Splenic Flexure Mobilization in Sigmoid and Rectal Resections: A Systematic Review and Meta-Analysis of Observational Studies

Objective: There is no consensus regarding whether splenic flexure mobilization (SFM) should be performed selectively or routinely for sigmoid and rectal resections. The aim of this study was to evaluate the impact of SFM on anastomotic leak and surgical site infection rates in sigmoid and rectal resections. Methods: PubMed, MEDLINE, EMBASE, Cochrane Library, and Scopus databases were searched by two independent researchers. Anastomotic leak was the primary endpoint. Inclusion criteria were clinical studies comparing SFM to non-SFM during sigmoid and rectal resections. The Mantel-Haenszel method with a random-effects model was used. The odds ratio (OR) was used for dichotomous variables, whereas the mean difference (MD) was used for continuous variables. Results: Six of 74 potentially eligible studies totaling 12,398 patients (4,356 with SFM and 8,042 without SFM) were selected for further examination. The overall bias risk was found to be high. There was no significant difference in anastomotic leak rates when SFM patients were compared to their non-SFM counterparts [OR (95%CI) = 2.00 (0.95, 4.18); p=0.07]. SFM patients had a longer operating time [MD (95%CI) = 31.62 (24.51, 38.72); p<0.001] and increased incisional SSI rates compared to their non-SFM counterparts [11.1% vs. 9.1%; OR (95%CI) = 1.23 (1.09, 1.40); p=0.0008]. A subgroup analysis of rectal cancer cases found significantly higher anastomotic leak rates with SFM [5.4% vs. 1.5%; OR (95%CI) = 2.37 (1.09, 5.16); p=0.03]. Conclusion: This systematic review found that SFM was not associated with significantly decreased anastomotic leak rates. SSI rates were significantly increased in patients undergoing SFM.