The Safety of Selective Use of Splenic Flexure Mobilization in Sigmoid and Rectal Resections—Systematic Review and Meta-Analysis

Abstract

Background: According to traditional textbooks on surgery, splenic flexure mobilization is suggested as a mandatory part of open rectal resection. However, its use in minimally invasive access seems to be limited. This stage of the procedure is considered difficult in the laparoscopic approach. The aim of this study was to systematically review literature on flexure mobilization and perform meta-analysis. Methods: A systematic review of the literature was performed using the Medline, Embase and Scopus databases to identify all eligible studies that compared patients undergoing rectal or sigmoid resection with or without splenic flexure mobilization. Inclusion criteria: (1) comparison of groups of patients with and without mobilization and (2) reports on overall morbidity, anastomotic leakage, operative time, length of specimen, number of harvested lymph nodes, or length of hospital stay. The outcomes of interest were: operative time, conversion rate, number of lymph nodes harvested, overall morbidity, mortality, leakage rate, reoperation rate, and length of stay. Results: Initial search yielded 2282 studies. In the end, we included 10 studies in the meta-analysis. Splenic flexure is associated with longer operative time (95% confidence interval (CI) 23.61–41.25; p < 0.001) and higher rate of anastomotic leakage (risk ratios (RR): 1.02; 95% CI 1.10–3.35; p = 0.02), however the length of hospital stay is shorter by 0.42 days. There were no differences in remaining outcomes. Conclusions: Not mobilizing the splenic flexure results in a significantly shorter operative time and a longer length of stay. Further research is required to establish whether flexure mobilization is required in minimally invasive surgery.

Effect of splenic flexure mobilization performed via medial-to-lateral and superior-to-inferior approach on early clinical outcomes in elective laparoscopic resection of rectal cancer.

“…Moreover, they should also recognize that the incidence of anastomotic leakage can be reduced by SFM [9, 11, 25–27]. However, there are some studies in the literature advocating that SFM should be performed in selected cases due to its learning curve and complexity, prolonged operative time, and the increased risk for splenic, pancreatic, and adjacent organ injury [6, 7, 12–14, 16]. Ferrara et al reported that SFM increased the operative time, the incidence of conversion to open surgery, and the complexity of the operation.…”

“…The authors also noted that SFM had no superiority in terms of postoperative complications and oncological outcomes [14]. In a recent systematic review, Nowakowski et al reported that SFM led to a 3.2-fold increase in the operative time and a 3-fold increase in the incidence of anastomotic leakage compared to the patients who did not undergo SFM [7]. Inarguably, the absence of prospective, randomized, and controlled studies on SFM remains an important issue.…”

Review of Colonic Anastomotic Leakage and Prevention Methods

“…Mobilization of the splenic flexure is considered to be an essential step during laparoscopic anterior resection. If performed properly, it can achieve a tension-free anastomosis by providing sufficient colonic length, leading to a decrease in the risk of colorectal leakage [ 64 ]. This procedure is a crucial and essential part in all left-sided colorectal surgeries, allowing for an adequate resection with good blood supply.…”

Prevention of anastomotic leakage using a polyglycolic acid sheet in double-stapling technique anastomosis for rectal surgery

“…Therefore, various surgical techniques have been devised. For example, an evaluation of the intestinal blood flow using indocyanine green (ICG) fluorescent [ 6 , 7 ], sufficient mobilization of the left colon including splenic flexure for tension-free anastomosis [ 8 , 9 ], improvements in stapling devices [ 10 , 11 ] and the placement of a transanal tube for decompression of anastomosis [ 12 , 13 ]. However, anastomotic leakage in rectal surgery remains one of the most serious postoperative complications.…”