A Sanchez Ruiz, MD, E Grzona, MD, M Bun, MD, A Canelas, MD, M Laporte, MD, C Peczan, MD, N Rotholtz, MD
Colorectal Surgery Division – Hospital Aleman de Buenos Aires. Argentina.
BACKGROUND: Routine mobilization of the splenic flexure (SFM) for left colectomy and its variants is controversial. The pros are getting adequate surgical specimen; to retrieve sufficient number of nodes and minimize the incidence of anastomotic leak. The cons are that increases the complexity of the procedure and the operating time.
Objective: The aim of this study was to evaluate the impact of the (SFM) and to identify predictive factors that predispose its realization.
DESIGN: Retrospective analysis of a prospective database.
MATERIAL AND METHODS: A retrospective analysis based on a prospective database was performed on all patients operated between June 2000 to May 2012. All patients who underwent procedures that could potentially require MSF were included. The series was divided into three groups: left colectomy (CI); sigmoidectomy (S) and low anterior resection (LAR). Turn these groups were subdivided in those where the SFM wasn’t necessary (CI1; S1; RA1) and those where the SFM who performed (CI2; S2; RA2). Surgical time; complications rate; anastomotic leak rate; hospital length of stay; intestinal recovery; number of lymph nodes retrieved; and length of the specimen were the variables analyzed between the groups. The variables analyzed as predictors for MSF: age, sex, BMI ≥ 30 and ≥ 2 ASA.
RESULTS: 1076 laparoscopic colon surgeries were performed in the period of time analyzed. Of these, 593 were procedures with potential MSF. In 359 (60.5%) of cases the SFM was not performed. Subgroups were distributed as follows: CI1: 161 (27.1%); S1: 326 (55%); LAR1: 106 (17.9%); CI2: 118 (73%); S2: 69 (21.3%); and LAR2: 47 (44.3%). When CI group was analyzed subgroup 2 had a longer operative time (CI1vsCI2: 165vs214 min, p = <0.05); higher number of intraoperative complications (CI1vsCI2: 2.3vs8.5%, p = <0.05), fewer lymph nodes retrieved (CI1vsCI2: 17vs14, 8, p = <0.05) as well as increased length of the specimen (CI1vsCI2: 21 vs 25.7 cm, p = <0.05). There were no differences in the anastomotic leak rates. In the S group, only longer operative time was found in subgroup 2 (S1vsS2: 142vs192 min, p = <0.05). LAR2 had longer operative time (LAR1vsLAR2: 192vs 243 192 min, p = <0.05); longer length of stay (LAR1vsLAR2: 4.4 vs 6.8 days, p = <0.05); longer time for oral tolerance (LAR1vsLAR2: 1.5 vs. 2.7 days p = <0.05); bigger length of specimen (LAR1vsLAR2: 18.6vs22, 5 cm, P <0.05); but the number of lymph nodes removed was lower (LAR1vsLAR2: 16.5vs14, 6, p = <0.05). There were no difference in the rate of dehiscence. BMI> 30 was the only independent predictive factor to avoid the SFM into the three groups (p = <0.05).
CONCLUSIONS: SFM increases surgical time and intraoperative complications without reducing the risk of anastomotic leak. Based on these findings SFM should not be carried out routinely.
Program Number: P015