de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 https://doi.org/10.1186/s13017-021-00365-0 RESEARCH ARTICLE Open Access Emergency surgery for splenic flexure cancer: results of the SFC Study Group database Nicola de’Angelis1,2 , Eloy Espin3, Frederic Ris4, Filippo Landi5, Bertrand Le Roy6, Federico Coccolini7, Valerio Celentano8,9, Angela Gurrado10, Denis Pezet6, Giorgio Bianchi1, Riccardo Memeo11, Giulio C. Vitali4, Alejandro Solis3, Christine Denet12, Salomone Di Saverio13, Gian Luigi de’Angelis14*, Miquel Kraft3, Paula Gonzálvez-Guardiola15, Aine Stakelum16, Fausto Catena17, David Fuks12, Des C. Winter16, Mario Testini10, Aleix Martínez-Pérez1 and on behalf of the SFC Study Group Abstract Background: The effectiveness of surgical treatment for splenic flexure carcinomas (SFCs) in emergency settings remains unexplored. This study aims to compare the perioperative and long-term outcomes of different alternatives for emergency SFC resection. Method: This multicenter retrospective study was based on the SFC Study Group database. For the present analysis, SFC patients were selected if they had received emergency surgical resection with curative intent between 2000 and 2018. Extended right colectomy (ERC), left colectomy (LC), and segmental left colectomy (SLC) were evaluated and compared. Results: The study sample was composed of 90 SFC patients who underwent emergency ERC (n = 55, 61.1%), LC (n = 18, 20%), or SLC (n = 17, 18.9%). Bowel obstruction was the most frequent indication for surgery (n = 75, 83.3%), and an open approach was chosen in 81.1% of the patients. A higher incidence of postoperative complications was observed in the ERC group (70.9%) than in the LC (44.4%) and SLC groups (47.1%), with a significant procedure-related difference for severe postoperative complications (Dindo-Clavien ≥ III; adjusted odds ratio for ERC vs. LC:7.23; 95% CI 1.51-34.66; p = 0.013). Anastomotic leakage occurred in 8 (11.2%) patients, with no differences between the groups (p = 0.902). R0 resection was achieved in 98.9% of the procedures, and ≥ 12 lymph nodes were retrieved in 92.2% of patients. Overall and disease-free survival rates at 5 years were similar between the groups and were significantly associated with stage pT4 and the presence of synchronous metastases. Conclusion: In the emergency setting, ERC and open surgery are the most frequently performed procedures. ERC is associated with increased odds of severe postoperative complications when compared to more conservative SFC resections. Nonetheless, all the alternatives seem to provide similar pathologic and long-term outcomes, supporting the oncological safety of more conservative resections for emergency SFCs. Keywords: Splenic flexure carcinoma, Emergency surgery, Mortality, Survival, Colectomy, Cancer * Correspondence: gianluigi.deangelis@unipr.it 14 Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 Page 2 of 10 Introduction centers to compose a multicenter database on SFC pa- The surgical treatment of splenic flexure carcinoma tients undergoing surgery in both elective and emer- (SFC) has been traditionally neglected in the literature, gency settings between January 2000 and January 2018. mainly because of its relatively low incidence, as it repre- The participating centers were University Hospital Henri sents only 3 to 5% of all colonic cancers [1–4]. In recent Mondor of Creteil, France; Institute Mutualiste Mon- years, however, several studies have questioned which tsouris of Paris, France; University Hospital of type of resection would provide the best surgical and Clermont-Ferrand, France; University Hospital of Gen- oncological outcomes in patients with SFCs [1, 5–13]. eva, Switzerland; Vall d’Hebron University Hospital of Despite a substantial lack of standardization regarding Barcelona, Spain; Viladecans Hospital of Barcelona, the nomenclature of the different surgical alternatives Spain; University Hospital Dr. Peset of Valencia, Spain; to resect SFCs, three main surgical procedures are Portsmouth Hospitals NHS Trust, UK; Addenbrooke’s performed, namely, extended right colectomy (ERC), Hospital of Cambridge, UK; St Vincent’s University Hos- left colectomy (LC), and segmental left colectomy pital of Dublin, Ireland; University Medical School “Aldo (SLC) [5, 14, 15]. All these procedures are considered Moro” of Bari, Italy; and Bufalini Hospital of Cesena, alternatives for curative resections of these tumors, Italy. which are located on the border between the right Anonymous patient data were retrieved from each and left colon and have dual lymphatic drainage to- local database and merged into a common database that ward the superior and inferior mesenteric vessels [16]. was centralized by the leading center and further set for Indeed, two recent meta-analyses concluded that no the present statistical analyses. Due to the retrospective procedure-related difference exists in terms of postop- design of the study, which was conducted exclusively erative morbidity, mortality, lymph node yield, and using patient records, no institutional review board ap- patient survival [14, 16]. Consequently, a more con- proval was required. All personal data were managed in servative SLC, for a long time considered oncologi- conformity to the principles declared to the National cally inadequate [17], is considered a safe and Commission for Data Protection and Liberties. The effective option for the treatment of SFCs [5, 18]. study was reported following the recommendations In contrast, the outcomes of these different resections listed in the STROBE checklist for cohort and case–con- when performed in acute clinical situations remain sub- trol studies [22]. stantially unexplored. Although SFCs have been associ- ated with a poorer prognosis than cancers from other colonic subsites due to the high risk of bowel obstruc- Study population tion [3, 19, 20], the number of emergency cases reported For the present analyses, SFC patients were selected if in the literature is limited. Indeed, no prior study has they met the following criteria: (1) age > 18 years; (2) considered emergency SFC resections exclusively. Previ- colon cancer located at the splenic flexure (i.e., 10 cm ous works investigated either samples of elective SFC proximal toward the transverse colon or 10 cm distal to cases only [5, 6, 9, 11] or mixed populations of patients, the descending colon [2, 5, 17]) as assessed by preopera- including both elective and emergency operations, none tive computed tomography (CT) and confirmed during of which provided subgroup analyses on emergency surgery and at the pathologic report [2, 6, 17]; (3) any cases [7, 8, 10, 18, 21]. In these studies, emergency pa- AJCC TNM stage [23]; (4) obstructive or perforated neo- tients represented 5.7 to 50% of the samples, with an ab- plasm requiring emergency surgery; (5) curative-intent solute number of cases ranging from 34 to 75 patients surgical resection; and (6) one- or two-stage surgery (via [2, 7, 8, 10, 18, 21]. The authors, however, consistently temporary stoma). Patients with synchronous colonic reported that ERC was the preferred approach to treat carcinomas, untreatable metastatic disease, and polyposis SFCs presenting as intestinal obstruction [14]. coli were excluded. Emergency surgery was defined as The present study aims to compare the perioperative an unplanned procedure performed within 48 h of hos- and long-term outcomes of the different surgical alterna- pital admission [10, 18]. As previously described [5], tives for SFC resection in emergency settings using the three types of surgical procedures were performed for SFC Study Group database [5]. SFC resection: ERC, LC, and SLC [2, 5, 14, 15]. Both lap- aroscopic and open procedures were considered. Inter- Methods ventions were carried out by general and colorectal Study design surgeons. Patients were treated and followed-up accord- The present study was designed as an ancillary analysis ing to national protocols [5]. Adjuvant chemotherapy by the SFC Study Group. As previously described [5], the was generally indicated in patients with TNM III/IV tu- SFC Study Group was established in March 2017 and in- mors or in those presenting cancers with unfavorable volved 11 European surgical units from tertiary care histopathological features. de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 Page 3 of 10 Study outcomes surgery. Five patients were excluded because they did not The study outcomes were the same as those reported previ- meet all the inclusion criteria or due to missing data. Fi- ously on the elective management of SFCs [5] and included nally, the present study sample was composed of 90 pa- intraoperative variables (e.g., operative time, blood loss), tients who underwent emergency ERC (n = 55, 61.1%), LC postoperative variables (e.g., postoperative morbidity and (n = 18, 20%), or SLC (n = 17, 18.9%) (Fig. 1). SFCs were mortality, length of hospital stay), quality of the surgical re- located at the splenic flexure (n = 56, 62.2%), up to 10 cm section (e.g., resection margin status, number of retrieved proximal toward the transverse colon (n = 17, 18.9%), or lymph nodes), and overall survival (OS) and disease-free sur- up to 10 cm distal toward the descending colon (n = 17, vival (DFS) up to 5 years. Conversion was defined as a pre- 18.9%), without differences between the 3 surgical proced- mature interruption of the laparoscopic approach before the ure groups (p = 0.389). For the majority of patients, sur- resection phase was concluded [24, 25]. Postoperative mor- gery was indicated due to bowel obstruction (n = 75, bidity and mortality were defined as events that occurred 83.3%), whereas the remaining presented with a perfor- during the hospital stay or within 90 days after surgery. Post- ation (n = 15, 16.7%). No procedure-related differences operative complications were graded according to the were observed (p = 0.451). No endoscopic colonic stent Dindo-Clavien classification [26], with grades of III or more was used as a bridge to surgery. Overall, 73 patients identifying severe complications. Postoperative ileus was de- (81.1%) underwent open surgery; a higher frequency of fined as the absence of bowel movements or flatus associated laparoscopy was observed for LC and SLC procedures with intolerance of oral intake lasting more than 3 days post- than ERC, but the difference was not statistically signifi- operatively [27, 28]. Resections were classified as R0 when a cant (p = 0.051). The majority of interventions (57.8%) complete removal of the tumor with free resection margins were performed by colorectal surgeons without and no peritoneal spread were objectivized macro- and procedure-related differences (p = 0.379). Demographic, microscopically. clinical, preoperative, and histopathological characteristics for the total study sample and by surgical procedure are Statistical analysis displayed in Table 1. Demographics, clinical characteristics, and study out- comes were compared between the 3 procedures applied Comparisons between the three surgical procedures for to resect SFCs using the chi-squared test for categorical SFCs variables and Kruskal-Wallis tests for continuous vari- No procedure-related differences were observed except ables. A multivariate analysis was performed by includ- for age, ASA score, and suspected extracolic organ in- ing demographic, preoperative, and oncological variables volvement upon CT scan (Table 1). In the histopatho- that reached a p value < 0.1 in the univariate analysis. logical analysis, patients in the LC group had the largest Adjusted p values were reported for the overall compari- tumors and presented a higher prevalence of perineural sons, and whenever significant, two-by-two group com- invasion and moderately or poorly differentiated cancers. parisons were also explored. Bonferroni correction was Regarding the intra- and postoperative outcomes, a applied. Adjusted odds ratios (AORs) were calculated higher incidence of postoperative complications was ob- and presented with the 95% confidence interval (CI). served in the ERC group (70.9%) than in the LC (44.4%) The Kaplan-Meier method was used for the survival and SLC groups (47.1%); however, a significant analyses, and the log-rank (Mantel-Cox) test was applied procedure-related difference was noted only when con- for group comparisons. OS was defined as the time from sidering severe postoperative complications (Dindo-Cla- surgery to disease-related death and was censored at the vien ≥ III) (p = 0.011). A similar trend was also observed last follow-up date if no events occurred. DFS was de- for the time to return to regular diet, which was longer fined as the time from surgery to disease recurrence and for patients operated on by ERC (p = 0.054) (Table 2). was censored at the last follow-up date if no events oc- In the adjusted model, the only significant between- curred. Univariate and multivariate Cox proportional group difference was observed for the rate of severe hazards regression models were used to identify inde- postoperative complications; ERC was associated with an pendent predictors of survival. increased risk of Dindo-Clavien ≥ III, particularly when Statistics were carried out with SPSS (Statistical Pack- compared to LC (AOR 7.23; 95% CI 1.51-34.66; p = age for the Social Sciences, IBM SPSS Statistics, Version 0.013). 23 for Macintosh; IBM Corp., Armonk, NY, USA). A p Overall, 2/17 (11.7%) patients required conversion value < 0.05 was considered statistically significant. from laparoscopy to open surgery, one in the LC group and one in the SLC group. Reasons for conversion in- Results cluded technical difficulties due to bulky tumors (1) and The original SFC Study Group database included 494 SFC difficult exposure and inadequate visualization due to patients. Of these, 95 patients underwent emergency tumor fixation (1). Anastomotic leakage occurred in 8 de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 Page 4 of 10 Fig. 1 Study sample selection flowchart from the SFC Study Group database. ERC, extended right colectomy; LC, left colectomy; SLC, segmental left colectomy for splenic flexure carcinomas (SFCs) (11.2%) patients, with no differences between groups (p as isolated liver metastasis (7), isolated pulmonary me- = 0.902). Seventeen patients (18.9%) required reopera- tastasis (3), liver and pulmonary metastasis (1), periton- tion for the following reasons: anastomotic leakage (8), eal carcinomatosis (2), and systemic metastatic disease postoperative evisceration (2), hemoperitoneum due to (2), with no differences among the groups (p = 0.563). splenic bleeding (3), explorative laparotomy for sus- The 1-, 2-, and 5-year DFS rates were 80.3%, 74.3%, and pected anastomotic leakage that was not objectivized (2), 57.5%, respectively, for the ERC group; 84.6%, 75.2%, peritonitis due to bowel perforation (1), and peritoneal and 60.2%, respectively, for the LC group; and 78.7%, lavage and drainage for pancreatic fistula (1). No group 69.6%, and 58.2%, respectively, for the SLC group (p = difference was observed (p = 0.802). Overall mortality 0.402). The 5-year DFS for the entire study sample was within 90 days was 11.1%. R0 resection was achieved in 67.3%. 98.9% of the patients, and at least 12 lymph nodes were Stage pT4 and the presence of synchronous metastases retrieved in 92.2% of resections, without significant were found to be independent predictors for OS and procedure-related differences (Table 2). All patients who DFS (Table 3). received a temporary stoma underwent stoma closure within 4 months of SFC surgery. The overall mean Discussion follow-up time was 41.59 (± 33.48) months, with no The present multicenter retrospective study is the first, group differences (p = 0.406). The OS and DFS are to our knowledge, to describe and compare the out- shown in Figs. 2 and 3, respectively. comes of the different surgical resections performed for The 1-, 2-, and 5-year OS rates were 86.2%, 78.6%, and SFCs presenting as a surgical emergency. Our results 62.6%, respectively, for the ERC group; 87.4%, 79.4%, confirm that ERC and open surgery are the most fre- and 58.9%, respectively, for the LC group; and 93.3%, quently performed procedures in this clinical situation. 77%, and 63.4%, respectively, for the SLC group (p = Moreover, ERC appears to be associated with higher 0.697). The 5-year OS for the entire study sample was rates of severe postoperative complications. Comparable 58.4%. short- and long-term oncologic outcomes are observed Overall, 18 patients (22.5%) developed cancer recur- between ERC, LC, and SLC, supporting the feasibility rence: 13 (27.7%) in the ERC group, 3 (17.6%) in the LC and safety of more conservative SFC resections in emer- group, and 2 (12.5%) in the SLC group (p = 0.394). Of gency settings. these, 5 patients (6.2%) developed local recurrence, and The choice of which procedure to perform for cancers 15 patients (18.7%) developed distant metastases, such located at the splenic flexure remains essentially based de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 Page 5 of 10 Table 1 Demographic, clinical, imaging, and histological/oncological characteristics of SFC patients operated on by ERC, LC, and SLC Total sample (n = 90) ERC (n = 55) LC (n = 18) SLC (n = 17) P value Demographic and clinical variables Gender (M/F) [n] 53/37 33/22 12/6 8/9 0.482 Age (year) [median (range)] 71 (33-94) 73 (38-94) 61.5 (33-90.7) 74.7 (43-84.3) 0.044 Age > 75 (year) [n (%)] 34 (37.8) 22 (40) 4 (22.2) 8 (47.1) 0.274 2 BMI (kg/m ) [median (range)] 25.8 (14-34) 25.3 (14-34) 22 (17-32.3) 26.1 (21-34) 0.082 Obesity (BMI ≥ 30 kg/m2) [n (%)] 16 (17.8) 10 (18.2) 2 (11.1) 4 (23.5) 0.626 ASA score [n%] 0.043 • I-II 42 (46.7) 21 (38.2) 13 (72.2) 8 (47.1) • III-IV 48 (53.3) 34 (61.8) 5 (27.8) 9 (52.9) Pre-operative leukocytes (109/L) [mean (SD)] 10.96 (4.73) 11.5 (5.21) 10.99 (3.60) 8.95 (3.48) 0.198 Weight loss > 10% [n (%)] 25 (27.8) 16 (29.1) 6 (33.3) 3 (17.6) 0.550 Pre-operative serum CEA (U/mL) [median (range)] 33.65 (0.4-275.5) 33.65 (1.10-244.7) 54.7 (0.4-275.5) 23 (1.4-92.9) 0.241 Comorbidity (> 1) [n (%)] 38 (42.2) 25 (45.5) 6 (33.3) 7 (41.2) 0.662 Diabetes [n (%)] 14 (15.6) 10 (18.2) 2 (11.1) 2 (11.8) 0.689 Cardiopulmonary diseases [n (%)] 57 (63.3) 32 (58.2) 12 (66.7) 13 (76.5) 0.372 Kidney failure [n (%)] 6 (6.7) 4 (7.3) 1 (5.6) 1 (5.9) 0.958 Neurocognitive disorders [n (%)] 14 (15.6) 7 (12.7) 2 (11.1) 5 (29.4) 0.213 Smoking [n (%)] 30 (33.3) 20 (36.4) 6 (33.3) 4 (23.5) 0.618 Indication for surgery [n (%)] 0.451 • Colonic obstruction 75 (83.3) 48 (87.3) 14 (77.8) 13 (76.5) • Colonic perforation 15 (16.7) 7 (12.7) 4 (22.2) 4 (23.5) Surgical approach [n (%)] • Laparoscopy 17 (18.9) 6 (10.9) 6 (33.3) 5 (29.4) 0.051 • Open surgery 73 (81.1) 49 (89.1) 12 (66.7) 12 (70.6) Previous abdominal surgery [n (%)] • Laparoscopy 6 (6.7) 4 (7.3) 0 2 (11.8) 0.363 • Open surgery 20 (22.2) 11 (20) 3 (16.7) 6 (35.3) 0.340 One- or two-stage surgery [n (%)] 0.236 • One-stage surgery with primary anastomosis 70 (77.8) 46 (83.6) 12 (66.7) 12 (70.6) • Two-step procedure by temporary ostomy 20 (22.2) 9 (16.4) 6 (33.3) 5 (29.4) Simultaneous splenectomy [n (%)] 8 (8.9) 5 (9.1) 3 (16.7) 0 0.222 Preoperative imaging assessment on CT-scan Tumor size (largest dimension, cm) [mean (SD)] 4.44 (2.01) 4.24 (1.67) 5.55 (2.92) 3.93 (1.46) 0.070 Peri-colic nodal involvement [n (%)] 40 (44.4) 21 (38.2) 9 (50) 10 (58.8) 0.283 Patients with suspected extra-colic organs involved [n (%)] 5 (5.6) 0 5 (27.8) 0 < 0.0001 Suspected synchronous metastasis [n (%)] 16 (17.8) 11 (20) 2 (11.1) 3 (17.6) 0.693 Histological/oncological variables Stage of disease AJCC [n (%)] 0.490 •I 5 (5.6) 5 (9.1) 0 0 • II 34 (37.8) 21 (38.2) 8 (44.4) 5 (29.4) • III 40 (44.4) 22 (40) 9 (50) 9 (52.9) • IVa 11 (12.2) 7 (12.7) 1 (5.6) 3 (17.6) Vascular invasion [n (%)] 27 (30) 15 (27.3) 6 (33.3) 6 (35.3) 0.772 Lymphatic invasion [n (%)] 33 (36.7) 17 (30.9) 8 (44.4) 8 (47.1) 0.360 de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 Page 6 of 10 Table 1 Demographic, clinical, imaging, and histological/oncological characteristics of SFC patients operated on by ERC, LC, and SLC (Continued) Total sample (n = 90) ERC (n = 55) LC (n = 18) SLC (n = 17) P value Perineural invasion [n (%)] 24 (26.7) 11 (20) 9 (50) 4 (23.5) 0.042 Tumor size-largest dimension (cm) [mean (SD)] 4.6 (1.73) 4.56 (1.94) 5.19 (1.35) 4.07 (1.19) 0.039 Tumor grade [n (%)] 0.024 • Well differentiated 26 (28.9) 21 (38.2) 3 (16.7) 2 (11.8) • Moderately differentiated 48 (53.3) 22 (40) 12 (66.7) 14 (82.4) • Poorly differentiated 16 (17.8) 12 (21.8) 3 (16.7) 1 (5.9) Adjuvant treatment [n (%)] 44 (48.9) 24 (43.6) 11 (61.1) 9 (52.9) 0.408 Significant p values are indicated in bold AJCC American Joint Committee on Cancer, ASA American Society of Anesthesiology, BMI body mass index, CEA carcinoembryonic antigen, CT computed tomography, ERC extended right colectomy, LC left colectomy, SLC segmental left colectomy, SFC splenic flexure cancer on the surgeon’s experience and preference. In the set- suggesting a short-term benefit in performing more lim- ting of elective surgery, accumulating evidence consist- ited SFC resections (LC and SLC) [5, 6, 11, 18]. ently shows no difference in terms of oncological For emergency surgery, however, a few studies did not outcomes and survival between ERC, LC, and SLC [14, provide any subgroup analysis separately assessing the 16]; however, some previous comparative studies re- outcomes for the different types of SFC resection per- ported that extensive SFC resections are associated with formed as emergency and elective surgery. The main higher rates of postoperative complications, particularly reason for this lack of evidence could be related to the postoperative ileus [5, 6], and longer recovery times [5], very low incidence of emergency SFCs. To date, all the Table 2 Operative and postoperative outcomes in SFC patients (n = 90) operated on by ERC, LC, and SLC Variables ERC (n = 55) LC (n = 18) SLC (n = 17) p value Adjusted p value Operative time (min) [mean (SD)] 212.71 (70.91) 206.11 (47.67) 215.06 (67.37) 0.986 0.415 b Conversion to laparotomy [n (%)] 0 1 (16.7) 1 (20) 0.531 0.102 Operative blood loss (mL) [mean (SD)] 202.18 (153.43) 213.89 (193.57) 194.12 (151.70) 0.951 0.994 Number of intraoperative transfused patients [n (%)] 4 (7.3) 4 (22.2) 3 (17.6) 0.183 0.077 Intraoperative complication [n (%)] 10 (18.2) 0 2 (11.8) 0.141 0.997 Patients with post-operative complication [n (%)] 39 (70.9) 8 (44.4) 8 (47.1) 0.057 0.064 Anastomotic leakagea [n (%)] 6 (13) 1 (8.3) 1 (8.3) 0.892 0.902 Postoperative ileus [n (%)] 9 (16.4) 2 (11.1) 1 (5.9) 0.514 0.393 Severe postoperative complications (Dindo-Clavien ≥III) [n (%)] 27 (49.1) 2 (11.1) 5 (29.4) 0.011 0.032* Time to flatus [mean (SD)] 6.15 (5.08) 4.67 (2.08) 4.75 (3.09) 0.288 0.455 Return to regular diet [mean (SD)] 9.58 (6.24) 6.89 (3.37) 7.5 (6.5) 0.054 0.585 Hospital stay, days [mean (SD)] 17.62 (14.7) 14.40 (2.29) 17.75 (20.57) 0.735 0.465 Mortality at 90 days [n (%)] 8 (14.5) 1 (5.6) 1 (5.9) 0.430 0.677 Readmission within 60 days [n (%)] 4 (8.5) 1 (5.6) 0 0.477 0.987 Positive resection margin [n (%)] 1 (1.8) 0 0 0.725 1 Number of lymph nodes harvested [mean (SD)] 24.8 (12.97) 29.89 (11.53) 21.06 (6.89) 0.064 0.189 • ≥12 lymph nodes [n (%)] 49 (89.1) 18 (100) 16 (94.1) 0.308 0.250 Significant p values are indicated in bold ERC extended right colectomy, LC left colectomy, SLC segmental left colectomy, SFC splenic flexure cancer * Adjusted odds ratio and 95% confidence interval for pairwise comparisons: ERC vs. LC = 0.013; OR: 7.23 (95% CI: 1.51-34.66) ERC vs. SLC = 0.212; OR: 2.12 (95% CI: 0.65-6.91) LC vs. SLC = 0.334; OR: 0.24 (95% CI: 0.01-4.25) a Calculated for patients with primary anastomosis b Calculated for patients operated on by laparoscopy de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 Page 7 of 10 324 SFC patients operated on between 2004 and 2015 and found a significantly higher frequency of ERC than LC as emergency procedures (22.8% vs. 10.8%, respect- ively). Moreover, the authors observed higher mortality, overall morbidity, and surgical site infections for emer- gency procedures, disregarding the type of resection (i.e., ERC+LC). Importantly, all emergent procedures in the study were performed by open surgery [21]. Martin Aré- valo et al. [8] performed a propensity score matching study including 52 (30.5%) emergency surgeries (26 ERC, 17 LC, and 9 SLC), which were analyzed together with elective procedures. Therefore, the present study describes the largest sample of emergency SFC resec- tions published so far. Consistent with the previous literature, ERC was the most frequently performed procedure, representing 61% of all emergency resections. Similarly, open surgery was Fig. 2 Survival analyses (Kaplan-Meier method) for overall survival for SFC patients operated on by ERC (extended right colectomy), LC chosen in more than 80% of cases, which is the main dif- (left colectomy), and SLC (segmental left colectomy) ference compared to the elective SFC resections of the SFC Study Group database published previously by de’Angelis et al. [5] in which 74.4% were laparoscopic available evidence for SFC resection is supported by procedures. This difference can be easily linked to the retrospective evaluations of single or multicenter studies clinical scenario in which the surgeon has to choose the spanning very long time frames (up to 20 years) to have surgical approach facing an SFC presenting as bowel ob- a relatively large number of cases. The SFC Study Group struction (83% of cases) or perforation. ERC and open database included 494 SFC patients, of whom 95 (19.2%) surgery are usually preferred because they may be tech- were treated emergently. This percentage is higher than nically easier in the presence of proximal colonic disten- those reported in other multicenter studies with large sion or may be mandatory due to concerns about the sample sizes. Degiuli et al. [18] analyzed a nationwide viability of the cecum [8, 14]. Indeed, the experience of population of 1304 SFC patients, only 5.7% of which the surgeon on call, who may not always be a specialized underwent emergency surgery over the considered colorectal and/or laparoscopic surgeon, could have an period of 10 years. Binda et al. [21] included 16.6% of impact on this choice [10, 21]. Binda et al. [21] observed emergency cases in their multicenter study sample of some differences in terms of the choice of the surgical procedure and approach when comparing general sur- geons vs. colorectal surgeons, but only for elective sur- gery. In the present study, almost 60% of the procedures were performed by specialized colorectal surgeons, and no difference was observed between the ERC, LC, and SLC groups. The type of resection and the surgeon’s ex- perience have also been related to some surgical out- comes, such as postoperative complications, R0 resection, and lymph node yield. The present findings suggest that ERC may be associated with increased odds of developing severe postoperative complications when compared with LC and SLC; however, similar and favor- able pathologic outcomes were observed for all SFC re- section alternatives, with an R0 obtained in almost 99% of cases and more than 12 lymph nodes harvested in 92% of patients. Importantly, these data confirm the findings already reported for elective ERC, LC, and SLC [5, 10, 14, 16], supporting the oncological safety of more Fig. 3 Survival analyses (Kaplan-Meier method) for disease-free conservative SFC resections in emergency settings. Pa- survival for SFC patients operated on by ERC (extended right tient survival rates were comparable among the ERC, colectomy), LC (left colectomy), and SLC (segmental left colectomy) LC, and SLC groups, with a global sample 5-year OS of de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 Page 8 of 10 Table 3 Univariate and multivariate Cox regression hazard analyses of predictors of overall and disease-free survival Whole sample (n = 80*) Overall survival Disease-free survival Variables Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis p value HR (95% CI) p value Adjusted HR (95% CI) p value HR (95% CI) p value Adjusted HR (95% CI) Male vs. female 0.666 0.375 Age > 75 year 0.493 0.312 Comorbidity > 1 0.742 0.085 Open vs. laparoscopic 0.880 0.966 approach ERC vs. LC + SLC 0.596 0.200 Synchronous metastasis < 0.0001 13.37 < 0.0001 11.39 < 0.0001 23.92 > 0.0001 27.72 (5.34-33.45) (4.46-29.11) (6.98-81.97) (7.17-87.15) pT4 vs. pT1-3 0.007 2.95 0.046 2.31 0.024 2.92 0.028 3.04 (1.33-6.54) (1.17-5.27) (1.15-7.44) (1.12-8.26) pN+ vs. pN0 0.146 0.059 Harvested lymph nodes 0.814 0.976 < 12 Adjuvant chemotherapy 0.690 0.111 Dindo-Clavien ≥ III 0.452 0.411 Obstruction vs. 0.935 0.356 perforation HR < 1 indicates an improvement in survival (positive prognostic factor); HR > 1 indicates a worse survival (negative prognostic factor) Significant p values are in bold characters HR hazards ratio, CI for confident interval, AJCC American Joint Committee on Cancer, SFC splenic flexure cancer *After removing patients deceased within 90 days post-surgery (n = 10) 58.4%. These rates are inferior to those reported in stud- higher incidence of severe postoperative complications, ies concerning elective SFC resections or mixed popula- whereas R0 resection, lymph node yield, tumor recur- tions [14, 16], but they are comparable to the study by rence, and survival rates are comparable between ERC, Odermatt et al. [10] that considered the highest percent- LC, and SLC. These findings also support the feasibility age of emergency surgery in their sample (50% of pa- and safety of more conservative SFC resections in emer- tients). Poorer OS and DFS may be expected in gency settings. emergency patients who present with significant comor- bidities, unstable conditions, or advanced tumor stage at Abbreviations diagnosis [10]. The present results, taking into account ASA: American Society of Anesthesiologists; BMI: Body mass index; potential confounders, showed that for patients operated CT: Computed tomography; DFS: Disease-free survival; ERC: Extended right colectomy; LC: Left colectomy; OS: Overall survival; SFC: Splenic flexure on in emergency settings, predictors for OS and DFS are carcinoma; SLC: Segmental left colectomy essentially associated with tumor characteristics, particu- larly stage pT4 and the presence of synchronous metastasis. Acknowledgements The authors would like to thank the World Society of Emergency Surgery. The present retrospective study has some limitations, and these findings should be interpreted and generalized with caution because they are based on a sample of pa- Authors’ contributions NdeA, AMP, and GB contributed to the data managing, statistical analyses, tients operated on in several European referral centers and manuscript drafting. All authors contributed to the data collection and over a long period of time. The potential impact of manuscript revisions, and all approved the final version of the manuscript. selection and reporting bias cannot be excluded. Funding Conclusion No authors received funding or resources in relation to this article. The present study, based on a relatively large sample of SFC patients undergoing emergency surgery, confirms Availability of data and materials that ERC and open surgery are the most frequently per- There are no data from individual authors that reach the criteria for formed procedures. ERC appears to be associated with a availability. de’Angelis et al. World Journal of Emergency Surgery (2021) 16:20 Page 9 of 10 Declarations cancers between the distal transverse and proximal descending colon. Ann R Coll Surg Engl. 2016;98(5):303–7. https://doi.org/10.1308/rcsann.2016.0112. Ethics approval and consent to participate 8. Martin Arevalo J, Moro-Valdezate D, Garcia-Botello SA, Pla-Marti V, Garces- Due to the retrospective design of this study conducted exclusively on Albir M, Santiago LP, et al. Propensity score analysis of postoperative and patients’ records, no institutional review board was required. Patients signed oncological outcomes after surgical treatment for splenic flexure colon informed consents for the use of their medical records for scientific cancer. Int J Colorectal Dis. 2018;33:1201–13. purposes. Personal data were treated in conformity to the principles 9. Rega D, Pace U, Scala D, Chiodini P, Granata V, Fares Bucci A, et al. declared to the National Commission for Data Protection and Liberties and Treatment of splenic flexure colon cancer: a comparison of three different ascertained in the Declaration of Helsinki. surgical procedures: experience of a high volume cancer center. Sci Rep. 2019;9(1):10953. https://doi.org/10.1038/s41598-019-47548-z. Consent for publication 10. Odermatt M, Siddiqi N, Johns R, Miskovic D, Khan O, Khan J, et al. Short- Not applicable. and long-term outcomes for patients with splenic flexure tumours treated by left versus extended right colectomy are comparable: a retrospective Competing interests analysis. Surg Today. 2014;44(11):2045–51. https://doi.org/10.1007/s00595- All authors declare that they have no competing interests in relation to the 013-0803-2. matter of this publication. 11. Bademci R, Bollo J, Martinez Sanchez C, Hernadez P, Targarona EM. Is segmental colon resection an alternative treatment for splenic flexure Author details cancer? J Laparoendosc Adv Surg Techn Part A. 2019;29:621–6. 1 Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional 12. Chenevas-Paule Q, Trilling B, Sage PY, Girard E, Faucheron JL. Laparoscopic Hospital F. 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