM.

RESULTS

First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure "Box"(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access.

CONCLUSION

With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure "Box" is a useful way to learn and teach this surgical maneuver.

Acute Pancreatitis: A Rare Post-Colonoscopy Sequela

Abdominal pain is a common but benign symptom after colonoscopy. We report a case of acute pancreatitis that occurred just after an elective screening colonoscopy; this is a rare event with very few reported cases. A healthy, asymptomatic male underwent screening colonoscopy at our center and developed abdominal pain and emesis after the procedure. An abdominal X-ray ruled out perforation but laboratory tests revealed elevated levels of amylase and lipase. The patient had no etiological risk factors for pancreatitis. The presumed mechanism of pancreatitis in this case is mechanical and pressure trauma from excessive insufflation, external abdominal pressure, and repeated withdrawal of the colonoscope due to tight angulation of the splenic flexure, a structure that is in close proximity to the pancreatic tail. Acute pancreatitis should be considered in the differential diagnosis of patients who present with abdominal pain after colonoscopy once more common etiologies have been excluded.

Elective surgery for tumours of the splenic flexure: a French inter-group (AFC, SFCD, FRENCH, GRECCAR) survey

BACKGROUND

In an elective setting, there is no consensus regarding the type of colectomy that is best for patients with tumors of the splenic flexure: segmental left colectomy (or splenic flexure colectomy), left hemicolectomy or subtotal colectomy (or extended right hemicolectomy). In the United Kingdom, extended right hemicolectomy is preferred by surgeons. The aim of the present survey was to report on the practices in France for this particular tumor location.

METHODS

Between 15/07/17 and 15/10/17, members of two French surgical societies [the French Association of Surgery (AFC) and the French Society of Digestive Surgery (SFCD)] and two French surgical cooperative groups [the French Federation of Surgical Research (FRENCH) and the French Research Group of Rectal Cancer Surgery (GRECCAR)] were solicited by email to answer an online anonymous questionnaire.

RESULTS

A total of 190 out of 420 surgeons participated in this study (response rate 45%). The preferred procedure was splenic flexure colectomy (70%), followed by left hemicolectomy (17%) and subtotal colectomy (13%). The most used surgical approach was laparoscopy (63%), followed by laparotomy (31%) and hand-assisted laparoscopy (6%). Lymph node dissection was extended to the middle colic artery in 29% of splenic flexure colectomies and in 33% of left hemicolectomies. Twenty-nine percent of responders thought that tumors of the splenic flexure had a worse prognosis in comparison with other colonic sites, because of insufficient lymph node dissection (73%) or a more advanced stage (50%) at diagnosis. However, this opinion did not change the type of colectomy performed.

CONCLUSIONS

There is a strong consensus in France to operate tumors of the splenic flexure with a splenic flexure colectomy and lymph node dissection limited to the left colic artery.

[Feasibility and safety of the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure]

Objective: To investigate the feasibility and safety of the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure. Methods: A retrospective cohort study was performed. Clinical data of 157 colorectal cancer patients undergoing the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure at Gastrointestinal Surgical Department of Guangdong Provincial People's Hospital from July 2015 to June 2018 were retrospectively analyzed. Of 157 cases, 17 were transverse colon cancer, 94 were descending colon cancer, 25 were sigmoid cancer and 21 were rectal cancer; 89 were male and 68 were female; mean age was (61.8±10.3) years and mean body mass index was (23.2±3.7) kg/m(2). The medial approach "four-step method" in the laparoscopic mobilization of splenic flexure was performed as follows: (1) The root vessels were treated with the "provocation" technique to expand the Toldt's gap. This expansion was extended from the lateral side to the peritoneum reflex of left colonic sulcus, from the caudal side to the posterior rectal space, and from the cephalad side to the lower edge of pancreas. (2) The left colonic sulcus was mobilized, converging with the posterior Toldt's gap. Mobilization was carried out from cephalad side to descending colon flexure, freeing and cutting phrenicocolic ligament and splenocolic ligament, and from caudal side to peritoneal reflex. (3) Gastrocolic ligament was moblized. Whether to enter the great curvature of stomach omentum arch when the gastrocolic ligament was cut, that was, whether to clean the fourth group of lymph nodes, should be according to the tumor site and whether serosal layer was invaded. (4) Transverse mesocolon was moblized and transected at the lower edge of the pancreatic surface, merging with the posterior Toldt's gap, and from lateral side to lower edge of the pancreatic body, merging with the lateral left paracolonic sulcus. Safety and short-term clinical efficacy of this surgical procedure was summarized. Results: All the patients completed this procedure. During operation, 3 cases were complicated with organ injury, including 1 case of colon injury, 1 case of spleen injury and 1 case of pancreas injury. No operative death and conversion to open surgery was found. The average operation time was (147.5±35.1) minutes, the average intra-operative blood loss was (40.8±32.7) ml and the average number of harvested lymph node was (16.1±5.8), including (4.0±2.3) of positive lymph nodes. The first exhaust time after surgery was (41.3±20.6) hours, the fluid intake time was (1.5±1.3) days, the postoperative hospital stay was (5.2±2.3) days. Eight (5.1%) cases developed postoperative complications, and all were improved and discharged after conservative treatments. According to the TNM classification system, postoperative pathology revealed that 31 patients were stage I, 51 were stage II, 53 were stage III, 22 were stage IV. Conclusion: The medial approach "four-step method" is safe and feasible, which can effectively decrease the operation difficulty of the laparoscopic mobilization of the splenic flexure.

Laparoscopic resection of splenic flexure colon cancers: a retrospective multi-center study with 117 cases

The objective is to investigate the short- and long-term outcomes of laparoscopic resections of splenic flexure colon cancers in three Italian high-volume centers. The laparoscopic resection of splenic flexure colon cancers is a challenging procedure and has not been completely standardized, mainly due to the technical difficulty, the arduous identification of major blood vessels, and the problems associated with anastomosis construction. In this retrospective cohort observational study, a consecutive series of patients treated in three Italian high-volume centers with elective laparoscopic resection of the splenic flexure for cancer is analyzed. The observational period was from January 2008 to August 2017. Patient demographics and clinical features, operative data, and short- and long-term outcomes were prospectively recorded in a specific database and were retrospectively analyzed. During the observation period, 117 patients were selected. Conversion to open surgery was necessary in 15 patients (12.8%). Of 102 complete laparoscopic procedures, multi-visceral resection was performed in 13 cases (12.7%). Postoperative surgical complications occurred in 13 patients (12.7%), with 3 cases of anastomotic leak (2.9%) and 3 cases of re-operation (2.9%). The postoperative mortality in this population was null. The 5-year overall survival rate was 84.3%, and the 5-year disease-free survival rate was 87.8%. Laparoscopic resection of the splenic flexure is feasible and safe in high-volume centers. Compared to the results of other laparoscopic colonic resections, the short- and long-term outcomes are similar, but the conversion rate is higher.

Arterial anatomy of the splenic flexure using preoperative three-dimensional computed tomography

BACKGROUND

To perform a safe and precise laparoscopic surgery for the splenic flexure cancer, it is important for surgeons to gain a preoperative understanding of the running of the feeding artery of the splenic flexure. We evaluated the blood supply to the splenic flexure by using preoperative three-dimensional computed tomography (3D-CT).

METHOD

We retrospectively analyzed a total of 88 patients with colorectal cancer who underwent preoperative 3D-CT at our institutions between April 2016 and June 2017.

RESULTS

The arterial blood supply to the splenic flexure was divided into four patterns as follows: type 1, the left branch of the middle colic artery (MCA) with common trunk and the left colic artery (LCA) (n = 48, 54.5%); type 2, the left branch of the MCA with independent origin and the LCA (n = 8, 9.1%); type3, the accessory-MCA (A-MCA) and the LCA (n = 27, 30.7%); and type4, the LCA alone (n = 5, 5.7%). The MCA had the common trunk of the right and left branches in the majority of cases (85.2%). The right and left branches of the MCA arose separately from the superior mesenteric artery (SMA) in 8 of 88 patients (9.1%).

CONCLUSIONS

The arterial patterns of the splenic flexure were classified into four patterns by using preoperative 3D-CT. The A-MCA existed in 30% of the patients in this study. These information should be helpful to perform the optimal surgery for the splenic flexure cancer.

Strategy of laparoscopic surgery for colon cancer of the splenic flexure: a novel approach

BACKGROUND

The splenic flexure (SF) anatomy is complex due to multiple vessels, surrounding organs, layers, and irregular adhesions [1-3].

METHODS

Our laparoscopic approach involves a lateral-to-medial approach to the left-sided transverse mesocolon (TM), a medial-to-lateral approach to the left mesocolon (LM), and take-down of the remnant SF. First, the omental bursa is opened and its posterior wall and the anterior layer of the TM are dissected along the pancreas, where a gauze is placed. The TM is spread cephalad. A window in the TM is opened in the gauze seen through the TM. If necessary, the middle colic vessels are divided with lymph node (LN) dissection. Then the left colic artery is divided with LN dissection using a medial approach. The LM is widely dissected from the retroperitoneum to reach the TM window. While observing the pancreas through the window, the LM and TM are divided from the pancreas close to the SF. The descending colon is mobilized from its lateral attachment. Finally, the SF is taken down from the spleen by separating remnant structures, including adhesions. Subsequently, functional end-to-end anastomosis was performed extracorporeally.

RESULTS

During March 2012-December 2016, 39 patients with left-sided transverse or descending colon cancer underwent this treatment. The mean operative time, blood loss, number of harvested LNs, and hospital stay duration were 283 min, 45 ml, 15, and 9 days, respectively. No patient needed conversion to open surgery or had organ injury, anastomotic leakage, or Clavien-Dindo III-V complications. There were 7/13/18/1 patients with Stage I/II/III/IV colon cancer, respectively. Nineteen cases had positive LNs. All patients were alive with one local and two distant recurrences at a mean 24-month follow-up.

CONCLUSIONS

This is a safe and effective surgical strategy for treating colon cancer of the SF, strategically designed to resect the SF after dissecting the surrounding structures.

Sex differences in the splenic flexure

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.

Importance of the Moskowitz artery in the laparoscopic medial approach to splenic flexure mobilization: a cadaveric study

BACKGROUND

The medial approach in laparoscopic splenic flexure mobilization is based on the entrance to the lesser sac just above the ventral edge of the pancreas (VEOP). The artery of Moskowitz runs through the base of the mesocolon, just above the VEOP. The aim of this study was to assess the incidence of the artery of Moskowitz, its route and its distance from the VEOP.

METHODS

We performed a cadaveric study on 27 human cadavers. The vascular arcades of the splenic flexure were dissected, the number of vascular arches, and the origin and localization of its terminal anastomosis were recorded. The splenic flexure avascular space (SFAS) was defined as the avascular zone in the mesocolon delimited by the VEOP, middle colic artery, ascending branch of the left colic artery and the vascular arch of the splenic flexure nearest to the VEOP and was quantified as the distance between the VEOP and the most proximal arch RESULTS: The artery of Drummond was identified in 100% of the cadavers. In 5 of 27 (18%) Riolan's arch was present, and in 3 of 27 (11%) the Moskowitz artery was found. The mean distance from the VEOP to the artery of Moskowitz was 0.3 cm (SD 0.04). This vascular arch travelled from the origin of the middle colic artery to the distal third of the ascending branch of the left colic artery. The SFAS was greater (p = 0.001) in cadavers that only presented the artery of Drummond (mean 6.8 cm; SD 1.25) than in those with Riolan's arch (mean 4.5 cm; SD 0.5) CONCLUSIONS: In the medial approach for laparoscopic mobilization of the splenic flexure, when only one of the arches is present, the avascular area is an extensive and secure territory. If the artery of Moskowitz is present, the area is nonexistent and this would contraindicate the approach due to risk of iatrogenic bleeding. A radiological preoperatory study could be essential for accurate and safe surgery in this area.

Subtotal colectomy versus left hemicolectomy for the elective treatment of splenic flexure colonic neoplasia

BACKGROUND

Optimal elective surgical treatment for splenic flexure neoplasm (SFN) is unclear. Subtotal colectomy (STC) and left hemicolectomy (LHC) are the two more common strategies used.

METHODS

Observational multicentric study comparing postoperative morbidity, mortality and long-term survival on patients with SFN electively operated by STC versus LHC between 2003 and 2014.

RESULTS

After revision of the databases, 144 patients were included (STC group, n = 68; LHC group, n = 76). No differences were found on epidemiological and surgical data. A higher global morbidity (58%vs37%, p = 0.014), surgical morbidity (50%vs33%, p = 0.037), postoperative ileus (37%vs20%, p = 0.023) and harvested lymph nodes (26vs18, p = 0.0001) were found on the STC group. No significant differences in complications according to severity, reoperation rate, hospital stay, mortality, recurrence or long-term survival were found between groups.

CONCLUSIONS

A higher surgical morbidity was found on the STC group, mainly due to mild postoperative ileus. No differences on long-term oncological results were found.

Evaluation of lymph flow patterns in splenic flexural colon cancers using laparoscopic real-time indocyanine green fluorescence imaging

PURPOSE

The treatment of splenic flexural colon cancer is not standardized because the lymphatic drainage is variable. The aim of this study is to evaluate the lymph flow at the splenic flexure.

METHODS

From July 2013 to January 2016, consecutive patients of the splenic flexural colon cancer with a preoperative diagnosis of N0 who underwent laparoscopic surgery were enrolled. Primary outcome is frequency of the direction of lymph flow from splenic flexure. We injected indocyanine green (2.5 mg) into the submucosal layer around the tumor and observed lymph flow using the laparoscopic near-infrared camera system in 30 min after injection.

RESULTS

Thirty-one patients were enrolled in this study. The lymph flow was visualized in 31 patients (100 %) without any complications. No case exhibited lymph flow in both the left colic artery (LCA) and left branch of the middle colic artery (lt-MCA) areas. There were 19 cases (61.3 %) with lymph flow directed to the area of the root of the inferior mesenteric vein (IMV), regardless of the presence of the left accessory aberrant colic artery. Lymph node metastases were observed in six cases (19.4 %), and all of the involved lymph nodes existed in lymph flow areas determined by real-time indocyanine green fluorescence imaging.

CONCLUSIONS

The findings of the lymph flow pattern of splenic flexure suggest that lymph node dissection at the root of the IMV area is important, and it may be not necessary to ligate both the lt-MCA and LCA, at least in cases without widespread lymph node metastases.

Anatomical siting of the splenic flexure using computed tomography

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.

Idiopathic proximal hemimegacolon in an adult woman

Idiopathic proximal hemimegacolon is a disorder characterized by bowel dilatation proximal to the splenic flexure. It is a very rare and therefore a poorly understood clinical entity. This report describes a case of idiopathic proximal hemimegacolon in a 44-year-old woman. The patient suffered from 2 episodes of constipation and bowel dilatation over 4 years and was successfully treated by medical therapy.