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20 Colon Cancer intheSplenic Flexure: Which Operation?
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237
proximal colon with resultant ischemia or serosal splitting, and this may necessitate
an extended right colectomy [4, 6]. ERH is associated with a higher number of
lymph nodes harvested in comparison to LH [7].
Lymph node resection has been a surrogate marker of quality for lymphadenectomy, but neither approach had signicant difference in yielding ≥12 LNs [7]. And
there was no difference in survival outcomes in any study.
The long-term function and quality of life should also be considered when choosing an operation for SFC.You etal., found measurable differences in quality of life
and number of bowel motions per day when comparing segmental versus extended
resections [14]. Because there is no clear oncologic benet of ERH or STC over LH
or SC, a segmental resection is preferred for SFC.
There are multiple limitations of this review. First, the denitions of each operation vary among studies, making it difcult to lump and compare, demonstrated in
Table20.3. Additionally, the three included metanalyses had several overlapping
studies among themselves and in one case a single institution had publications on
SFC with overlapping dates, suggesting that all patients were not unique [15, 16].
The meta-analysis by Hajibandeh etal., acknowledged this and performed sensitivity analyses which yielded no differences in outcomes [6]. All studies are retrospective from single institutions. No studies have been reported from the North American
population with the exception of a recently published NSQIP study with only shortterm outcomes [2].
Table 20.3 Denition of the surgical approaches used for splenic exure cancer resection
Segmental colectomy/
segmental left
colectomy/splenic
exure colectomy
denition
Ligation of left colic
artery and left
branches of the middle
colic artery.
Resection of the distal
part of the transverse
colon, the splenic
exure, and the
proximal descending
colon.
Colocolonic
anastomosis.
(continued)
Author
Hajibandeh
etal.
Extended right
hemicolectomy
denition
Ligation of
ileocolic (ICA),
right colic (RCA),
middle colic
(MCA) and
ascending branch
of the left colic
vessels (LCA).
Resection of the
right and
transverse colon
and a part of
descending colon.
Formation of an
ileocolic
anastomosis.
Left
hemicolectomy
denition
Ligation of left
colic and left
branch of the
middle colic
vessels.
Resection of the
colon from the
middle of the
transverse colon
to the rectosigmoid junction.
Formation of a
colorectal or
Colo-distal
sigmoid
anastomosis.
Subtotal
colectomy
denition
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Table 20.3 (continued)
Extended right
hemicolectomy
Author
Wang etal. Ligation of the
Martı
nez-Pe rez
etal.
denition
ICA, RCA, MCA
and LCA.
Resection from
the terminal ileum
to the middle
descending colon.
Ligation of
ileocolic, right
colic, middle
colic, and left
colic arteries.
Resection of the
terminal ileus and
the right,
transverse, and
proximal
descending colon.
Formation of an
ileocolostomy.
Left
hemicolectomy
denition
Ligation of the
left branch of the
MCA and IMA.
Resection of the
last third of the
transverse colon,
descending and
sigmoid colon
down to the
recto-sigmoid
union.
Ligation of the
inferior
mesenteric artery
and the left branch
of the middle
colic artery
Resection of the
colonic segment
between the left
third of the
transverse colon
and the colorectal
juncture (ie, left
half of the colon).
Colorectal
anastomosis or a
terminal
colostomy
Subtotal
colectomy
denition
Ligation of
the ileocecal
artery, right
colic artery,
middle colic
artery and
inferior
mesenteric
artery
(IMA).
Resection of
the right,
transverse,
descending
and sigmoid
colon down
to the
rectosigmoid
union.
H. Bhatt and K. Mathis
Segmental colectomy/
segmental left
colectomy/splenic
exure colectomy
denition
Resection of the bowel
between the left
branch of the MCA
and the LCA at its
origin from the IMA.
The left colic and left
branches of the middle
colic vessels are
ligated.
Resection of the distal
part of the transverse
colon, the splenic
exure, and the
proximal descending
colon.
Colocolonic
anastomosis is
performed between the
transverse and
descending sigmoid
colon.
20 Colon Cancer intheSplenic Flexure: Which Operation?
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239
Personal View ofData/ Expert Opinion
A standard operation for cancers of the splenic exure remains elusive due at
least in part to the unclear lymphovascular drainage of the splenic exure and the
relatively rare presentation of a tumor at this location. Many single institutions
have reported outcomes comparing multiple operations, including extended right
colectomy, left colectomy and segmental colectomy, and no signicant differences in long-term outcomes been shown or even suggested. We believe the operation should be individualized to the patient rather than protocolized. For early
stage, non- obstructing tumors at the splenic exure, we perform a segmental
colectomy with ligation of the left branch of the middle colic vessels and the left
colic vessels as well as the IMV followed by a colocolonic anastomosis. In a
patient who also has extensive diverticular disease, we may consider a left colectomy with a colorectal anastomosis. When a preoperative staging CT scan shows
concern for central lymphadenopathy, we will consider an extended right colectomy or subtotal colectomy with high ligation of the ileocolic and middle colic
vessels in addition to the left-sided vessels. And when the patient presents with
obstruction, we will perform an extended right colectomy if there is a concern of
cecal ischemia.
All elective SFC operations should be done in a minimally invasive fashion given
the oncologic safety and improvements in recovery outcomes.
While it is always preferred to have randomized trial evidence to inform these
decisions, it is not likely that a randomized trial will be feasible given the relative
rarity of SFCs. Prospective registries among many institutions would add value as
well as the public reporting of data from institutions in North America to further
understand patterns and outcomes. Additionally, the intraoperative ICG pilot studies
are fascinating and with some renement may allow a real time decision to be made
about extent of resection based on the uorescence.
In the meantime, we believe that the culmination of many low-quality studies
supports the use of a segmental colectomy for patients undergoing surgery for SFCs.
References
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2020;34(10):4436–43. https://doi.org/10.1007/s00464- 019- 07221- y.
2. Pang AJ, Marinescu D, Morin N, Vasilevsky CA, Boutros M.Segmental resection of splenic
exure colon cancers provides an adequate lymph node harvest and is a safe operative
approach– an analysis of the ACS-NSQIP database. Surg Endosc. 2022;36(8):5652–9. https://
doi.org/10.1007/s00464- 021- 08926- 9.
3. Matsuda T, Sumi Y, Yamashita K, et al. Anatomical and embryological perspectives in
laparoscopic complete mesocoloic excision of splenic exure cancers. Surg Endosc.
2018;32(3):1202–8. https://doi.org/10.1007/s00464- 017- 5792- 6.
4. Aldridge MC, Phillips RKS, Hittinger R, Fry JS, Fielding LP. Inuence of tumour site
on presentation, management and subsequent outcome in large bowel cancer. Br J Surg.
2005;73(8):663–70. https://doi.org/10.1002/bjs.1800730829.
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5. Kim MJ, Kim JH, Lee YS, etal. Short- and long-term outcomes of laparoscopic segmental left
colectomy for splenic exure colon cancer: comparison with propensity score matching. Ann
Surg Treat Res. 2021;101(5):274–80. https://doi.org/10.4174/astr.2021.101.5.274.
6. Hajibandeh S, Hajibandeh S, Hussain I, Zubairu A, Akbar F, Maw A.Comparison of extended
right hemicolectomy, left hemicolectomy and segmental colectomy for splenic exure colon
cancer: a systematic review and meta-analysis. Color Dis. 2020;22(12):1885–907. https://doi.
org/10.1111/codi.15292.
7. Wang X, Zheng Z, Chen M, etal. Subtotal colectomy, extended right hemicolectomy, left
hemicolectomy, or splenic exure colectomy for splenic exure tumors: a network metaanalysis. Int J Color Dis. 2021;36(2):311–22. https://doi.org/10.1007/s00384- 020- 03763- z.
8. Martínez-Pérez A, Brunetti F, Vitali GC, Abdalla S, Ris F, de’Angelis N.Surgical treatment
of colon cancer of the splenic exure: A systematic review and meta-analysis. Surg Laparosc
Endosc Percutan Tech. 2017;27(5):318–27. https://doi.org/10.1097/SLE.0000000000000419.
9. Degiuli M, Reddavid R, Ricceri F, et al. Segmental colonic resection is a safe and effective
treatment option for colon cancer of the splenic exure: a nationwide retrospective study of the
Italian society of surgical oncology–colorectal cancer network collaborative group. Dis Colon
Rectum. 2020;63(10):1372–82. https://doi.org/10.1097/DCR.0000000000001743.
10. Manceau G, Mori A, Bardier A, etal. Lymph node metastases in splenic exure colon cancer:
is subtotal colectomy warranted?: MANCEAU . J Surg Oncol. 2018;118(6):1027–33.
https://doi.org/10.1002/jso.25169.
11. Steele SR, Hull TL, Hyman N, Maykel JA, Read TE, Whitlow CB, editors. The ASCRS
textbook of colon and Rectal surgery. Springer International Publishing; 2022. https://doi.
org/10.1007/978- 3- 030- 66049- 9.
12. Vasey CE, Rajaratnam S, O’Grady G, Hulme-Moir M.Lymphatic drainage of the splenic exure dened by intraoperative Scintigraphic mapping. Dis Colon Rectum. 2018;61(4):441–6.
https://doi.org/10.1097/DCR.0000000000000986.
13. Watanabe J, Ota M, Suwa Y, Ishibe A, Masui H, Nagahori K.Evaluation of lymph ow patterns
in splenic exural colon cancers using laparoscopic real-time indocyanine green uorescence
imaging. Int J Color Dis. 2017;32(2):201–7. https://doi.org/10.1007/s00384- 016- 2669- 4.
14. You YN, Chua HK, Nelson H, Hassan I, Barnes SA, Harrington J, Segmental vs.
Extended colectomy: measurable differences in morbidity, function, and quality of life.
Dis Colon Rectum. 2008;51(7):1036–43. https://doi.org/10.1007/s10350- 008- 9325- 1.
15. de’Angelis N, Hain E, Disabato M, etal. Laparoscopic extended right colectomy versus laparoscopic left colectomy for carcinoma of the splenic exure: a matched case–control study. Int
J Color Dis. 2016;31(3):623–30. https://doi.org/10.1007/s00384- 015- 2469- 2.
16. The SFC Study Group, de’Angelis N, Martínez-Pérez A, etal. Extended right colectomy, left
colectomy, or segmental left colectomy for splenic exure carcinomas: a European multicenter
propensity score matching analysis. Surg Endosc. 2021;35(2):661–72. https://doi.org/10.1007/
s00464- 020- 07431- 9.
H. Bhatt and K. Mathis
Part III
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Rectal Cancer
Management ofT1 Rectal Cancer
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21
MaggieL.Westfal andMatthewG.Mutch
Introduction
Colorectal cancer is the third most common cancer for both men and women and is
the second leading cause of cancer-related deaths in the United States annually. In
2019, it was estimated that 145,600 new colorectal cancer cases were diagnosed in
the last year and an estimated 51,020 deaths will have occurred [1]. The treatment
for rectal cancer depends on the stage of disease at diagnosis. T1 cancers are dened
as those that have grown into the submucosa only. The Kudo classication denes
the degree of invasion into the submucosa as: upper third (sm1), middle third (sm2),
and lower third (sm3) of the depth into the submucosa [2]. The depth of invasion is
important as it is one of the characteristics that is used to classify lesions as low-risk
or high-risk of developing locoregional disease. The management of T1 rectal
tumors varies depending on the risk of locoregional disease, therefore this classication system is an important tool for surgeons.
Surgical management of rectal cancer is divided between local and radical resection. Total mesorectal excision (TME) is still considered the gold standard for the
curative surgical treatment of rectal cancer. TME is believed to result in a signicant
decrease in local recurrence rates and increased disease-free survival for locally
advanced disease, but is also associated with perioperative mortality ranging
between 2–4% [3, 4] and morbidity as high as 59% [5]. In order to decrease the
morbidity associated with a radical resection, several local excision techniques have
been developed. Despite the success of local excision in managing the tumor at the
index procedure with lower morbidity, many studies have questioned the oncologic
outcomes of local excision, specically in terms of high recurrence rates. This
M. L. Westfal (*) · M. G. Mutch
Washington University St. Louis, Colon and Rectal Surgery, St. Louis, MO, USA
e-mail: maggiew@wustl.edu; mutchm@wustl.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_21
243
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M. L. Westfal and M. G. Mutch
chapter will explore the management of T1 rectal cancer including presentation and
evaluation, operative management approaches, oncologic and quality of life outcomes, as well as review the evidence-based guidelines from both the National
Comprehensive Cancer Network (NCCN) and the American Society of Colon and
Rectal Surgeons (ASCRS).
PICO table
Patients
Patients with malignant
rectal polyp (T1 rectal
cancer)
Intervention Comparator
Trans-anal
excision
Total mesorectal
excision
Outcome
Recurrence-free survival,
overall survival, quality of
life
Presentation andEvaluation
Presentation
The widespread implementation of screening colonoscopy has led to a parallel
increase in the detection of early staged rectal cancer including T1N0M0 lesions.
Rectal cancers at this stage have invaded into the submucosal layer of the rectal wall
without metastasis to the lymph nodes and other organs. The two most common
presentations of T1 rectal cancer are those that are discovered on colonoscopy
before or after endoscopic resection. Patients present with a pedunculated or sessile
polyp and are subsequently diagnosed with cancer either post-endoscopic resection
or post-endoscopic biopsy. A malignant rectal polyp is dened as an adenoma that
harbors a focus of cancer invading through the mucosa and into the submucosa [6].
Before making a decision about formal surgical resection for an endoscopically
resected pedunculated or sessile malignant polyp, surgeons should review the
pathology and consult with the patient regarding their management options [7].
If the patient undergoes endoscopic resection and is found to have cancer in the
polyp that is removed, it is imperative that the site be marked at the time of removal
or within 2weeks of removal in order monitor the site of removal going forward
[8]. Additionally, the pathology should reviewed and mismatch repair gene (MMR)
and microsatellite instability (MSI) testing should be completed. If a pedunculated
poly is removed and found to have invasive cancer with favorable histologic features and clear margins then the patient can be clinically observed [7, 9]. However,
if a sessile polyp is removed and found to have invasive cancer, the patient can be
observed or undergo transanal local excision or transabdominal resection pending
the presence of high-risk features and the status of the resection margins. If the
patient undergoes fragmented resection and the margin cannot be assessed or there
is evidence of unfavorable histologic features then the patient should undergo preoperative work up for either local or radical excision [8]. Further details regarding
the indications for operative intervention and pre-operative work-up will be discussed further below.
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245
Evaluation
A cancer-specic history should be obtained eliciting disease-specic symptoms,
associated symptoms, family history and perioperative medical risk. Symptoms of
rectal cancer that need to be discussed are bleeding, pain, or symptoms related to
obstruction. Urinary, sexual and bowel function should be reviewed, and symptoms
indicative of malignant stulas or severe radiating pain may alert the surgeon to
locally advanced disease involving adjacent pelvic organs. Family history should
include documentation of relevant pre-malignant lesions and cancers including
details like age at diagnosis and the lineage of affected rst- and second-degree relatives. Patients should be asked about known predisposing hereditary cancer syndromes, prior genetic testing, and family ancestry or ethnicity that may be relevant.
Finally, a patient’s medical tness to undergo surgery should be assessed in order to
plan for the appropriate operative intervention [1]. Routine lab values including preoperative chemistry, blood counts and a baseline CEA should be obtained before
initiating treatment [10].
Physical exam should include documentation of the distance of the distal extent
of the tumor from the anal verge and the cancer’s relationship to the sphincter complex. Distance should be assessed by digital examination and endoscopy. Rigid
proctoscopy may provide a more accurate measurement than exible endoscopy.
Endoscopic tattooing for purposes of anticipated intraoperative localization or to
facilitate mucosal surveillance in the event of a clinical complete response in the
setting of neo-adjuvant therapy may be helpful [1]. Before elective treatment, the
histological diagnosis of invasive cancer should be conrmed and patients should
undergo a full colonoscopy in order to rule out synchronous lesions. The incidence
of synchronous colorectal cancer is low at 1–3% but the incidence of synchronous
adenomas or other polyps remains as high as 30% in the literature [11–14]. If preoperative colonoscopy is not performed due to the need for urgent intervention or in
the setting of an obstructing rectal cancer, then completion colonoscopy should be
performed post-operatively.
In terms of staging, rectal cancer should be staged accordingly to the American
Joint Committee on Cancer TNM system before initiating any treatment. A rectal
cancer protocol MRI is the preferred modality for locoregional clinical staging.
Endorectal ultrasound may be considered when differentiating between early T
stages or when MRI is contraindicated [1, 15]. The recommendations for MRI staging of rectal cancer includes using a standardized technical protocol and reporting
template that includes assessment of the depth of tumor penetration, presence of
loco-regional nodal metastases, and the relationship between the lesions within the
mesorectum and mesorectal fascia [16–18]. The NCCN denes a positive circumferential resection margin (CRM) as within one millimeter of the mesorectal fascia
[19] and MRI can help predict surgical clearance of the CRM [16, 18, 20]. In addition to MRI, clinical staging for metastatic disease includes a CT scan of the chest,
abdomen, and pelvis [1].
Finally, the management of patients with rectal cancer should utilize a multidisciplinary approach. Each case should be discussed in a tumor board that includes
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representatives from surgery, pathology, radiology, radiation oncology, and medical
oncology. The decision of treatment modality is a balance between the presence of luminal disease, risk of nodal metastasis, functional impact and patient preference. Due to
the complexity of decision making, extensive patient counseling is imperative.
Additionally, if patients are going to have an ostomy as part of their surgical treatment,
pre-operative education and stoma site marking should be performed by a trained
ostomy educator. Pre-operative stoma marking and education has been shown to
improve time to ostomy prociency and decrease ostomy-related complications [21, 22].
M. L. Westfal and M. G. Mutch
Management Approach
Local Resection
Transanal local excision can be considered for patients with favorable tumors that are
mobile and non-xed, less than 30% of the circumference of the bowel, less than
3cm in size, a margin that is clear for greater than 3mm, within 8cm from the anal
verge, T1 depth of invasion, well to moderately differentiated without lymphovascular invasion (LVI), perineural invasion (PNI), or tumor budding [7, 8, 23]. The currently available transanal approaches to resection of T1 tumors include: transanal
excision (TAE), transanal endoscopic surgery (TES), transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS). There is a robotic
assisted TAMIS (R-TAMIS) platform that utilizes the Da Vinci robotic system that it
is not yet approved for use but has been shown to be both effective and safe in small
trials [24]. The use of TEM and TAMIS can allow for local excision of more proximal lesions. The benet of a full thickness excision compared to endoscopic removal
allows for a more comprehensive pathologic evaluation. Final pathologic review of a
locally excised T1 rectal cancer maximizes the ability to stratify for the risk of nodal
metastasis allowing for a nal decision between local excision and radical resection.
For patients with low-risk tumors (sm1 depth of invasion, no high risk features (LVI,
PNI, tumor budding), and well or moderately differentiated) the risk of nodal metastasis is low at 1–3%. However, sm3 tumors with high-risk features can have a risk of
nodal metastasis as high as 35%, thus these factors must be considered when making
a decision regarding the need for radical resection [25].
There is controversy as to whether malignant colorectal polyps with a sessile
conguration can be successfully treated by endoscopic removal. Per the ASCRS
guidelines, the literature remains varied with some data indicating that endoscopically removed sessile malignant polyps have a signicantly greater incidence of
adverse outcomes (residual disease, recurrent disease, mortality, and hematogenous
metastasis but not lymph node metastasis), while other data suggests that conguration by itself is not a signicant variable for adverse outcomes and sessile polyps
with grade I or grade II histology, negative margins, and no LVI can be successfully
treated with endoscopic polypectomy alone [1]. If the lesion has low-risk features,
there may still be benet from further transanal or TEM excision to ensure there is
no residual local disease.
21 Management ofT1 Rectal Cancer
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Local excision involves full-thickness excision down to perirectal fat ideally
with a greater than or equal to 10 millimeter grossly normal circumferential margin
and 2-millimeter-deep margin [19]. The advantages to this approach are minimal
morbidity, sphincter sparing, rapid recovery, and minimal mortality [26, 27]. The
signicant limitation of this approach is the inability to pathologically stage the
mesorectal lymph nodes. Given this limitation and the signicantly higher local
recurrence rate after local excision compared to APR or LAR, some authors suspect
that this is due to lymph node micrometastatic disease that is undetectable on imaging and not assessed with local excision [23, 27, 28]. Thus, highlighting the importance of a thorough pathologic evaluation and patient counseling.
247
Radical Resection
As mentioned previously, the gold standard for the treatment of rectal cancer
remains a transabdominal resection with total mesorectal excision. In terms of operative approaches, depending on the location of the tumor, an abdominoperineal
resection or low anterior resection with colorectal or coloanal anastomosis can be
performed. The treating surgeon should be experienced in rectal cancer surgery and
specically with TME. Sphincter preservation and restoration of organ integrity
should be achieved without compromise of oncologic resection and consideration
of anticipated patient functional outcome and quality of life [1, 8]. TME involves en
bloc removal of the mesorectum, including associated vascular and lymphatic structures, fatty tissue, and mesorectal fascia as a tumor package through sharp dissection that spares the autonomic nerves [29–31].
For patients with T1 malignant polyps with unfavorable histologic features (positive margins, LVI, PNI, poor differentiation or sm2 or 3 invasion into the submucosa) [25, 32] or when the specimen is fragmented and/or margins cannot be
assessed, further rectal resection is warranted. A positive margin for an endoscopically removed polyp has been dened as the presence of tumor cells within the
diathermy of the transected margin [7, 33–35]. Additionally, several studies have
shown that tumor budding is an adverse histologic feature associated with adverse
outcomes and may preclude polypectomy as an adequate treatment of endoscopically removed T1 tumors [36, 37]. These poor prognostic features carry a 10–19%
risk of nodal metastasis so local excision will not provide adequate treatment.
Additionally, in terms of timing of radical resection, results of immediate surgery in
cases of high-risk pathology have shown superior results to those after salvage surgery at the time of local recurrence [38, 39].
Neoadjuvant andAdjuvant Therapy
Several studies have attempted to discern whether neo-adjuvant or adjuvant therapy
may benet patients undergoing local excision for T1 rectal cancer. Local excision
has also been performed after neoadjuvant chemoradiation for select T1/T2 lesions
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