Because of the gravity, this maneuver indices the sliding of the transverse colon toward the right abdominal quadrants, with traction on the distal segment of the transverse and subsequent widening of the angle between the axis of the descending colon and the axis of the transverse colon.
In this position, after complete straightening of the scope, pushing can be resumed and progression occurs in most cases. In the impossibility to pass the splenic flexure, the colonoscope is straightened until the operator feels that the tip of the scope is free to move and that there is no resistance on the shaft.
Then, the stiffness is increased to the maximum level level 3 , and the colonoscope is again pushed avoiding an excess tip deflection that would inevitably lead again to a walking-stick handle effect.
The rationale behind the use of the variable stiffness function lies in the higher resistance of the scope to the passive flexion in the sigmoid colon, and therefore the ability to better transmit the vector force to the tip of the instrument Fig. The gravity drags the mobile segments and transforms the acute angles red circle into obtuse angles green circle , easier to intubate. Also in this case the passing of the splenic flexure can be facilitated by asking the patient for a deep inspiration that lowers the diaphragm and the flexure accordingly.
However, other symptoms you may experience with this condition include:. While symptoms from splenic flexure syndrome may not be life-threatening, this condition can cause severe pain.
If your symptoms become unbearable or worsen over time, seek immediate medical attention. Splenic flexure syndrome occurs when gas builds up or becomes trapped in your colon. Thought to be the primary cause of this condition, gas accumulation causes trapped air to push on the inner lining of your stomach and digestive tract.
As a result, pressure can build on surrounding organs causing pain and discomfort. Passing gas can help to relieve the pain, but that can become very difficult with this condition.
Before recommending treatment, your doctor will rule out other cardiac and gastrointestinal conditions. Your physician will conduct a full examination of your symptoms and review your current diet and medical history.
There is no specific test used to diagnose splenic flexure syndrome. However, there are a number of diagnostic procedures doctors can use to find the source of your pain. Some of the more common diagnostic tests include:. In some cases, splenic flexure syndrome improves and goes away on its own from flatulence or consistent bowel movements. Your doctor may recommend laxatives and other digestive aids to reduce constipation and improve digestion.
Your doctor may also recommend antacid medication to relieve bloating and stomach pain by reducing excessive gas production. Multiorgan resection was performed in There were no perforations of the cancer or violation of the tumor during the procedures.
No differences were found among three groups in the surgery characteristics. Characteristics of surgery were reported in Table 2. Mean length of hospital stay was 7. The postoperative outcomes were uneventful or with less severe complications Clavien I—II in 96 patients Three patients developed a significant anastomotic leak requiring a reoperation; in one patient a splenectomy was necessary owing to a splenic postoperative bleeding; one patient was treated with Vacuum Assisted Closure VAC therapy for a severe wound complication; one patient developed a large intraabdominal collection that was drained under radiological assistance; one patient died of intestinal ischemia with a days mortality rate 1.
No significant differences in complications according to severity, reoperation rate, hospital stay, day mortality, were observed in the three groups.
Postoperative characteristics were reported in Table 2. Tumor-free resection margin was reported in all specimens and tumor distance from proximal and distal margins was always adequate. A pT4 tumor were found in only 4. Carcinoma of moderate differentiation G2 was present in 84 patients of patients. The mean number of harvested lymphnodes was Histopathologic characteristics were reported in Table 3. The median follow up was 42 months IQR 24—70 months. During follow-up, 30 recurrences and 19 deaths occurred 12 for tumor progression.
No statistically significant differences were found for progression free survival Fig. Progression free survival curves by surgical treatment groups.
Overall survival curves by surgical treatment groups. The optimal surgical approach for splenic flexure cancer has not been clearly established and it is debated, mainly for the incomplete understanding of the peculiar dual lymphatic drainage of this region, related to the superior and inferior mesenteric vessels 3 , 5 , 6.
By histological examination Nakagoe and coworkers demonstrated that the majority of metastatic lymphnodes are located along the paracolic arcade and the left colic artery Vasey et al. Some authors believe that an extended right or left hemicolectomy is better indicated to guarantee the removal of all potentially involved lymphnodes along the superior mesenteric vessels 6 , 8 , They consider the segmental resection less radical than extended hemicolectomy and usually perform the former in older patients or for palliation in cases of extensive disease In contrast, other Authors 2 , 3 , 10 reported that the dual lymphatic drainage did not confer a survival disadvantage and extended resection was unnecessary.
A correct oncological lymphoadenectomy in colorectal cancer should involve the removal of at least 12 lymphnodes in the surgical specimen 27 , In our study we investigated oncological outcomes in 3 groups of patients, all treated for splenic flexure cancer between January and May , comparing segmental resection versus extended right or left hemicolectomy, to search for the best oncological surgical approach for splenic flexure cancer. At our knowledge, this is the first study that compare three different surgical approaches for splenic flexure cancer with a so large cohort of patients.
Despite this is a monocentric study, the statistic analysis including patients appears adequate, confirming the oncological feasibility of the segmental resection compared with extended resections, with similar oncologic quality of resection and postoperative outcomes.
In the searched literature, almost all studies about splenic flexure cancer surgery compare the right extended colon resection versus the left extended colon resection, with poor data concerning the long-term oncological outcomes 25 , 32 , Our results showed no significant differences in the oncological outcomes between the three groups.
In terms of surgical quality surrogates, the number of harvested lymphnodes and R0 rate were similar in the 3 groups. The proportion of patients with more than 12 harvested lymphnodes was also not significantly different. The higher number of harvested lymphnodes in the ERH group, was probably associated to larger extension of resected colon with least 3 colonic vascular pedicles, as also reported by other authors According to Perrakis et al.
We believe that the motivation for extensive resections appears to failin front of comparable R0 margin rate and oncologic outcomes, and that a resection extended to near organs is mandatory only in real case of tumor infiltration. As far as complication rates, no technique seems safer than others. No significant differences in complications according to severity, reoperation rate, hospital stay, day mortality, were found among three groups.
Looking at the long-term survival outcomes, the type of procedure was not a significant predictor, with no significant differences among the three groups. Our results suggest that a segmental splenic flexure resection is oncologically adequate for splenic flexure carcinoma.
As in all colon cancer surgery a correct CME procedure, including a sharp dissection along embryological planes and achieving a specimen with intact mesocolic fasciae which envelope the lymphatic drainage of the tumor is mandatory. Furthermore, the resection for splenic flexure carcinoma includes foremost the left colic and secondly the left branch of the middle colic lymphoadenectomy, guaranteeing the removal of the mostly involved lymphatic drainage of a splenic flexure cancer.
Despite the limitations of a retrospective study, our results provide valuable support for the oncological adequacy of a segmental resection of splenic flexure cancer. The R0 margin and a lymphoadenectomy with at least 12 harvested lymphnodes together with the surgical specimen, are the foundation of a correct surgical procedure, independently from the extension of the resection. Complete mesocolic excision is the way to achieve an optimal lymphnode yield.
Hence, the surgical strategy in terms of extension of colonic resection seems not to have an influence on the final stage classification and the survival. Steffen, C. Carcinoma of the splenic flexure. Dis Colon Rectum. Levien, D. Survival after resection of carcinoma of the splenic flexure. Shaikh, I.
Does the outcome of colonic flexure cancers differ from the other colonic sites? Int J Colorectal Dis. Article Google Scholar. Nakagoe, T. Carcinoma of the splenic flexure: multivariate analysis of predictive factors for clinicopathological characteristics and outcome after surgery.
J Gastroenterol. Bourgouin, S. Three-dimensional determination of variability in colon anatomy: applications for numerical modeling of the intestine.
J Surg Res. Odermatt, M. Left colic flexure. Reference article, Radiopaedia. URL of Article. Relations superiorly: spleen posteriorly: left kidney.
Applied Radiological Anatomy. Read it at Google Books - Find it at Amazon. Related articles: Anatomy: Abdominopelvic. Promoted articles advertising.
0コメント