Mahdi Hussain Al Bandar, Yoon Dae Han, Jamal Al Sabilah, Mohammed Al Suhaimi, Min Soo Cho, HyukHur, Byung Soh Min, Kang Young Lee and Nam Kyu Kim*
Department of Surgery, Yonsei University, College of Medicine, Seoul, Korea
Received: 21 September, 2016; Accepted: 17 October, 2016; Published: 18 October, 2016
Nam Kyu Kim, MD, Phd, FRCS, Department of Surgery, Division of Colorectal Surgery, Colorectal Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea, 50 Yonsei-ro Seodaemun-gu, Seoul 120-752, Korea, Tel: +82-2-2228-2117; Fax +82-2-313-8289; E-mail:
Al Bandar MH, Han YD, Al Sabilah J, Al Suhaimi M, Cho MS, et al. (2016) Optimum Level of Vessel Ligation in Splenic Flexure Cancer. J Surg Surgical Res. 2(1): 055-059.10.17352/2455-2968.000032
© 2016 Al Bandar MH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Splenic flexure; Left colon cancer; Vessel ligation; Optimum level
Aim: To investigate the level of vessel ligation in splenic flexure cancer (SFC) in term of oncology outcome and overall survival.
Methods: From 2005 until 2012 records reviewed. 43 patients diagnosed with SFC enrolled and analyzed. Patients categorized based on the level of vessel ligation. Left branch of middle colic (LMA) and left colic artery division (LCA) compared to ligation of LCA and marginal of middle colic artery (MMC).
Results: Twenty-four patients (55.8%) had LCA plus MMC, 19 patients (44.2%) approached at LCA plus LMA. Stage 1 rated at 25% in LCA plus MMC vs. 26.31% in LCA plus LMA, stage 2 and 3 found 33.4%, 4.2% vs. 42.1%, 31.57%, p=0.772, respectively. Harvested lymph nodes were similar, 19 ± 10 vs. 15 ±6.7, p=0.17, respectively. Recurrence rate found relatively greater in LCA plus MMC group compared to of LCA plus LMA but haven’t reached statistical significant, 16.6% vs. 10.52%, p=0.56, respectively. 5-year disease-free survival and overall survival rate were similar in both groups.
Conclusion: Higher level of vessel ligation has not add significant different in overall outcome, however, has a potential role to lower the risk of recurrence rate in SFC patients.
Splenic flexure carcinoma (SFC) incidence is very low in colorectal cancer (CRC) that has been reported in 2 to 8 % of the total colonic cancer. Often time presented in an advanced stage with high risk of obstruction that contributed in poor prognosis [1,2]. In addition, some other studies mentioned about the rate of SFC obstruction that accounted four times greater than other colon cancer sites , and that’s due to late presentation and insidious onset of the disease. Poor prognostic features of SFC could reflect the behavior of tumor biology and characteristics of SFC, which are poorly defined. Therefore, extensive surgical resection has to be addressed well in order to achieve better results. Basically, Excision of the tumor along vascular supply and its lymphatic drainage accounted for bottom line to reduce the chance of local recurrence in CRC .
Japanese Society for Cancer of the Colon and Rectum rules , emphasizing the policy of oncology safety. They stated the necessity of tumor dissection at its root as well as separation of meso-colon fascia from adherent retropretoneal fascia. Subsequently, more lymph node would be anticipated. Therefore, the determination of the tumor-related supplying arteries is critical for deciding the range of lymph node dissection in a certain tumor location. In 1995, Toyota et al. , published rationale for extent of lymph node dissection for right colon cancer, which subsequently became one of the main bases for deciding the range of lymph node dissection in Hohenberger’s proposal for right sided colon cancer. He emphasized unique concept at which anatomical fascia planes should be followed to yield high number of metastatic lymph node and named it complete mesocolon excision (CME) . CME technique contributed to enhance overall survival and reduce local recurrent rate dramatically from 82.1% to 89.1% and 6.5% to 3.6%, respectively . Bokey et al.  showed enhanced overall survival up to 15.6% when dissection take place in embryological planes. Moreover, central venous ligation and division of feeding vessel at the root have shown a successful concept to retrieved higher number of lymph node metastasis . On top of that, higher number of lymph node harvested attributed in accurate staging . CME principles for right-sided resection equivalent to the current TME principles for left sided resection.
Therefore, optimal vessel ligation has been discussed and studied well in the right-sided colon cancer with anticipated success to achieve oncological benefits. However, guideline to determine the level of vessel ligation in SPC is still remained in debates. The concept of high vessel ligation is to include resection of the paracolic nodes, intermediate nodes and apical lymphnodes, which defined as D3 lymph-adenectomy. D3 lymph-adenectomy have been widely used and accepted in Japan, China and Korea [10-12]. In case of SFC, whether high level of vessel ligation is required to include LMC artery or not, yet has not been proposed. To our knowledge, this is the first study aiming to investigate the adequacy of vessel ligation in SFC in term of overall survival (OS) and local recurrence.
Materials and Methods
Throughout 2005 until 2012 records were reviewed and analyzed retrospectively.170 Patients diagnosed with distal transverse colon cancer operated by left colectomy were investigated. Follow up charts and management had been prospectively collected. Further analysis performed and 43 patients histologically proven adenocarcinoma of SFC were enrolled in our study. They were allocated according to the level of vessel ligation (LCA plus MMC) marked as group (A) vs. (LCA plus LMA) as group (B). Level of vessel ligation was completely decided according to surgeon’s preferences due to the lack of standard guidelines. Therefore, faculty members have made an effort to determine the level of vessel ligation by their own experience.
Patient’s characteristics, peri-operative clinical results, and long-term oncologic outcomes were compared and matched between two groups as shown in Table 1. Exclusion criteria were old age more than 85 year old, synchronous primary tumor, stage VI disease, clinically unfit for surgery, American Society of Anesthesiologists (ASA) III-IV, tumor involved adjacent organ and non-complaint patients, and otherwise all other patients were included. For each patient data including gender, age, body mass index (BMI), conversion to laparotomy, intra-operative complications, post-operative complications, number of excised lymph nodes, readmission, and reoperation rates were studied. In addition, 4-6 cycles of adjuvant chemotherapy (ACT) were given to whom diagnosed with adenocarcinoma with tumor extend beyond T1b or deeper, particularly for those cannot tolerate general anesthesia, unfit for definitive operation or according to patients request and selecting for wait and see approach with close monitoring. Data were prospectively recorded in a CRC database and retrospectively analyzed.
Diagnostic staging and postoperative care
Colonoscopy, biopsy and computed tomography (CT) scan were used for diagnosis in all patients. The American Joint Committee on Cancer (AJCC) 7thedition classification and stage groupings were used for tumor assessment. Staging of the tumor achieved by chest X-ray, chest and abdomen CT scan as well as liver MRI in case of suspected liver metastasis. Tumor was successfully localized by either colonoscopy tattooing with Indian ink or intra-operative colonoscopy marking in case of early CRC.
Patients monitored postoperatively in a uniform protocol among our institution stuffs and oncology department. Patients managed and closely observed in the floor by an expert physician assistance and full team of surgeons on duty. In term of feeding after surgery, sips of water will be allowed in 24 hours after surgery then fluid diet will follow in the next 48 hours after surgery. Abdominal drains usually removed at 5th day postoperatively if there was no suspicious bleeding or abdominal collections. As long as patients tolerated orally, passed flatus and declared smooth postoperative recovery, can be discharged home and followed up in out patient’s clinic within 2 weeks’ time then every 3 months for the first year and every 6 months for the first 2 years and then annually thereafter until death or until they were lost to follow-up. In accordance with common practice at our institute, a clinical diagnosis was considered a sufficient evidence of recurrence; however, radiological or endoscopic confirmation was essential. In order to maximize our care, each visit to our out patients clinic, we routinely do clinical examinations, common blood chemistry (CBC) tests, serum CEA level, chest X-ray and abdominal and pelvic CT if needed as well as annual colonoscopy to rule out any possible recurrent or developing secondary tumor. Other imaging modalities (CT, MRI and bone scans) requested in case of recurrence or metastases were anticipated.
Five expert surgeons in the field of CRC with an experience of more than 200 procedures were selected to join our study criteria. This Study conducted in a very highly sophisticated setting in joint commission international (JCI) approved oncology center. Before 2007, procedures were performed by exploratory laparatomy but we changed our practice to laparoscopic surgery afterward. All patients routinely received mechanical bowel preparation. Low molecular weight heparin for deep venous thrombosis prophylaxis was used routinely. Antibiotic prophylaxis with cefuroxime was given 30 minutes before anesthesia induction and two doses postoperatively. All patients placed in a low lithotomy position, protected by straps for legs and pneumatic device to prevent deep venous thrombosis. In laparoscopic operation, five ports placed trans-abdominally, general inspection to rule out immediate complications or distant metastasis deposits. All our procedures started from medial to lateral approach with oncological concept or radical tumor resection, complete lymph-adenectomy and central ligation of the feeding vessels. In addition, no touch technique is a well-known approach in our institute at which crucial tumor dissection and tumor extraction through abdominal wall by using Alexis retractor in order to prevent tumor contact to skin. Procedure end with two drains placed in the abdomen cavity to monitor perioperative complication probabilities that removed at 5th day postoperatively. Likewise in open surgery, all oncology principles and safety were as identical as in laparoscopic group except cosmoses part where longer incision expected in open surgery, which usually located at midline of the abdomen and extended longer as per necessary.
OS was defined as the time from surgery to death from any cause. DSS was defined as the time from surgery to death related to cancer. DFS was defined as the time from surgery to any recurrence. Postoperative complications were grouped according to the time of the event; any adverse events occurring within 30 days. Splenic flexure cancer was defined as a tumor located in the distal third of the transverse colon, or in the left colonic angle, or in the proximal descending colon within10 cm from splenic flexure . Recurrent is identified if any mass or nodule had shown in the imaging studies during follow up time. In term of technical part, level of vessel ligation confirmed by expert surgeons and reassert by gross examination of the specimen.
Data are summarized as frequencies and percentages for categorical variables. Medians and ranges are used for continuous variables. Chi-squared tests were used to compare proportions and independent t test was performed for comparison of continuous variables. Uni-variable analysis of OS and DFS were carried out by the Kaplan-Meier method. All results were considered statistically significant if p value was less than 0.05. Statistical Package for the Social Sciences for Windows (Version 20.0, Chicago, IL) was used for data analyzing.
From early 2005 till the end of 2012, forty-three patients diagnosed with SFC enrolled in our data analysis. Majority of SFC patients in our institute were men, accounting for 33 patients (76.7%), 10 patients (23.3 %) were women. The mean age was 66 year old, ranging between (37- 83years). Patient’s weight were almost identical in both groups with BMI average of (23.1 ± 2.9 vs. 23.4 ±2.6, p=0.69) in-group A and B, respectively. CEA marker was not significantly changed post-operatively, as it was within normal range preoperatively at an average of 3.6- 4.6 µg/ml. All our patients were operated with a curative intent. Minimum invasive surgery started at early 2007 in our institute that we had few patients operated by exploratory laparotomy, 9 patients (21%) vs. 34 patients (79%), p=0.003, respectively as demonstrated in Table 1.
Tumor stage and histological finding chemotherapy course
There were no significant different in tumor stage between both group. Stage 1 rated at 25% in group A vs. 26.31% in group B, stage 2 and 3 found 33.4%, 4.2% vs. 42.1%,31.57%, p=0.77, respectively. Both arms received resemble course of ACT, afloropyrimidine-based regimen. There was no neo-adjuvent therapy had given to our patients. 15 patients received ACT in group A whereas 8 patients received ACT in group B, without statistical significant difference between two arms of the study as shown in Table 2. The mean longest diameter of the tumors was 5.4 ± 4 in group A and 4.7 ± 2.1 in group B, p=0.469. According to the cell differentiation, majority of the tumor grade turned out to be moderately differentiated cancer, rated at 19 patients (79.1%) in group A and 15 patients (69.9%) in group B. Few other patients found to be well or poorly differentiated cell tumors. Overall p values were insignificant in regards tumor cell differentiation in both groups, p= 0.63. Incidence of lympho-vascular invasion reached only 6 (25%) vs. 3 patients (15.78%), p= 0.461, in A and B group, respectively. Tumor clearance achieved successfully in both arms in term of proximal margin achieved at 14.1 ±6.5cm in groups B and 8.8 ± 3.9cm in group A, p=0.006. Distal margin reported at 11 ± 7.4cm and 9.8 ± 4.7cm, p=0.58, respectively. Total lymph node harvested was oncologically safe in both groups at an average of 19 ± 10 lymph nodes in group A and 15 ±6.7 lymph nodes in group B. As well as the rate of positive lymph nodes retrieved in our patients were at 1.6 ± 4 and 1.4 ± 2.7,p=0.882, respectively, as shown in Table 3,3A.
Overall survival and local recurrent rate
Local recurrence reported in 4 patients (16.6%) at group A and only 2 patients (10.5%) found in group B but had not reached statistical significant difference between both groups (p=0.56).DFS analyzed at 79.1 month vs. 84.7 month respectively with 95% confident interval at (67.4- 90.8) in group A and (73.4 – 96) in group B. overall survival rated at 75.2 month vs. 79.1 month with 95% confident interval (64.1-86.24) and (64.3 -93.9) respectively, which haven’t shown statistical differences between both groups (p>0.05) as shown in Figure 1. There were no death-related, immediate postoperative complications (within1 month of surgery). No peri-operative complications were recorded for both study groups. No conversion case was reported in our entire patients group.
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