Updates Surg DOI 10.1007/s13304-015-0282-7
ORIGINAL ARTICLE
Splenic flexure colon cancers: minimally invasive treatment Valentino Fiscon • Giuseppe Portale Giovanni Migliorini • Flavio Frigo
•
Received: 8 September 2014 / Accepted: 3 February 2015 Ó Italian Society of Surgery (SIC) 2015
Abstract Optimal treatment of splenic flexure (SF) colon cancer—less than 10 % of all colorectal cancers is a matter of debate, in particular with regard to the optimal extent of radical surgery, according to the oncological principles of curative resection. Aims of this study were to assess the clinicopathological characteristics and report operative data and survival of patients with SF colon cancers. Shortand mid-term outcome of patients undergoing laparoscopic curative resection for SF colon cancer between June 2005 and September 2011 was assessed. The analysis considered 16 patients: 10 underwent segmental resection, 4 left hemicolectomy and 2 subtotal colectomy. There were no intraoperative deaths or major morbidity. The median operative time was 185 min. The median number of lymph nodes harvested was 17. Disease-free survival rate at 30-month follow-up was 75 %. Laparoscopic resection of SF cancer is feasible and safe. Oncological principles of disease-free margins and minimum node harvest can be respected even with segmental resection. Keywords Splenic flexure Colon cancer Minimally invasive surgery Laparoscopy
Introduction Carcinoma of the splenic flexure (SF) is quite uncommon, accounting for less than 10 % of all colon cancers [1–3]. It is associated with a high risk of obstruction and historically
V. Fiscon G. Portale (&) G. Migliorini F. Frigo Department of General Surgery, Azienda ULSS 15 ‘Alta Padovana’, Via Casa di Ricovero, 40, 35013 Cittadella, Padova, Italy e-mail: [email protected]
considered as burdened by a poor prognosis [1, 2]. The treatment of choice has not been fully standardized and there is no complete agreement on which should be the optimal extent of radical surgery, according to the oncological principles of curative resection. Part of this is due to the limited number of patients, given the rarity of colon cancers in this location, and to the technical difficulties in laparoscopic identification of the segmental colic vessels (middle and left colic artery) and consequent lymph node dissection. The aims of this study were to assess the clinicopathological characteristics and report operative data and survival of patients with SF colon cancers.
Materials and methods We evaluated the medical records of all patients with primary colorectal cancer referred to our unit who underwent surgery with curative intent between June 2005 and September 2011. The study included only patients who had their main tumor located in the SF, defined as the colonic tract between the distal third of the transverse colon and the proximal part of the descending colon. Perioperative workup included physical examination and standard laboratory tests. The American Society of Anesthesiology (ASA) classification was used to assess the operative risk. Barium enema study and colonoscopy were performed to assess the tumor’s features. Ultrasound and CT scans of the abdomen (and chest in selected cases) were obtained in all patients to rule out any metastatic disease. In case of unclear identification of tumor location, colonoscopy was repeated for tattooing of the tumor. The correct diagnosis of tumor location at the SF was confirmed intraoperatively by observing the lesion or the tattoo.
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All patients received a mechanical bowel cleansing comprising 4 l of polyethylene glycol electrolyte solution, the day before surgery. Broad-spectrum intravenous antibiotics were started at induction of anesthesia; all patients received low molecular weight heparin and anti-thrombotic stockings in the perioperative period (usually the same day of surgery) and continued for 20–25 days after the patient’s discharge. Analgesia was given via an epidural catheter. Laparoscopic approach, as a rule in our unit for colorectal cancer patients, was offered to all patients, unless an invasion of the surrounding organs (spleen, stomach, pancreas) was clearly evident on preoperative CT scans. The decision to convert was based on the following: (1) advanced disease (e.g., T4 bulky mass with infiltration of surrounding structures); (2) technical problems; (3) intraoperative complications which could not be managed laparoscopically. Postoperative morbidity included any minor or major, medical or surgical, complication. Patients underwent SF segmental resection, left hemicolectomy or subtotal colectomy. Surgical techniques have been described extensively elsewhere [4]. Briefly, for left hemicolectomy, the inferior mesenteric vein (IMV) is isolated at its origin at the level of Treitz, with the patient in reverse Trendelenburg position. The left colon with its mesentery is detached from the renal fascia and from the retroperitoneum in a medial-to-lateral direction to the parieto-colic reflexion (laterally) and to the pancreas (superiorly). The IMV is divided. The gastrocolic ligament is incised and the transverse colon and the splenic flexure are mobilized. With the patient in a steep Trendelenburg position, the peritoneum is opened medially to the right iliac artery. The ureter and gonadal vessels are identified. The inferior mesenteric artery (IMA) is identified and ligated; anterior perinephric fascia (Toldt) is separated from the renal fascia. The rectum is then divided using an EchelonÒ stapler. The specimen is extracted through a small suprapubic incision. Adequate plastic devices protect the minilaparotomic incision to reduce the risk of wound infection; the absence of leakage of pneumoperitoneum through the trocar incisions helps preventing port-site metastases. The anastomosis is performed laparoscopically and transanally with circular stapler. In case of segmental resection, the IMA is identified and the left colic is selectively sectioned. The omentum covering the resected colon is completely removed. A hand-sewn termino-terminal colo-colic anastomosis is performed extracorporeally. In case of subtotal colectomy, after completing left hemicolectomy, the terminal ileum is identified and the ileo-colic vessels are ligated. The right colon is mobilized with its mesentery from the renal fascia and retroperitoneum, preserving the duodenum, the ureter and gonadal vessels. Ligation of the middle colic vessels along with lymphadenectomy is performed at the origin of the superior mesenteric artery and
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the hepatic flexure is taken down. The mobilized colon is exteriorized. The anastomosis is performed laparoscopically and transanally with circular stapler, after inserting the anvil in the ileum. Patients were started on a liquid diet, if tolerated, within 72 h. Epidural and urinary catheters were removed after 48 and 72–96 h postoperatively. Criteria for patient discharge required that there be tolerance of soft diet, bowel movement and no apparent necessity for an in-hospital stay. Patients were followed up routinely by the operating surgeon and seen at least once after discharge at 4 weeks after surgery and subsequently for oncological follow-up, on a regular basis, by the surgeon and/or oncologist every 6 months with physical examination, tumor markers, abdominal ultrasound and CT scan and colonoscopy (the latter, yearly). Data are expressed as medians and interquartile ranges. Survival estimates were calculated using the Kaplan–Meier method.
Results Over the last 6 years 505 patients with colorectal cancer underwent resection with curative intent: 17 with open and 486 with laparoscopic surgery (96.2 %). There were 17 (3.4 %) patients with cancer located at the SF. All but one were resected with minimally invasive technique. One patient with SF cancer infiltrating surrounding tissues on preoperative CT scan was operated with open surgery. Among the 16 laparoscopically resected patients, there were 10 segmental resections, 4 left hemicolectomies and 2 subtotal colectomies. Left hemicolectomy was reserved to those patients with symptomatic diverticular disease or a second malignancy located in the left colon other than the one in the splenic flexure. Subtotal colectomy was reserved to those two patients with double malignancy. One patient had malignancy in the splenic flexure and two large polypoid lesions (high-grade dysplasia with focal adenocarcinoma) in the right colon and in the distal sigmoid colon. Another patient had malignancy in the splenic flexure, large polypoid lesion (high-grade dysplasia with focal adenocarcinoma) in the right colon and symptomatic diverticular disease. All polypoid lesions were large and not amendable of endoscopic resection. The demographic information, clinical characteristics of the patients and procedures performed are summarized in Table 1. One-third (6/16, 37.5 %) of the patients were ASA 2, the remaining were ASA 3. Two of 16 (12.5 %) patients presented obstructing lesions: one had a colonic stent and another one a diverting colostomy before curative surgery. Ten patients presented SF cancer only and underwent segmental resection. Four patients had left
Updates Surg
hemicolectomy: two presented SF cancer and large polypoid lesion of the sigmoid colon, not amendable of endoscopic resection; two had SF cancer and symptomatic diverticular disease of the descending colon. Two patients underwent subtotal colectomy: they both had SF cancer and multiple large polypoid lesions in the right and left colon, as explained above. The median operative time was 185 min (IQR: 157–221). The procedure was completed laparoscopically in 15 (93.7 %) patients. In one patient, the procedure was converted to an open procedure due to severe adhesions from previous major abdominal surgery. Intraoperative complication occurred in one patient, due to bleeding from the spleen; he required splenectomy but not conversion. TNM tumor stage distribution is reported in Table 2. One-third of the patients had stage III or IV disease. Two patients had a large polypoid lesion with high-grade dysplasia; 12 (75 %) had moderately differentiated tumors, one a well-differentiated and one a poorly differentiated tumor. The median number of lymph nodes collected was Table 1 Demographics, clinical characteristics and procedures performed (total n = 16) Gender (M/F)
13/3
a
Age (years)
75.3 (69.2-79.5)
BMIa
25.4 (23.5-26.8)
17 (16.5 median when excluding patients undergoing subtotal colectomy). The proximal and distal margins of resection were 5 cm (3.5–6.5) and 10 cm (7–12), when considering SF segmental resection patients only. Three patients (18.7 %) had mucinous carcinoma. Morbidity and mortality The mortality rate was nil. The overall morbidity rate was 6.2 %, one patient with wound infection, who was re-admitted within 30 days and had the abscess drained bedside. Median hospital stay was 10 days (9–11). Oncological outcome The median follow-up was 28.7 months (13.9–38). One patient (stage IV disease) died of distant (liver) metastases at 10 months after surgery and three other patients developed distant metastases: one (stage IIa) liver and spleen, one (stage IV) liver and lung, and another (stage IIa) liver and peritoneum. They all followed courses of adjuvant chemotherapy. Local recurrences were not reported either in patients undergoing segmental resection or more extensive resections. Disease-free survival rate at 30-month follow-up was 75 %.
Procedures performed Segmental resection
10
Left hemicolectomy
4
Subtotal colectomy
2
Data are expressed as N,
a
Median (IQR)
Table 2 Intra- and postoperative data, pathological data, short- and mid-term results (total n = 16) Operative timea (min)
185 (157-221)
Conversionsb
1
Intraoperative complicationsc Tumor lengtha (cm)
1 3.5 (3-6)
Lymph nodes removeda, N
17 (13.7-27.2)
TNM stage Tis
2
Stage I
0
Stage II
9
Stage III
2
Stage IV
3
30-day morbidityb
1
Wound infection
1
a
Follow-up , mos
28.7 (13.9-3.8)
Reoperations
0
Data are expressed as requiring splenectomy
a
median (IQR);
b
N;
c
one splenic lesion
Discussion The SF colon cancer is a pretty rare condition, covering 5–8 % of all colon cancers [1–3]. Several controversies persist regarding the optimal curative treatment of cancer in this location. Part of it is related to the particular blood supply of this area, with a variable contribution of both the inferior mesenteric artery—via the left colic artery—and the superior mesenteric artery—via the middle colic artery. To respect the oncological principles of complete lymph node removal along the vessels nourishing the SF, different operations have been proposed in the past, ranging from extended right hemicolectomy to standard left hemicolectomy, with or without splenectomy, to more limited resection of the SF [5–7]. The anecdotal idea that SF cancers could have a worse prognosis compared to other colon cancer sites depends on two observations: first, the double lymphatic drainage of SF cancers—through both superior and inferior mesenteric veins, and second, the tendency to present colonic obstruction at a more advanced stage of the disease. All these hypotheses have been overcome by data showing comparable prognosis between cancers located in the SF and in the remaining colonic segments [3]. Curative surgery guaranteed, in fact, similar survivals for left, right and SF colon cancers in a paper by Nakagoe [8]. Further, more recent publications have reported similar oncological
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results after segmental resection of SF—with selective ligation of the left branch of the middle colic artery and the left colic artery and standard left hemicolectomy with ligation of the inferior mesenteric artery at its origin [9, 10]. And the reason lies in that only a minimal—if any—part of the nodes involved in the disease are along the middle colic artery or its left branch, as shown by Nakagoe [5]: only 1 out of 24 nodes along the left branch of the middle colic artery and 0 out of 6 at the root of the middle colic artery were positive. Most of our patients with SF cancers underwent segmental resection, accomplished laparoscopically. For those who presented satellite polypoid lesions in the left colon or symptomatic diverticular disease, a left hemicolectomy seemed reasonable. In the two patients with polyps both in the left and in the right colon, other than the cancer at the SF, a subtotal colectomy was performed. We did not find particular difficulties with the standard laparoscopic approach applied to segmental SF resection. However, we feel that the vascular dissection and SF takedown could be accomplished more easily during a robotic procedure, as suggested by Casciola and co-workers [11]. In none of our patients a splenectomy was planned preoperatively for oncological reasons. Splenectomy was performed in one case only, following inadvertent splenic lesion. This was the only splenectomy (0.22 %) in 455 laparoscopic resections of left colon or rectum for benign or malignant disease in the last 6 years. Studies on lymphatic drainage of the colon had a long time ago demonstrated direct flow from the SF to the splenic hilum and pancreatic tail. However, several reports have shown that splenectomy and distal pancreasectomy in the setting of a curative resection of SF cancer do not improve 5-year survival: Khafagy and Stearns found no lymph node metastases in any of their 10 patients undergoing splenectomy and distal pancreasectomy for SF cancer [12]. And similar results, though with fewer patients, were reported by Nakagoe, Killingback and Walfisch [8, 13, 14]. In terms of respecting the oncological principles of margin-free resection and complete nodal clearing, we achieved these results in all our patients. When considering the less extended procedures of segmental resection—in those patients presenting SF location only and without other polypoid lesions—the proximal and distal margins of resection were long enough and the number of nodes was 17. The latter was well above the standard of 12 nodes proposed back in 1990 by fielding and currently included in multiple guidelines for colon and rectal cancer surgery [15–18]. In this series we did not report any postoperative death. However, we have to keep in mind that patients with SF cancer may present colonic obstruction; further more, it is well documented that survival outcome after emergency surgery for colonic cancer is associated with a high
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morbidity and mortality rate [19]. In a recent Scottish report on right and left flexure cancers (with one-third of SF cancer patients presenting obstruction) the mortality rate after emergency surgery was 23 % [20]. In conclusion, with this report we confirm that laparoscopic approach to SF colonic cancers is feasible and that oncological principles of nodal clearing and disease-free margins can be respected, even with limited resections. Conflict of interest The authors have no conflict of interest to disclose.
References 1. Aldridge MC, Phillips RK, Hittinger R, Fry JS, Fielding LP (1986) Influence of tumour site on presentation, management and subsequent outcome in large bowel cancer. Br J Surg 73:663–670 2. Levien DH, Gibbons S, Begos D, Byrne DW (1991) Survival after resection of carcinoma of the splenic flexure. Dis Colon Rectum 34:401–403 3. Kim CW, Shin US, Yu CS, Kim JC (2010) Clinicopathologic characteristics, surgical treatment and outcomes for splenic flexure colon cancer. Cancer Res Treat 42:69–76 4. Fiscon V, Portale G, Migliorini G, Frigo F (2010) Laparoscopic resection of colorectal cancer in elderly patients. Tumori 96:704–708 5. Nakagoe T, Sawai T, Tsuji T et al (2001) Surgical treatment and subsequent outcome of patients with carcinoma of the splenic flexure. Surg Today 31:204–209 6. Sadler GP, Gupta R, Foster ME (1992) Carcinoma of the splenic flexure: a case for extended right hemicolectomy? Postgrad Med J 68:487 7. McGory ML, Zingmond SD, Sekeris E, Ko CY (2007) The significance of inadvertent splenectomy during colorectal cancer resection. Arch Surg 142:668–674 8. Nakagoe T, Sawa T, Tsuji T et al (2000) Carcinoma of the splenic flexure: multivariate analysis of predictive factors for clinicopathological characteristics and outcome after surgery. J Gastroenterol 35:528–535 9. Rouffet F, Hay JM, Vacher B et al (1994) Curative resection for left colonic carcinoma: left hemicolectomy vs. segmental colectomy. A prospective, controlled, multicenter trial. French Association for Surgical Research. Dis Colon Rectum 37:651–659 10. Secco GB, Ravera G, Gasparo A, Percoco P, Zoli S (2007) Segmental resection, lymph node dissection, and survival in patients with left colon cancer. Hepatogastroenterology 54:422–426 11. Ceccarelli G, Biancafarina A, Patriti A et al (2010) Laparoscopic resection with intracorporeal anastomosis for colon carcinoma located in the splenic flexure. Surg Endosc 24:1784–1788 12. Khafagy MM, Stearns MW (1973) Carcinoma of the splenic flexure. Dis Colon Rectum 16:504–507 13. Killingback MJ (1970) Extended resection for carcinoma of the splenic flexure. Proc R Soc Med 63:136–137 14. Walfisch S, Stern H (1989) Use of thoracoabdominal incision for cancer of the splenic flexure in the obese patient. Dis Colon Rectum 32:169–170 15. Fielding LP, Arsenault PA, Chapuis PH et al (1991) Clinicopathological staging for colorectal cancer: an International Documentation System (IDS) and an International Comprehensive Anatomical Terminology (ICAT). J Gastroenterol Hepatol 6:583–596
Updates Surg 16. Otchy D, Hyman NH, Simmang C et al (2004) Practice parameters for colon cancer. Dis Colon Rectum 47:1269–1284 17. Nelson H, Petrelli N, Carlin A et al (2001) Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 93:583–596 18. Stocchi L, Fazio VW, Lavery I, Hammel J (2011) Individual surgeon, pathologist, and other factors affecting lymph node harvest in stage II colon carcinoma. Is a minimum of 12 examined lymph nodes sufficient? Ann Surg Oncol 18:405–412 19. Crozier JE, Leitch EF, McKee RF, Anderson JH, Horgan PG, McMillan DC (2009) Relationship between emergency
presentation, systemic inflammatory response, and cancer-specific surgical in patients undergoing potentially curative surgery for colon cancer. Am J Surg 197:544–549 20. Shaikh IA, Suttie SA, Urquhart M, Amin AI, Daniel T, Yalamarthi S (2012) Does the outcome of colonic flexure cancers differ from the other colonic sites? Int J Colorectal Dis 27:89–93
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ORIGINAL ARTICLE
Splenic flexure colon cancers: minimally invasive treatment Valentino Fiscon • Giuseppe Portale Giovanni Migliorini • Flavio Frigo
•
Received: 8 September 2014 / Accepted: 3 February 2015 Ó Italian Society of Surgery (SIC) 2015
Abstract Optimal treatment of splenic flexure (SF) colon cancer—less than 10 % of all colorectal cancers is a matter of debate, in particular with regard to the optimal extent of radical surgery, according to the oncological principles of curative resection. Aims of this study were to assess the clinicopathological characteristics and report operative data and survival of patients with SF colon cancers. Shortand mid-term outcome of patients undergoing laparoscopic curative resection for SF colon cancer between June 2005 and September 2011 was assessed. The analysis considered 16 patients: 10 underwent segmental resection, 4 left hemicolectomy and 2 subtotal colectomy. There were no intraoperative deaths or major morbidity. The median operative time was 185 min. The median number of lymph nodes harvested was 17. Disease-free survival rate at 30-month follow-up was 75 %. Laparoscopic resection of SF cancer is feasible and safe. Oncological principles of disease-free margins and minimum node harvest can be respected even with segmental resection. Keywords Splenic flexure Colon cancer Minimally invasive surgery Laparoscopy
Introduction Carcinoma of the splenic flexure (SF) is quite uncommon, accounting for less than 10 % of all colon cancers [1–3]. It is associated with a high risk of obstruction and historically
V. Fiscon G. Portale (&) G. Migliorini F. Frigo Department of General Surgery, Azienda ULSS 15 ‘Alta Padovana’, Via Casa di Ricovero, 40, 35013 Cittadella, Padova, Italy e-mail: [email protected]
considered as burdened by a poor prognosis [1, 2]. The treatment of choice has not been fully standardized and there is no complete agreement on which should be the optimal extent of radical surgery, according to the oncological principles of curative resection. Part of this is due to the limited number of patients, given the rarity of colon cancers in this location, and to the technical difficulties in laparoscopic identification of the segmental colic vessels (middle and left colic artery) and consequent lymph node dissection. The aims of this study were to assess the clinicopathological characteristics and report operative data and survival of patients with SF colon cancers.
Materials and methods We evaluated the medical records of all patients with primary colorectal cancer referred to our unit who underwent surgery with curative intent between June 2005 and September 2011. The study included only patients who had their main tumor located in the SF, defined as the colonic tract between the distal third of the transverse colon and the proximal part of the descending colon. Perioperative workup included physical examination and standard laboratory tests. The American Society of Anesthesiology (ASA) classification was used to assess the operative risk. Barium enema study and colonoscopy were performed to assess the tumor’s features. Ultrasound and CT scans of the abdomen (and chest in selected cases) were obtained in all patients to rule out any metastatic disease. In case of unclear identification of tumor location, colonoscopy was repeated for tattooing of the tumor. The correct diagnosis of tumor location at the SF was confirmed intraoperatively by observing the lesion or the tattoo.
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All patients received a mechanical bowel cleansing comprising 4 l of polyethylene glycol electrolyte solution, the day before surgery. Broad-spectrum intravenous antibiotics were started at induction of anesthesia; all patients received low molecular weight heparin and anti-thrombotic stockings in the perioperative period (usually the same day of surgery) and continued for 20–25 days after the patient’s discharge. Analgesia was given via an epidural catheter. Laparoscopic approach, as a rule in our unit for colorectal cancer patients, was offered to all patients, unless an invasion of the surrounding organs (spleen, stomach, pancreas) was clearly evident on preoperative CT scans. The decision to convert was based on the following: (1) advanced disease (e.g., T4 bulky mass with infiltration of surrounding structures); (2) technical problems; (3) intraoperative complications which could not be managed laparoscopically. Postoperative morbidity included any minor or major, medical or surgical, complication. Patients underwent SF segmental resection, left hemicolectomy or subtotal colectomy. Surgical techniques have been described extensively elsewhere [4]. Briefly, for left hemicolectomy, the inferior mesenteric vein (IMV) is isolated at its origin at the level of Treitz, with the patient in reverse Trendelenburg position. The left colon with its mesentery is detached from the renal fascia and from the retroperitoneum in a medial-to-lateral direction to the parieto-colic reflexion (laterally) and to the pancreas (superiorly). The IMV is divided. The gastrocolic ligament is incised and the transverse colon and the splenic flexure are mobilized. With the patient in a steep Trendelenburg position, the peritoneum is opened medially to the right iliac artery. The ureter and gonadal vessels are identified. The inferior mesenteric artery (IMA) is identified and ligated; anterior perinephric fascia (Toldt) is separated from the renal fascia. The rectum is then divided using an EchelonÒ stapler. The specimen is extracted through a small suprapubic incision. Adequate plastic devices protect the minilaparotomic incision to reduce the risk of wound infection; the absence of leakage of pneumoperitoneum through the trocar incisions helps preventing port-site metastases. The anastomosis is performed laparoscopically and transanally with circular stapler. In case of segmental resection, the IMA is identified and the left colic is selectively sectioned. The omentum covering the resected colon is completely removed. A hand-sewn termino-terminal colo-colic anastomosis is performed extracorporeally. In case of subtotal colectomy, after completing left hemicolectomy, the terminal ileum is identified and the ileo-colic vessels are ligated. The right colon is mobilized with its mesentery from the renal fascia and retroperitoneum, preserving the duodenum, the ureter and gonadal vessels. Ligation of the middle colic vessels along with lymphadenectomy is performed at the origin of the superior mesenteric artery and
123
the hepatic flexure is taken down. The mobilized colon is exteriorized. The anastomosis is performed laparoscopically and transanally with circular stapler, after inserting the anvil in the ileum. Patients were started on a liquid diet, if tolerated, within 72 h. Epidural and urinary catheters were removed after 48 and 72–96 h postoperatively. Criteria for patient discharge required that there be tolerance of soft diet, bowel movement and no apparent necessity for an in-hospital stay. Patients were followed up routinely by the operating surgeon and seen at least once after discharge at 4 weeks after surgery and subsequently for oncological follow-up, on a regular basis, by the surgeon and/or oncologist every 6 months with physical examination, tumor markers, abdominal ultrasound and CT scan and colonoscopy (the latter, yearly). Data are expressed as medians and interquartile ranges. Survival estimates were calculated using the Kaplan–Meier method.
Results Over the last 6 years 505 patients with colorectal cancer underwent resection with curative intent: 17 with open and 486 with laparoscopic surgery (96.2 %). There were 17 (3.4 %) patients with cancer located at the SF. All but one were resected with minimally invasive technique. One patient with SF cancer infiltrating surrounding tissues on preoperative CT scan was operated with open surgery. Among the 16 laparoscopically resected patients, there were 10 segmental resections, 4 left hemicolectomies and 2 subtotal colectomies. Left hemicolectomy was reserved to those patients with symptomatic diverticular disease or a second malignancy located in the left colon other than the one in the splenic flexure. Subtotal colectomy was reserved to those two patients with double malignancy. One patient had malignancy in the splenic flexure and two large polypoid lesions (high-grade dysplasia with focal adenocarcinoma) in the right colon and in the distal sigmoid colon. Another patient had malignancy in the splenic flexure, large polypoid lesion (high-grade dysplasia with focal adenocarcinoma) in the right colon and symptomatic diverticular disease. All polypoid lesions were large and not amendable of endoscopic resection. The demographic information, clinical characteristics of the patients and procedures performed are summarized in Table 1. One-third (6/16, 37.5 %) of the patients were ASA 2, the remaining were ASA 3. Two of 16 (12.5 %) patients presented obstructing lesions: one had a colonic stent and another one a diverting colostomy before curative surgery. Ten patients presented SF cancer only and underwent segmental resection. Four patients had left
Updates Surg
hemicolectomy: two presented SF cancer and large polypoid lesion of the sigmoid colon, not amendable of endoscopic resection; two had SF cancer and symptomatic diverticular disease of the descending colon. Two patients underwent subtotal colectomy: they both had SF cancer and multiple large polypoid lesions in the right and left colon, as explained above. The median operative time was 185 min (IQR: 157–221). The procedure was completed laparoscopically in 15 (93.7 %) patients. In one patient, the procedure was converted to an open procedure due to severe adhesions from previous major abdominal surgery. Intraoperative complication occurred in one patient, due to bleeding from the spleen; he required splenectomy but not conversion. TNM tumor stage distribution is reported in Table 2. One-third of the patients had stage III or IV disease. Two patients had a large polypoid lesion with high-grade dysplasia; 12 (75 %) had moderately differentiated tumors, one a well-differentiated and one a poorly differentiated tumor. The median number of lymph nodes collected was Table 1 Demographics, clinical characteristics and procedures performed (total n = 16) Gender (M/F)
13/3
a
Age (years)
75.3 (69.2-79.5)
BMIa
25.4 (23.5-26.8)
17 (16.5 median when excluding patients undergoing subtotal colectomy). The proximal and distal margins of resection were 5 cm (3.5–6.5) and 10 cm (7–12), when considering SF segmental resection patients only. Three patients (18.7 %) had mucinous carcinoma. Morbidity and mortality The mortality rate was nil. The overall morbidity rate was 6.2 %, one patient with wound infection, who was re-admitted within 30 days and had the abscess drained bedside. Median hospital stay was 10 days (9–11). Oncological outcome The median follow-up was 28.7 months (13.9–38). One patient (stage IV disease) died of distant (liver) metastases at 10 months after surgery and three other patients developed distant metastases: one (stage IIa) liver and spleen, one (stage IV) liver and lung, and another (stage IIa) liver and peritoneum. They all followed courses of adjuvant chemotherapy. Local recurrences were not reported either in patients undergoing segmental resection or more extensive resections. Disease-free survival rate at 30-month follow-up was 75 %.
Procedures performed Segmental resection
10
Left hemicolectomy
4
Subtotal colectomy
2
Data are expressed as N,
a
Median (IQR)
Table 2 Intra- and postoperative data, pathological data, short- and mid-term results (total n = 16) Operative timea (min)
185 (157-221)
Conversionsb
1
Intraoperative complicationsc Tumor lengtha (cm)
1 3.5 (3-6)
Lymph nodes removeda, N
17 (13.7-27.2)
TNM stage Tis
2
Stage I
0
Stage II
9
Stage III
2
Stage IV
3
30-day morbidityb
1
Wound infection
1
a
Follow-up , mos
28.7 (13.9-3.8)
Reoperations
0
Data are expressed as requiring splenectomy
a
median (IQR);
b
N;
c
one splenic lesion
Discussion The SF colon cancer is a pretty rare condition, covering 5–8 % of all colon cancers [1–3]. Several controversies persist regarding the optimal curative treatment of cancer in this location. Part of it is related to the particular blood supply of this area, with a variable contribution of both the inferior mesenteric artery—via the left colic artery—and the superior mesenteric artery—via the middle colic artery. To respect the oncological principles of complete lymph node removal along the vessels nourishing the SF, different operations have been proposed in the past, ranging from extended right hemicolectomy to standard left hemicolectomy, with or without splenectomy, to more limited resection of the SF [5–7]. The anecdotal idea that SF cancers could have a worse prognosis compared to other colon cancer sites depends on two observations: first, the double lymphatic drainage of SF cancers—through both superior and inferior mesenteric veins, and second, the tendency to present colonic obstruction at a more advanced stage of the disease. All these hypotheses have been overcome by data showing comparable prognosis between cancers located in the SF and in the remaining colonic segments [3]. Curative surgery guaranteed, in fact, similar survivals for left, right and SF colon cancers in a paper by Nakagoe [8]. Further, more recent publications have reported similar oncological
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results after segmental resection of SF—with selective ligation of the left branch of the middle colic artery and the left colic artery and standard left hemicolectomy with ligation of the inferior mesenteric artery at its origin [9, 10]. And the reason lies in that only a minimal—if any—part of the nodes involved in the disease are along the middle colic artery or its left branch, as shown by Nakagoe [5]: only 1 out of 24 nodes along the left branch of the middle colic artery and 0 out of 6 at the root of the middle colic artery were positive. Most of our patients with SF cancers underwent segmental resection, accomplished laparoscopically. For those who presented satellite polypoid lesions in the left colon or symptomatic diverticular disease, a left hemicolectomy seemed reasonable. In the two patients with polyps both in the left and in the right colon, other than the cancer at the SF, a subtotal colectomy was performed. We did not find particular difficulties with the standard laparoscopic approach applied to segmental SF resection. However, we feel that the vascular dissection and SF takedown could be accomplished more easily during a robotic procedure, as suggested by Casciola and co-workers [11]. In none of our patients a splenectomy was planned preoperatively for oncological reasons. Splenectomy was performed in one case only, following inadvertent splenic lesion. This was the only splenectomy (0.22 %) in 455 laparoscopic resections of left colon or rectum for benign or malignant disease in the last 6 years. Studies on lymphatic drainage of the colon had a long time ago demonstrated direct flow from the SF to the splenic hilum and pancreatic tail. However, several reports have shown that splenectomy and distal pancreasectomy in the setting of a curative resection of SF cancer do not improve 5-year survival: Khafagy and Stearns found no lymph node metastases in any of their 10 patients undergoing splenectomy and distal pancreasectomy for SF cancer [12]. And similar results, though with fewer patients, were reported by Nakagoe, Killingback and Walfisch [8, 13, 14]. In terms of respecting the oncological principles of margin-free resection and complete nodal clearing, we achieved these results in all our patients. When considering the less extended procedures of segmental resection—in those patients presenting SF location only and without other polypoid lesions—the proximal and distal margins of resection were long enough and the number of nodes was 17. The latter was well above the standard of 12 nodes proposed back in 1990 by fielding and currently included in multiple guidelines for colon and rectal cancer surgery [15–18]. In this series we did not report any postoperative death. However, we have to keep in mind that patients with SF cancer may present colonic obstruction; further more, it is well documented that survival outcome after emergency surgery for colonic cancer is associated with a high
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morbidity and mortality rate [19]. In a recent Scottish report on right and left flexure cancers (with one-third of SF cancer patients presenting obstruction) the mortality rate after emergency surgery was 23 % [20]. In conclusion, with this report we confirm that laparoscopic approach to SF colonic cancers is feasible and that oncological principles of nodal clearing and disease-free margins can be respected, even with limited resections. Conflict of interest The authors have no conflict of interest to disclose.
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