Segmental resection of splenic flexure colon cancers provides an adequate lymph node harvest and is a safe operative approach – an analysis of the ACS-NSQIP database

Introduction Fewer than 10% of colon cancers are found at the splenic flexure. A standard surgical approach to these cancers has not been defined. The goal of this study was to compare lymph node harvest and post-operative morbidity between segmental resection and formal left hemicolectomy for splenic flexure colon cancers. Method Patients diagnosed with a splenic flexure cancer were identified from the 2012–2018 ACS-NSQIP colectomy-targeted database. Patients were categorized based on type of surgical resection – left hemicolectomy with colorectal anastomosis or segmental colectomy with colocolonic anastomosis. Demographic, clinicopathologic, and post-operative outcomes were compared between groups. Factors independently associated with lymph node harvest, operative time, and post-operative morbidity were investigated by linear and binomial logistic regression models. Results A total of 3,049 patients underwent colectomy for a splenic flexure cancer. Of these, 83.6% had a segmental colectomy and 73% were performed by a minimally invasive approach. T- and N-stage did not differ between segmental and left hemicolectomy groups (p = 0.703 and p = 0.429, respectively). Inadequate nodal harvest (< 12 nodes) was infrequent and similar between the two procedures (7.4% vs. 9.1%, p = 0.13). Operative time was significantly shorter for segmental colectomy (213 ± 83.5 min vs. 193 ± 84.1 min, p < 0.0001) and major morbidity was similar between the two surgical techniques (8.4% vs. 8.9%, p = 0.75). After accounting for demographic, clinicopathologic, and operative factors, binomial logistic regression showed that type of procedure was not significantly associated with LN harvest (OR 0.80, 95%CI 0.54–1.17) or major morbidity (OR 1.17, 95%CI 0.36–3.81). However, on linear regression, segmental splenic flexure resection was associated with shorter operative time (estimate 20.29, 95%CI 12.61–27.97, p < 0.0001). Conclusion Splenic flexure resection for colon cancer is associated with an adequate lymph node harvest. Compared to a formal left hemicolectomy, a segmental resection also has a shorter operative time with equivalent post-operative morbidity.

Pneumatosis cystoides intestinalis in a trauma patient presenting with pneumoperitoneum: a case report

Background Pneumatosis cystoides intestinalis is a rare and usually benign condition in which multiple thin-walled cysts develop in the submucosa or subserosa of the gastrointestinal tract. While usually asymptomatic, severe cases can result in pneumoperitoneum, which can be managed surgically or medically depending on circumstances. We present a case of a patient with pneumatosis cystoides intestinalis, which presented as pneumoperitoneum following trauma. To our knowledge, there are no other published cases in which a trauma patient with pneumoperitoneum was found to have radiologic evidence of pneumatosis cystoides intestinalis. Case presentation We present the case of a 37-year-old Hispanic male admitted to the hospital after being involved in a motorcycle accident. Computed tomography imaging of the abdomen and pelvis with oral and intravenous contrast demonstrated trace pneumoperitoneum, possibly originating from the splenic flexure of the colon without evidence of extravasation of oral contrast. Laparoscopy with conversion to exploratory laparotomy revealed bowel abnormalities at the distal transverse colon and splenic flexure, which were identified as pneumatosis cystoides intestinalis by pathology. There was no evidence of bowel perforation. A panel of abdominal radiologists attended the computed tomography interpretation to note that incidental atraumatic or traumatic rupture of the cysts could have caused the pneumoperitoneum. The patient had an uncomplicated postoperative course and was transferred to another facility per insurance request. Conclusions When presenting in the context of trauma, pneumatosis cystoides intestinalis can lead to difficult management decisions. To our knowledge, there are no existing evidence-based guidelines for the scenario of concurrent pneumatosis cystoides intestinalis, blunt abdominal trauma, and pneumoperitoneum in a patient with a benign abdominal exam. This patient’s pneumoperitoneum was likely caused by rupture of preexisting cysts rather than frank bowel perforation. Patients who are asymptomatic, lack signs of clinically worrisome disease, and have a low pretest probability will likely not benefit from surgery and can be medically managed. Thorough discussion between surgeons and radiologists can be helpful when evaluating the clinical significance of a patient’s pneumatosis cystoides intestinalis and aid in the decision to perform surgery.