Surgical management strategies for colorectal malignancies of the splenic flexure - A systematic review and network meta-analysis

David Lennon; Mark Donnelly; John Mahon; Éanna J Ryan; Odhrán K Ryan; Matthew G Davey; Ann Hanly; Rory Kennelly; Des C Winter; Sean Martin

doi:10.1016/j.ejso.2023.107087

Surgical management strategies for colorectal malignancies of the splenic flexure - A systematic review and network meta-analysis

Eur J Surg Oncol. 2023 Nov;49(11):107087. doi: 10.1016/j.ejso.2023.107087. Epub 2023 Sep 28.

Authors

Affiliations

¹ Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland. Electronic address: lennond3@tcd.ie.
² Royal College of Surgeons Ireland, St Stephens Green, Dublin 2, Ireland.
³ Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.

PMID: 37793302
DOI: 10.1016/j.ejso.2023.107087

Abstract

Background: Extended right hemicolectomy (ERHC) or left hemicolectomy (LHC) are accepted as the standard-of-care for colonic tumours of the splenic flexure. Lymphatic drainage at this site is poorly defined and subject to significant heterogeneity. Nevertheless, emerging evidence demonstrates the potential oncological safety of segmental splenic flexure colectomy (SFC).

Aim: To perform a systematic review and network meta-analysis (NMA) to compare outcomes following ERHC, LHC and SFC for splenic flexure tumours (SFTs).

Methods: A systematic review was performed as per PRISMA guidelines. NMA was performed using R Shiny and Netmeta packages.

Results: A total of 13 studies, involving 6176 patients (ERHC n = 785; LHC n = 1527; SFC n = 3864) were included in the NMA. There was no difference in overall survival (OS) (SFC vs LHC Hazard Ratio [HR] 1.0, 95% Credible Interval [CrI] 0.76,1.34; SFC vs ERHC HR 1.18, 95% CrI 0.85,1.58) between the groups. SFC had a shorter operation time (Mean 176.37 min; Mean Difference [MD] SFC vs LHC 20.34 min 95% CrI 10.9, 29.97; SFC vs ERHC MD 22.19 95% CrI 11.09, 33.29) but also had a lower average lymph node yield (LNY) compared with ERHC (MD 7.15, 95% CrI 5.71, 8.60). ERHC had a significantly higher incidence of post-operative ileus (Odds Ratio [OR] 3.47, 95% CrI 1.11, 10.84). There was also no difference observed for minimally invasive approaches, anastomotic leak rate, perioperative mortality, reoperation rates or length of stay.

Conclusions: While SFC may allow for reduced operative duration and improved bowel function postoperatively. SFC, LHC, ERHC are all acceptable approaches for curative resection of cancers of the splenic flexure, with no difference in OS observed. Thus, surgeon preference and candidate-specific factors will likely determine the management of SFTs.

Keywords: Colorectal cancer; Extended right hemicolectomy; Left hemicolectomy; Splenic flexure colectomy.

Publication types

Meta-Analysis
Systematic Review
Review

MeSH terms

Colon, Transverse* / pathology
Colon, Transverse* / surgery
Colonic Neoplasms* / surgery
Colorectal Neoplasms* / pathology
Colorectal Neoplasms* / surgery
Humans
Network Meta-Analysis
Severe Fever with Thrombocytopenia Syndrome* / pathology
Splenic Neoplasms*