Colonic cancer, a malignant tumor originating in the colon, ranks as the third most common cancer globally and has become the second leading cause of cancer-related deaths worldwide, constituting a major public health burden [1]. For non-metastatic colon cancer, surgical resection remains the cornerstone of curative treatment [2]. Currently, laparoscopic colectomy is well-established, offering significant advantages over open surgery, including reduced intraoperative blood loss, faster recovery of bowel function, shorter hospital stays, comparable oncologic safety, and a decreased incidence of severe complications [3, 4, 5]. Nevertheless, according to several studies, the overall complication rate remains considerable, ranging from 20% to 30% [6, 7, 8]. Therefore, further efforts to reduce postoperative complications remain an area of research focus [9].

The transverse colon presents unique anatomical challenges due to its mid-abdominal location, where it is suspended between the hepatic and splenic flexures, as well as its complex vascular and lymphatic anatomy [10]. Laparoscopic resection of transverse colon cancer often requires specialized technical maneuvers, such as complete dissection of the middle colic vessels and mobilization of both colonic flexures. These procedures may result in distinct complication profiles compared to other colonic segments [11]. Consequently, risk factors established from studies on other colon segments may not apply to patients undergoing dedicated laparoscopic resection of transverse colon cancer.

This study aims to specifically analyze the risk of complications arising in patients with transverse colon cancer receiving laparoscopic transverse colectomy. The selection of candidate risk factors was based on a targeted review of contemporary literature on complications associated with laparoscopic colorectal surgery, with particular attention paid to pathophysiological mechanisms related to the technical characteristics of transverse colon surgery. Specifically, the analysis was structured across three dimensions: First, patient-related factors included diabetes mellitus and high body mass index (BMI), both well-established systemic risk factors associated with surgical site infections and impaired wound healing [12]. Second, technique-related factors were considered, particularly the frequent usage of extracorporeal anastomosis in transverse colon due to its mid-abdominal location. Although commonly employed, this approach may lead to greater incision exposure and mesenteric traction, and is therefore hypothesized to carry a higher risk of complications [13]. Third, surgery-related factors were evaluated, with operation time serving as an integrated indicator of procedural complexity. Transverse colon surgery is inherently more complex owing to the need to address both flexures and the middle colic vessels [14]. Additionally, age, preoperative anemia, among others, were also included due to their consistent associations with major abdominal surgery complications [15, 16]. This multidimensional screening approach was designed to comprehensively evaluate the unique risk profile of laparoscopic transverse colectomy.

The primary objective of this retrospective clinical study is to identify independent risk factors of perioperative complications among patients undergoing laparoscopic colectomy for transverse colon cancer. Our findings hold potential to be translated into a valuable preoperative risk assessment tool for facilitating personalized patient counseling and guiding targeted preventive strategies, with an ultimate goal of improving patient outcomes.

This retrospective analysis identified three independent risk factors for perioperative complications following laparoscopic colectomy in patients with transverse colon cancer: comorbid diabetes mellitus, extracorporeal anastomosis, and an operation time exceeding 3 h. These findings provide crucial evidence for identifying high-risk patients and optimizing perioperative management strategies. Below, we discuss the underlying mechanisms and clinical implications of these risk factors in light of existing literature.

Our study demonstrated that comorbid diabetes mellitus is an independent risk factor for increased perioperative complications after laparoscopic colectomy for transverse colon cancer. This finding aligns with conclusions from multiple studies on colonic cancer surgery. A Finnish population-based study reported significantly elevated complication rates after laparoscopic resection in stages I–III colon cancer patients with diabetes [24]. Furthermore, post hoc analysis of a prospective multicenter randomized controlled trial confirmed diabetes as an independent risk factor for surgical site infections following laparoscopic right hemicolectomy [6]. The increased risk of adverse outcomes after colorectal surgery in diabetic patients has well-established pathophysiological bases. Primarily, impaired immune function plays a central role: chronic hyperglycemia substantially compromises neutrophil chemotaxis, phagocytosis, and bactericidal activity, leading to diminished cellular immunity and heightened susceptibility to both local wound infections and systemic sepsis [25]. Secondarily, impaired tissue repair constitutes another critical factor: diabetes-associated microangiopathy disrupts tissue perfusion and oxygenation, delaying healing at surgical incision sites and anastomoses while markedly increasing the risk of anastomotic leakage [26]. Additionally, reduced organ reserve capacity should not be overlooked: diabetic patients often exhibit subclinical organ dysfunction, diminishing their overall tolerance to surgical trauma and anesthetic stress [27]. Given these mechanisms, rigorous perioperative glycemic control is imperative for diabetic patients undergoing transverse colectomy and should be prioritized equally with surgical technique. Evidence indicates that elevated postoperative infection risks correlate strongly with hyperglycemic states, while appropriate insulin therapy demonstrates a dose-response relationship in mitigating this risk [27]. Therefore, implementing targeted protocols such as insulin pump therapy to maintain perioperative blood glucose within an optimal range represents a key modifiable intervention for reducing complication rates in this patient population.

In this study, extracorporeal anastomosis was identified as the only risk factor of perioperative complications from among the technique-related factors screened. This finding strongly aligns with evolving trends in laparoscopic colonic surgery and existing evidence. With advancements in minimally invasive techniques, intracorporeal anastomosis has emerged as a preferred alternative to extracorporeal anastomosis. Technologically, intracorporeal anastomosis enables complete reconstruction of the gastrointestinal tract entirely within the abdominal cavity, typically requiring only a small accessory incision for specimen extraction—eliminating the need to exteriorize both ends of the colonic segment required by extracorporeal anastomosis [28]. This fundamental difference yields multiple clinical advantages: intracorporeal anastomosis significantly reduces abdominal wall incision size, minimizes traction and torsion on the colon and its mesentery, facilitates earlier postoperative bowel function recovery, shortens hospital stays, and lowers overall complication rates after laparoscopic left/right hemicolectomy [29, 30]. A systematic review and meta-analysis further substantiated that compared to extracorporeal anastomosis, intracorporeal anastomosis accelerates patient recovery and substantially reduces infections and total complications following right hemicolectomy [31].

Anatomically, the broad and mobile nature of the transverse mesocolon poses unique challenges for extracorporeal anastomosis. When anastomosis was performed extracorporeally, limited working space may necessitate increased manipulation of the intestinal loops, potentially compromising perfusion at the anastomotic site. Conversely, under magnified laparoscopic visualization, intracorporeal anastomosis allows surgeons to achieve precise tension-free sutures while preserving optimal blood supply—two critical pillars for preventing anastomotic leakage [32, 33]. A Study demonstrated superior perioperative outcomes with intracorporeal anastomosis in transverse colon cancer patients, including a higher likelihood of achieving adequate surgical margins (4.2 cm) and increased lymph node harvest counts [30]. Moreover, technological innovations, such as linear stapling devices and barbed sutures, have enhanced both the feasibility and safety of intracorporeal anastomosis, thereby expanding the applicability for totally laparoscopic colectomy [30]. Where available, medical centers should prioritize utilizing intracorporeal approaches that fully leverage laparoscopic advantages and adhere to the principles of physiological preservation, adequate blood supply, and tension-free technique. Emphasizing intracorporeal anastomosis as a key focus for technical refinement represents a promising strategy to improve surgical outcomes in patients with transverse colon cancer.

This study confirmed that an operation time exceeding 3 hours constitutes another significant independent risk factor for perioperative complications following laparoscopic resection in transverse colon cancer patients. Consistent with recent evidence, post hoc analysis of the Radical Extent of lymphadenectomy—D2 dissection versus complete mesocolic excision of LAparoscopic Right Colectomy for right-sided colon cancer (RELARC) trial identified procedures lasting over 180 minutes as an independent predictor of complications in laparoscopic right hemicolectomy [6]. Similarly, a retrospective analysis based on the Minimally-invasivE surgery for oncologic Right ColectomY (MERCY) study group database demonstrated a significant association between operation time $\ge$200 minutes and complication rates [34]. Shen et al. [35] also reported that operation time substantially impacts both short- and long-term outcomes after curative resection for colorectal cancer. Prolonged surgical duration essentially serves as a composite indicator reflecting procedural complexity and operational efficiency. In transverse colon cancer surgery, adherence to common mesocolic excision (CME) principles often requires technically demanding steps, including gastrocolic ligament release, pancreatic capsule dissection, and lymph node clearance at the root of the middle colic vessels, all of which are inherently time-consuming maneuvers [36]. Furthermore, extended operation times frequently correlate with challenging cases involving large tumors, locally advanced disease, or severe adhesions. Pathophysiologically, such cases are known to be associated with increased surgical trauma and higher perioperative risks [6]. Therefore, judicious control of operation time while ensuring oncologic radicality and surgical quality is of clinical significance. To achieve this, proficient laparoscopic skills, enhanced preoperative radiological assessment, precise surgical planning, improved team coordination, and effective management of intraoperative contingencies are required. For high-risk patients anticipating lengthy procedures, intensified perioperative management protocols are recommended to minimize complication risks.

In this study, we demonstrated that a combined model incorporating the three validated risk factors is essentially more effective in perioperative complication prediction. The model achieved an AUC value of 0.825, demonstrating significantly improved discriminative ability compared to any individual risk factor (diabetes: AUC = 0.643; extracorporeal anastomosis: AUC = 0.695; prolonged operation time: AUC = 0.668). There are three theoretical bases for integrating diabetic comorbidities, extracorporeal anastomosis, and prolonged surgical duration ($>$3 hours) into a composite predictor. First, each factor represents an independent and clinically actionable risk domain, namely patient physiological status, surgical technique, and procedural complexity. Second, these factors frequently co-occur in practice and may exert synergistic effects, where combined exposure elevates risk beyond the sum of individual effects; isolated assessment would underestimate such compounded risks. Third, a comprehensive evaluation enables practical risk stratification, distinguishing patients requiring standard care from those with multiple risk factors necessitating enhanced perioperative optimization and vigilance. This integrated approach thus provides a more comprehensive and clinically applicable assessment than single-factor evaluation. For patients identified as high-risk by the composite predictor, more intensive management strategies might be considered—such as optimizing perioperative blood glucose control, assigning experienced senior surgeons to ensure precise anastomotic techniques, and admitting patients to intensive care units postoperatively for close monitoring. Such approaches may facilitate personalized patient management and potentially optimize allocation of healthcare resources. Nevertheless, it must be emphasized that this study was conducted at a single center using retrospective observational data; thus, the clinical applicability of these findings warrants further validation through prospective studies or external cohorts.

It should be noted that in the present cohort, the complication group had a relatively high proportion of patients with ASA grade III–IV (69.77%) and poorly differentiated tumors (74.42%). Although these figures appear higher than those reported in some previous studies, they are not necessarily erroneous. One possible explanation is that our institution serves as a referral center for complex colorectal cancer cases, leading to an over-representation of patients with poorer general condition and more aggressive tumor biology. Additionally, the retrospective design and specific inclusion/exclusion criteria (e.g., exclusion of patients with incomplete records) may have introduced selection bias. Importantly, the data were carefully rechecked and confirmed to be accurate. Thus, these findings reflect the real-world situation of our study population and may remain valid, provided the interpretation is approached with caution.

This study has several limitations. First, the single-center retrospective design may introduce selection and information biases. Second, the relatively small sample size may reduce the statistical power for specialized analysis of certain rare yet serious complications, such as anastomotic leakage. Additionally, intraoperative variables, including estimated blood loss, intraoperative transfusion status, and fluctuations in hemodynamic or temperature, were not included in the study. Although these factors are known to influence surgical outcomes, they were excluded due to non-standardized recording to avoid introducing bias. Consequently, the current predictive model primarily reflects preoperative risk stratification and surgical strategy choices. Furthermore, dichotomizing continuous variables (such as operation time) facilitates clinical interpretation but results in a loss of statistical power and prevents the exploration of potential dose-response relationships with complication risks. Future prospective, multicenter studies with standardized perioperative data collection and the use of continuous variable modeling methods are necessary to further expand the model by integrating more validated intraoperative factors.

In summary, this retrospective study demonstrates that comorbid diabetes mellitus, use of extracorporeal anastomosis, and prolonged operation time ($>$3 hours) are independent risk factors for perioperative complications in patients with transverse colon cancer following laparoscopic resection. The combined predictive model incorporating these factors shows strong discriminative power, providing preliminary insights for facilitating preoperative risk stratification and personalized intervention formulation. Based on these findings, clinicians may consider strengthening perioperative glycemic management in diabetic patients, choosing the right anastomosis techniques to ensure tissue perfusion and tension-free anastomosis, and improving surgical proficiency and team coordination to reduce the duration of operation. Collectively, these interventions may contribute to enhanced postoperative recovery.

• This retrospective study identified comorbid diabetes mellitus, extracorporeal anastomosis, and operation time $>$3 hours as independent risk factors of complications in patients with transverse colon cancer following laparoscopic radical resection.

• The combined model incorporating these factors showed excellent predictive performance, with an AUC of 0.825, providing a practical tool for preoperative risk stratification.

• The study specifically addresses the unique anatomical and technical challenges of transverse colon cancer surgery, offering targeted evidence for this surgical context.

• These findings may directly inform clinical practice by optimizing patient selection, perioperative planning, and targeted interventions aimed at reducing postoperative morbidity.

The data used to support the findings of this study are available from the corresponding author upon request.

STJ and SW designed the research study. STJ drafted the manuscript. STJ and FY performed the research. STJ and LL analyzed the data. All authors contributed to the important editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study has been approved by the Ethics Review Committee of The First People’s Hospital of Yongkang (Approval number: 2025-LW-035) and strictly adheres to the principles outlined in the Declaration of Helsinki. The patients included in the study have signed the informed consent form.

Not applicable.

This research received no external funding.

The authors declare no conflicts of interest.