B. Resio1, K. Y. Pei1 1Yale University School Of Medicine,Surgery,New Haven, CT, USA
Introduction: Historically, splenic flexure mobilization (SFM) was recommended for left colectomies to ensure adequate length for a tension free anastomosis and thus potentially mitigate the incidence of anastomotic complications. Despite the exponential increase in the adoption of the laparoscopic approach to colectomies, the national practice pattern and outcomes of SFM among this group are unknown. This study investigates the use of and outcomes associated with SFM for laparoscopic, partial colectomies with anastomosis for left colon and rectal cancers.
Methods: The American College of Surgeons NSQIP database from 2007-2015 was queried for elective, laparoscopic, partial colectomies with anastomosis (CPT 44204, 44207, 44208) with/without SFM (CPT 44213) for colon cancer of the left colon or rectum (ICD9 153.2, 153.3, 154.0, 154.1) or (ICD10 C18.6, C18.7, C19, C20). Only cases labeled as elective were included and cases labeled as emergency or ASA 4/5 (life-threatening/ moribund) were excluded. Primary outcome measures included all complications, superficial, deep and organ space infections, anastomotic leaks, postoperative ileus, return to operating room, death, hospital length of stay (HLOS) and operative time. Logistic regression models were used to compare outcomes, adjusting for patient and operative characteristics.
Results: 17,319 cases were identified of which 39.2% underwent SFM. Specifically, the proportion of SFM for left colon, sigmoid, recto-sigmoid and rectum were 49.3%, 33.3%, 36.9% and 46.9%, respectively. There was an increase in the overall proportion of cases with SFM during the study period (10.9% increase from 2007 to 2015). Compared to colectomies without SFM, patients undergoing SFM had an increase in: all complications (17.6% vs 15.6%, risk adjusted OR 1.11, 95%CI: 1.02-1.20); organ space SSI (4.6% vs 3.4%, risk adjusted OR 1.22, 95%CI: 1.04-1.43); prolonged ileus (10.7% vs 8.1%, risk adjusted OR 1.23 95%CI: 1.05-1.44) and operative time (mean time 234 vs 197 min, p<0.0001, 95%CI: 231.3-236.3 vs 195.4-198.9). There was no significant difference after risk adjustment for superficial SSI, deep SSI, return to operating room, anastomotic leak, death and HLOS.
Conclusion: Splenic flexure mobilization is performed in less than 50% of elective, laparoscopic, left, partial colectomies for colon and rectal cancer and is associated with increased complications, prolonged ileus, and operative time. Study findings support selective splenic flexure mobilization.