Splenic flexure mobilization is associated with a lower risk of anastomotic leak in elective sigmoid colectomy for diverticular disease.

Abstract

Splenic flexure mobilization (SFM) is a technique hypothesized to decrease the risk of anastomotic leak by reducing anastomotic tension. Despite biological plausibility, prior studies have not demonstrated a consistent benefit. We evaluated the association between SFM and anastomotic leak rates in a large national cohort. This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program's colectomy-targeted database (2012-2022). Adult patients undergoing elective minimally invasive or open sigmoid colectomy without diversion for diverticular disease were included and stratified by intraoperative SFM. The primary outcome was anastomotic leak. Secondary outcomes included conversion to open approach, operating time and postoperative transfusion, acute kidney injury (AKI) and ileus. Of 16,963 patients meeting inclusion criteria, 54.2% (N = 9186) underwent SFM. Demographics were similar between groups, but mobilization was more likely performed with a laparoscopic approach (60.6% vs. 49.4%, p < 0.001). In univariate analysis, SFM was associated with fewer anastomotic leaks (1.7 vs. 2.2%, p = 0.028) but increased conversion to open (7.3 vs. 6.0%, p < 0.001), operating time (218 vs. 193 min, p < 0.001) and postoperative ileus (6.5 vs. 5.4%, p < 0.001). On multivariable regression, SFM was associated with a lower risk of anastomotic leak (OR = 0.79, p = 0.04) but increased operating time (28.5 min, p < 0.001), conversion to open (OR = 1.75, p < 0.001), postoperative ileus (OR = 1.21, p = 0.01), transfusion (OR = 1.22, p = 0.04) and AKI (OR = 1.41, p = 0.04). SFM is associated with a lower risk of anastomotic leak in patients undergoing sigmoid colectomy for diverticular disease, supporting its selective use when carefully weighed against the potential tradeoffs.