Intracorporeal vs extracorporeal anastomosis following neoplastic right hemicolectomy resection: a systematic review and meta-analysis of randomized control trials

Minimally Invasive Right Hemicolectomy With Intracorporeal Anastomosis-Eliminating the Painful 12 mm Port Paradox

BackgroundMinimally invasive right hemicolectomy with intracorporeal anastomosis (ICA) with relocation of the 12 mm port to the Pfannenstiel specimen incision is associated with reduced length of stay and postoperative ileus while preserving surgical and oncologic outcomes when compared to extracorporeal anastomosis (ECA).MethodsAn institutional review board (IRB)-approved retrospective review was conducted at a single center for all patients who underwent elective laparoscopic or robotic right hemicolectomy from 2015 to 2023. The 12 mm port for anastomosis stapler was placed in the planned Pfannenstiel specimen extraction site in all patients undergoing ICA.Results112 patients underwent minimally invasive right hemicolectomy (33 laparoscopic ECA, 1 robotic ECA, 51 laparoscopic ICA, 27 robotic ICA). Median operative times for ECA vs ICA were 149.8 and 183.1 minutes, respectively (P < .01). The median length of stay was shorter for ICA (2 vs 3 days, P < .01). Postoperative ileus was greater in the ECA group (8.8% vs 2.6%, P = .140). Hospital readmissions were higher in the ECA group (3 vs 1, P = .048). The rate of no evidence of disease at time of last oncology follow-up was in the ECA group (93.6%) vs in the ICA group (98.5%), P = .092. Recurrence rate was not significantly different when comparing the ECA group vs the ICA group (6.45% vs 4.55%, P = .708).DiscussionMinimally invasive right hemicolectomy with ICA is associated with a lower rate of postoperative ileus and shorter length of stay. Relocating the 12-mm port for the bowel stapler to the Pfannenstiel extraction site eliminates the painful 12-mm port paradox.

Short-term outcomes of extracorporeal versus intracorporeal side-to-side anastomosis after laparoscopic right hemicolectomy for colon cancer: an affiliated study of a multicenter snapshot study

BACKGROUND

Laparoscopic right hemicolectomy (RHC) is the primary surgical approach for right-sided colon cancer. Different ileo-colonic anastomosis techniques may lead to varied postoperative outcomes. This study aims to compare intracorporeal versus extracorporeal side-to-side anastomosis post laparoscopic RHC for short-term outcomes in right-sided colon cancer patients.

METHODS

This prospective, multicenter, cohort study utilized 1:1 propensity score matching (PSM) and inverse propensity of treatment weighting (IPTW) to address baseline imbalances. The primary endpoint was the incidence of anastomotic leakage (AL) within 30 days postoperatively, with its definition, diagnosis, and grading criteria standardized according to a published study.

RESULTS

A total of 1028 eligible patients were analyzed, with 316 in the intracorporeal anastomosis (IA) group and 712 in the extracorporeal anastomosis (EA) group. After both PSM and IPTW, all 17 covariates were balanced between groups. No statistically significant difference in AL incidence was found between the two groups (before matching, 1.8% in EA and 1.6% in IA, P = 0.78; PSM, 1.3% in EA and 1.6% in IA, P = 0.74; IPTW, 1.9% in EA and 1.6% in IA, P = 0.76). However, peak C-reactive protein levels within 3 days postoperatively were higher in the EA group (before matching, P < 0.001; PSM, P < 0.001; IPTW, P = 0.003). Patients in the IA group had earlier postoperative defecation (before matching, P = 0.01; PSM, P < 0.001) and a shorter total hospital stay (before matching, P = 0.01; IPTW, P = 0.046). Post-PSM analysis showed earlier flatus in the IA group (P = 0.03), while post-IPTW analysis indicated later postoperative eating resumption in the IA group (P = 0.046).

CONCLUSIONS

Intracorporeal anastomosis during laparoscopic RHC for right-sided colon cancer does not increase the incidence of AL or other short-term complications. Furthermore, it facilitates postoperative bowel function recovery.

Systematic review and meta-analysis comparing robotic total mesorectal excision versus transanal total mesorectal excision for rectal cancer

INTRODUCTION

The best approach for total mesorectal excision (TME) remains controversial. Two recently described approaches are robotic TME (RTME) and transanal TME (TaTME). This systematic review and meta-analysis aimed to compare the outcomes between robotic surgery and TaTME in patients undergoing rectal cancer resection.

METHODS

We structured this systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines 2020 and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. An electronic search of relevant literature was conducted on 20 May 2023. The protocol was registered in PROSPERO (CRD42023435259).

RESULTS

Eleven eligible nonrandomised studies were included in this study. The study included 2796 patients (RTME = 1800; TaTME = 996). The RTME group had a higher rate of complete TME. However, no significant differences were observed in mortality, morbidity, severe complications, operative time, conversion rate, anastomotic leak, hospital stay, CRM-positive resection margin, distal resection margin, number of harvested lymph nodes, abdominoperineal resection (APR) rate, or local recurrence between the RTME and TaTME groups.

CONCLUSION

The RTME technique may ensure a higher rate of complete TME than TaTME. However, no significant differences were observed in most postoperative outcomes and oncological safety between the RTME and TaTME groups. Evidence does not conclusively favor one technique over the other, highlighting the need for additional randomized controlled trials to better define their roles in rectal cancer surgery.

Laparoscopic assisted colectomy versus laparoscopic complete colectomy: a cost analysis

To compare the short-term outcomes and explore the potential economic benefits of laparoscopic-assisted colectomy with extracorporeal anastomosis (LAC/EA) vs. laparoscopic complete colectomy with intracorporeal anastomosis (LCC/IA) for patients with non-metastatic resectable colon cancer. Data of patients who underwent laparoscopic hemicolectomy from January 2017 to March 2023 were collected and analyzed. Propensity score matching (PSM) analyses was carried out to minimize the selection bias. Before PSM, a total of 113 patients met the inclusion criteria (39 in the LCC/IA vs. 74 in the LAC/EA). Clinicopathologic characteristics were comparable except for the median number of removed lymph nodes (P = 0.023). LCC/IA was associated with longer operative time, less intraoperative blood loss, and shorter incision length. The rate of 30-day postoperative complications was similar, but the time to first flatus and soft diet was shorter in the LCC/IA. No deaths were reported in either group within 30 days after surgery. Costs of surgical instruments (25,945.8 ± 1,918.0 vs. 23,551.9 ± 2,665.5 RMB; P < 0.01) were higher for the LCC/IA but overall costs were similar (LCC/IA, 43,220.0 ± 4,954.0 vs. LAC/EA, 41,269.2 ± 6,685.9 RMB; P = 0.112). After PSM, 38 patients in the LCC/IA and 63 patients in the LAC/EA were compared. LCC/IA was superior in terms of intraoperative blood loss, incision length, and postoperative functional recovery. There was an extra charge of 2385.0 RMB regarding surgical instruments in the LCC/IA but the overall cost did not reach statistical significance. LCC/IA is a feasible, safe, and cost-effective surgical treatment for patients with non-metastatic resectable colon cancer.

Intracorporeal versus Extracorporeal Anastomosis in Laparoscopic Right Hemicolectomy: An Updated Systematic Review and Meta-Analysis of Randomized Control Trials

INTRODUCTION

Laparoscopic right hemicolectomy has become the standard surgical procedure for the treatment of right colon disease; however, the choice of anastomosis remains controversial. This study aimed to compare the safety and efficacy of intracorporeal anastomosis and extracorporeal anastomosis in laparoscopic right hemicolectomy.

METHODS

A systematic literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library. Randomized controlled trials that compared intracorporeal anastomosis with extracorporeal anastomosis in patients with laparoscopic right hemicolectomy until June 4, 2023, are selected. The primary outcomes measured were incidence of anastomotic leakage within 30 days post-operation. Statistical analyses were performed using Review Manager (version 5.4.1).

RESULTS

Seven RCTs, including 720 patients, were eligible for the meta-analysis. The incidence of anastomotic leakage showed no significant difference between the intracorporeal anastomosis group and the extracorporeal anastomosis group (RR 0.93, 95% CI: 0.49, 1.76, p = 0.83, and I2 = 0%). However, the intracorporeal anastomosis group had significantly lower rates of postoperative ileus (RR 0.67, 95% CI: 0.45-0.99, p = 0.04, I2 = 46%) and surgical site infections (RR 0.34, 95% CI: 0.16-0.74, p = 0.007, I2 = 0%) compared to the extracorporeal anastomosis group. Additionally, patients in the intracorporeal anastomosis group experienced earlier postoperative passage of gas and stool (WMD -0.39, 95% CI: -0.60, -0.19, p = 0.0002, and I2 = 67%; WMD -0.53, 95% CI: -0.85, -0.21, p = 0.001, and I2 = 75%), as well as shorter hospital stays (WMD -0.46, 95% CI: -0.74, -0.18, p = 0.001, and I2 = 34%).

CONCLUSION

In laparoscopic right hemicolectomy, intracorporeal anastomosis does not increase the incidence of anastomotic leakage within 30 days post-operation compared to extracorporeal anastomosis. In addition, intracorporeal anastomosis resulted in faster recovery of bowel function. This suggests that intracorporeal anastomosis is safe and effective.

Evaluation of the short-term complications of intracorporeal anastomosis in right-sided colectomy

INTRODUCTION

The benefits of intracorporeal anastomosis in laparoscopic colorectal cancer surgery remain unclear. Therefore, we aimed to investigate the short-term postoperative outcomes of intracorporeal anastomosis.

METHODS

We retrospectively analyzed 87 patients who underwent laparoscopic surgery for right-sided colon tumors using a colon database.

RESULTS

Of the 87 patients, 23 underwent intracorporeal anastomosis and 64 underwent extracorporeal anastomosis. Intraoperative bleeding, wound length, exhaust gas, preoperative white blood cell count, and C-reactive protein (postoperative day 1) were higher in the extracorporeal anastomosis group than in the intracorporeal anastomosis group. The incidence of wound infection was higher in the intracorporeal anastomosis group than in the extracorporeal anastomosis group. In the irrigation water bacterial culture collected after anastomosis, the positive group had a higher white blood cell count on postoperative day 1 and higher C-reactive protein levels on postoperative day 3 than did the negative group. Patients who underwent chemical preparation had lower C-reactive protein levels on postoperative day 1 than did the group who did not undergo chemical preparation.

CONCLUSION

Despite the advantages of intracorporeal anastomosis in terms of wound length and intraoperative bleeding, the risk of infection may increase during the introduction phase. Fever and inflammatory responses are significantly elevated in culture-positive cases.

[Robotic Colorectal Surgery: Analysis of the First Three Years of Activity in a Hospital of the Portuguese National Health Service]

INTRODUCTION

Minimally invasive surgery has been increasingly accepted and used in colorectal surgery. Several studies report that robotic surgery may provide advantages over 'conventional' laparoscopy, namely in rectal surgery. This paper provides an account of the first three years of experience with robotic surgery in the Unidade de Patologia Colorretal of the Unidade Local de Saúde S. José.

METHODS

Variables were defined to develop a prospective database containing the data of consecutive patients operated by three internationally certified colorectal surgeons using the Da Vinci Xi® system between November 2019 and October 2022. The database was converted into an anonymized version that was used for this study. The analysis was performed on the data of all the patients operated during this period.

RESULTS

Eighty patients were included, 47 male, median age 70 years, and median BMI 26 kg/m2 . ASA score was II in 53.7% and III in 41.3% of pa- tients. Of the total, 97.6% had malignant or potentially malignant disease. Operative procedures consisted of 34 colectomies proximal to the splenic flexure, 20 distal colectomies and 26 anterior resections. There were two synchronous resections of liver metastases. Early perioperative outcomes and histopathological results were analyzed: median operative time: 300 minutes; median estimated blood loss: 50 mL; conversion rate: 2.5%; median days until first bowel movement: three days; median length of hospital stay: six days; complication rate: 20%, of which 5% were Clavien III and 0% Clavien IV/V; anastomotic leak rate: 2.5%; 30-day readmission rate: 1.3%; median lymph nodes resected: 20; R0 resection rate: 100%; mesorectal integrity rate: 95,8% complete/near complete.

CONCLUSION

Our results show that the adoption of robotic colorectal surgery in our center was safe and resulted in similar or improved short-term clinical outcomes and histopathological results when compared to those described in the literature.

Comparison of intracorporeal and extracorporeal anastomosis in laparoscopic right colectomy: an updated meta-analysis and trial sequential analysis

This meta-analysis was conducted to provide updated evidence regarding perioperative safety and efficacy, of IC and EC anastomosis in laparoscopic right colectomies. In this study, the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines were applied. The study protocol received a PROSPERO registration (CRD42020214596). A systematic literature search of the electronic scholar databases (Medline, Web of Science and Scopus) was performed. To reduce type I error, a trial sequential analysis (TSA) algorithm was introduced. The quality of evidence was evaluated based on the GRADE methodology. In total, 46 studies were included in this meta-analysis, Pooled comparisons and TSA confirmed that IC is superior in terms of incisional hernia (0.29; 95%CI: 0.19, 0.44), open conversion (0.45; 95%CI: 0.30, 0.67), reoperation (0.62; 95%CI: 0.46, 0.84]), LOS (- 0.76; 95%CI: - 1.03, - 0.49), blood loss (- 11.50; 95%CI: - 18.42, - 4.58), and cosmesis (- 1.71; 95%CI: - 2.01, - 1.42). Postoperative pain and return of bowel function were, also, shortened when the anastomosis was fashioned intracorporeally. The grading of most evidence ranged from 'low' to 'high'. Due to the discrepancy in the results of RCTs and non-RCTs, and the proportionally smaller sample size of the former, further randomized trials are required to increase the evidence of this comparison.

Robotic versus laparoscopic right hemicolectomy: a systematic review of the evidence

Robotics may facilitate the realization of fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis and off-midline extraction, when compared to laparoscopy. Our aim was to compare laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. MEDLINE was searched for original studies comparing laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. The systematic review complied with the PRISMA 2020 recommendations. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected and qualitatively assessed. Two-hundred and ninety-three publications were screened, 277 were excluded and 16 were retained for qualitative analysis. The majority of included studies were observational and of limited sample size. When the type of anastomosis was left at surgeon's discretion, intra-corporeal anastomosis was favoured in robotic right hemicolectomy (4/4 studies). When compared to laparoscopy, robotics allowed harvesting more lymph nodes (4/15 studies), a lower conversion rate to open surgery (5/14 studies), a shorter time to faeces (2/3 studies) and a shorter length of stay (5/14 studies), at the cost of a longer operative time (13/14 studies). Systematic review of existing studies, which are mostly non-randomized, suggests that robotic surgery may facilitate fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis, and offer improved post-operative recovery.

Best Evidence for Each Surgical Step in Minimally Invasive Right Hemicolectomy: A Systematic Review

Objective

The aim of this study was to systematically review the literature for each surgical step of the minimally invasive right hemicolectomy (MIRH) for non-locally advanced colon cancer, to define the most optimal procedure with the highest level of evidence.

Background

High variability exists in the way MIRH is performed between surgeons and hospitals, which could affect patients' postoperative and oncological outcomes.

Methods

A systematic search using PubMed was performed to first identify systematic reviews and meta-analyses, and if there were none then landmark papers and consensus statements were systematically searched for each key step of MIRH. Systematic reviews were assessed using the AMSTAR-2 tool, and selection was based on highest quality followed by year of publication.

Results

Low (less than 12 mmHg) intra-abdominal pressure (IAP) gives higher mean quality of recovery compared to standard IAP. Complete mesocolic excision (CME) is associated with lowest recurrence and highest 5-year overall survival rates, without worsening short-term outcomes. Routine D3 versus D2 lymphadenectomy showed higher LN yield, but more vascular injuries, and no difference in overall and disease-free survival. Intracorporeal anastomosis is associated with better intra- and postoperative outcomes. The Pfannenstiel incision gives the lowest chance of incisional hernias compared to all other extraction sites.

Conclusion

According to the best available evidence, the most optimal MIRH for colon cancer without clinically involved D3 nodes entails at least low IAP, CME with D2 lymphadenectomy, an intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision.

National implementation of an optimal standardised technique for right-sided colon cancer: protocol of an interventional sequential cohort study (Right study)

PURPOSE

Minimally invasive right hemicolectomy (MIRH) is the cornerstone of treatment for patients with right-sided colon cancer. This operation has evolved during recent decades, with many innovations and improvements but this has also resulted in high variability of uptake with subsequent substantial variableness. The aim of this ongoing study is to identify current surgical variations, determine the most optimal and standardised MIRH and nationally train and implement that technique to improve short-term clinical and long-term oncological outcomes.

METHODS

The Right study is a national multicentre prospective interventional sequential cohort study. Firstly, current local practice was evaluated. Subsequently, a standardised surgical technique for right-sided colon cancer was determined using the Delphi consensus method, and this procedure was trained during hands-on courses. The standardised MIRH will be implemented with proctoring (implementation cohort), after which the performance will be monitored (consolidation cohort). Patients who will receive a minimally invasive (extended) right hemicolectomy for cT1-3N0-2M0 colon cancer will be included. The primary outcome is patient safety reflected in the 90-day overall complication rate according to the Clavien-Dindo classification. Secondary outcomes will include intraoperative complications, 90-day mortality rate, number of resected tumour-positive lymph nodes, completeness of mesocolic excision, surgical quality score, locoregional and distant recurrence and 5-year overall survival. A total number of 1095 patients (365 per cohort) will be included.

DISCUSSION

The Right study is designed to safely implement the best surgical practice concerning patients with right-sided colon cancer aiming to standardise and improve the surgical quality of MIRH at a national level.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04889456, May 2021.

Incidence of and risk factors for postoperative ileus between right and left laparoscopic colectomy using propensity-score-matched analysis: A retrospective multicenter study

INSTRUCTION

In colon cancer, the incidence of postoperative ileus is reportedly higher for the right-side than for the left-side colon, but those studies included small numbers of subjects and contained several biases. Furthermore, risk factors for postoperative ileus remain unclear.

METHODS

This multicenter study reviewed 1986 patients who underwent laparoscopic colectomy between 2016 and 2021 for right-side (n = 907) and left-side (n = 1079) colon cancer. After propensity score matching, 803 patients in each group were matched.

RESULTS

Postoperative ileus occurred in 97 patients. Before matching, the proportion of female patients and median age were higher and frequency of preoperative stent insertion was lower with right colectomy (P < .001 each). After matching, the number of retrieved lymph nodes (17 vs 15, P < .001) and greater rates of undifferentiated adenocarcinoma (10.6% vs 5.1%, P < .001) and postoperative ileus (6.4% vs 3.2%, P = .004) were higher in right colectomy. Multivariate analysis revealed male gender (hazard ratio, 1.798; 95% confidence interval, 1.049-3.082; P = .32) and history of abdominal surgery (hazard ratio, 1.909; 95% confidence interval, 1.073-3.395; P = .027) as independent predictors of postoperative ileus in right-side colon cancer.

CONCLUSION

This study revealed a higher risk of postoperative ileus after right colectomy with laparoscopic surgery. Male gender and history of abdominal surgery were risk factors for postoperative ileus after right colectomy.

Intracorporeal Anastomosis and ERAS Program: The Winning Combination of Optimized Postoperative Outcomes After Laparoscopic Right Colectomy

BACKGROUND

Laparoscopic technique and the enhanced recovery after surgery (ERAS) protocol have become the standard of care in patients undergoing right colon cancer surgery, reducing hospital stay and postoperative morbidity. However, the optimal anastomosis technique [intracorporeal anastomosis (ICA) or extracorporeal anastomosis (ECA)] remains debated. This study aimed to determine the optimal perioperative approach (ICA vs. ECA combined with the ERAS program vs. standard care) for patients undergoing laparoscopic right colectomy for cancer.

MATERIALS AND METHODS

This single-center, retrospective study evaluated all consecutive patients who underwent laparoscopic right hemicolectomy for cancer between January 2012 and June 2021. Patient data were analyzed in 4 treatment groups according to the type of anastomosis and the care protocol. The primary endpoint was total postoperative hospital stay (THS). The secondary endpoints were recovery time and overall morbidity rate.

RESULTS

The baseline characteristics of the 373 included patients were comparable between the 4 groups. THS was significantly shorter in the ICA/ERAS group than in the ECA/standard and ICA/standard groups ( P <0.01), but there was no significant difference between the ICA/ERAS and ECA/ERAS groups (5.7 vs. 6.4 d; P =0.17). Recovery time was significantly shorter in the ICA/ERAS group ( P <0.01). The overall morbidity rate, including anastomotic morbidity, was comparable among the 4 groups. Regression analysis showed that ICA and the ERAS program were both predictive factors to reduce the THS and recovery time.

CONCLUSIONS

ICA combined with the ERAS program achieves the best outcomes and thus seems to be the optimal approach for the management of patients undergoing laparoscopic right colectomy for cancer.

Implementation of totally robotic right hemicolectomy: lessons learned from a prospective cohort

Robotics facilitates the realization of intra-corporeal anastomosis during right hemicolectomy and allows extracting the operative specimen through a C-section, offering potential benefits in terms of post-operative recovery and incidence of incisional hernia. Therefore, we progressively implemented robotic right hemicolectomy (robRHC) in our centre, and would like to report our initial experience with the technique. Consecutive patients who underwent robRHC within a single centre were prospectively included. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected. Sixty patients underwent robRHC in our centre. Indications for robRHC were colon cancer in 58 patients (96.7%) and polyps not amenable to endoscopic resection in 2 patients (3.3%). Fifty-eight patients underwent robRHC with D2 lymphadenectomy and central vessel ligation (96.7%), and two patients (3.3%) had robRHC associated with another procedure. All patients had intra-corporeal anastomosis. The mean ± operative time was of 200.4 ± 114.9 min. Two conversions (3.3%) to open surgery were performed. The mean ± SD length of stay was of 5.4 ± 3.8 days. Seven patients (11.7%) experienced a post-operative complication with a Clavien-Dindo score ≥ 2. Two patients (3.5%) had an anastomotic leak. The mean ± SD number of harvested lymph nodes was of 22.4 ± 7.6. All patients had negative pathological margins (R0 resection). To conclude, robotic RHC is a safe procedure, which can be implemented with satisfying peri- and post-operative outcomes. The potential benefits of the technique remain to be demonstrated by randomized controlled trials.

Laparoscopic vs. open loop ileostomy reversal: a meta-analysis of randomized and non-randomized studies

PURPOSE

The present meta-analysis compares laparoscopic loop ileostomy reversal (LLIR) with open loop ileostomy reversal (OLIR) to evaluate the advantages of the laparoscopic technique compared to the traditional open technique in ileostomy reversal.

METHODS

Primary endpoints were hospital stay and overall complications. Secondary endpoints were operative time, EBL, readmission, medical complications, surgical complications, reoperation, wound infection, anastomotic leak, intestinal obstruction, and cost of the procedures. The included studies were also divided based on the type of anastomotic approach: extracorporeal laparoscopic loop ileostomy reversal (ELLIR) and intracorporeal laparoscopic loop ileostomy reversal (ILLIR).

RESULTS

In the analysis, 4 studies were included. Three hundred fifty-four patients were enrolled. As primary outcomes, a significant difference was found in hospital stay between the LLIR and OLIR groups (MD = -0.67, 95% CI -1.16 to -0.19, P = 0.007). The overall complications outcome resulted in favor of the LLIR group (RR = 0.64, 95% CI 0.43-0.95, P = 0.03). As secondary outcomes, the operative time was in favor of the OLIR group (MD = 19.18, 95% CI 10.20-28.16, P < 0.001). Surgical complications were lower in the LLIR group than in the OLIR group. No other differences between the secondary endpoints were found. Subgroup analysis showed a significant difference in hospital stay between the ILLIR and OLIR groups (MD = -0.92, 95% CI -1.55 to -0.30, P = 0.004). The overall complications outcome significantly favored the ILLIR group (RR = 0.38, 95% CI 0.15-0.96, P = 0.04).

CONCLUSION

Our meta-analysis shows an advantage in terms of shorter post-operative hospitalization and reduction of complications of LLIR compared to OLIR. The sub-group analysis shows that performing an extracorporeal anastomosis exposes the same risks of the open technique.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a retrospective study

BACKGROUND

The surgical procedure for laparoscopic right colectomy (LRC) is not standardized. Some published studies show the superiority of ileocolic anastomosis (IIA), but the evidence so far is insufficient. This study aimed to investigate the potential advantages in postoperative recovery and safety of IIA in LRC.

METHODS

A total of 114 patients who underwent LRC with IIA (n = 58) or extracorporeal ileocolic anastomosis (EIA, n = 56) between January 2019 and September 2021 were enrolled. We collected certain factors as clinical features, intraoperative characteristics, oncological outcomes, postoperative recovery, and short-term outcomes. Our primary outcome was time to gastrointestinal (GI) function recovery. Secondary outcomes were postoperative complications within 30 days, postoperative pain, and length of hospital stay.

RESULTS

Faster GI recovery and less postoperative pain were observed in patients with IIA compared to EIA [time to first flatus: (2.4 ± 0.7) vs (2.8 ± 1.0) days, p < 0.01; time to liquid intake: (3.5 ± 0.7) vs (4.0 ± 1.1) days, p = 0.01; postoperative visual analogue scale score: (3.9 ± 1.0) vs (4.3 ± 0.6), p = 0.02]. No significant differences were detected in oncological outcomes or postoperative complications. IIA, rather than EIA, tended to be performed in patients with higher body mass index [(23.93 ± 3.52) vs (22.36 ± 2.87) kg/m², p = 0.01].

CONCLUSIONS

IIA is associated with faster GI function recovery and less postoperative pain and may be more favorable for obese patients.

Effect of intracorporeal anastomosis on postoperative ileus after laparoscopic right colectomy

PURPOSE

Laparoscopic right colectomy (LRC) with extracorporeal anastomosis (ECA) remains the most widely adopted technique despite mounting evidence that intracorporeal anastomosis (ICA) offers several advantages. This study aimed to compare the postoperative outcomes of ICA and ECA and to investigate the effect of ICA on postoperative ileus after LRC.

METHODS

This retrospective study included 45 patients who underwent ICA and 63 who underwent ECA in LRC for right-sided colonic diseases between January 2015 and December 2019.

RESULTS

There were no significant differences in total operation time, blood loss, total length of incisions, tolerance of diet, postoperative pain score on postoperative days 1 and 2, or length of hospital stays between the 2 groups. However, the ICA group had a significantly shorter time to first flatus passage (3.0 ± 0.9 days vs. 3.8 ± 1.9 days, P = 0.013). The rate of postoperative ileus was significantly higher in the ECA group (2.2% vs. 14.3%, P = 0.033); however, there was no significant difference in the overall morbidity within 30 days after surgery. Multivariate logistic regression analysis showed that the ECA technique (odds ratio [OR], 0.098; 95% confidence interval [CI]; 0.011-0.883, P = 0.038) and previous abdominal operation (OR, 5.269; 95% CI, 1.193-23.262; P = 0.028) were independent risk factors for postoperative ileus.

CONCLUSION

The postoperative outcomes of patients who underwent LRC with ICA or ECA were comparable, and ICA could reduce the incidence of postoperative ileus after LRC compared with ECA.

Mid-term outcomes of intracorporeal versus extracorporeal anastomosis after laparoscopic colectomy: a propensity score-matched cohort study from a single institution

PURPOSE

There is still insufficient discussion of the mid- to long-term safety of the intracorporeal anastomosis (IA) method of reconstruction after laparoscopic colectomy (LAC) for colon cancer. The present study clarified the postoperative mid-term results of IA based on recurrence and the incidence of incision hernia.

METHODS

This single-institution observational retrospective study included 268 patients with colon cancer who underwent IA or extracorporeal anastomosis (EA) after LAC at our institution between 2018 and 2021. The mid-term results of the IA group were compared with those of the EA group using a propensity score matching method.

RESULTS

The median follow-up periods were 36 and 25 months in the EA and IA groups, respectively (p < 0.0001). In this matched cohort study, the recurrence-free survival (RFS) rates were comparable between the IA and EA groups (each group, n = 72; 3-year RFS: IA, 92.1%; EA, 88.2%; hazard ratio, 0.78; 95% confidence interval, 0.25-2.40; p = 0.66). The cumulative incisional hernia rates were 9.8% and 9.9% (p = 0.99) for the IA and EA groups, respectively.

CONCLUSION

The safety of IA after LAC was demonstrated in this study, as IA after LAC showed good mid-term results, including with regard to the rates of recurrence and incisional hernia.

Intraoperative and postoperative short-term outcomes of intracorporeal anastomosis versus extracorporeal anastomosis in laparoscopic right hemicolectomy

Background

Intracorporeal anastomosis (IA) is a difficult but popular anastomotic approach for reconstruction of digestive tract after laparoscopic right hemicolectomy, which may reduce some limitations faced during extracorporeal anastomosis (EA).

Methods

A retrospective review of 78 patients who underwent laparoscopic right hemicolectomy by a veteran surgeon in a high-volume public tertiary hospital, including 50 patients with IA and 28 patients with EA. The intraoperative-related factors and short-term results of the two anastomotic approaches were compared.

Results

There was no significant difference in demographics and clinical characteristics between the two groups (P>0.05). The intraoperative blood loss was less (P=0.010) and the incision length was shorter (P<0.001) in the intracorporeal group. Postoperative farting time was faster (P=0.005) and postoperative pain score (VAS) was lower (P<0.001) in IA group. Although the anastomotic time of IA was shorter (P<0.001), the operative time of the two groups were similar. And number of lymph nodes harvested, NLR from POD₁ to POD₃, postoperative hospital stay and overall hospital stay between the two groups were comparable. Except for significant difference in abdominal infection rate, the Clavien-Dindo classification and the incidence of other postoperative complications were not statistically different. Moreover, the morbidity of abdominal infection decreased with time in the IA group (P=0.040).

Conclusion

IA is a reliable and feasible procedure, which has faster anastomotic time, earlier return of bowel function and superior postoperative comfort of patient, compared to EA. The postoperative complication rate of IA is similar to that of EA, and may be improved with the IA technical maturity of surgeons, which potentially contributes to the development of ERAS.

The effect of intracorporeal versus extracorporeal anastomosis in robotic right colectomy on perianastomotic perfusion: a substudy to a multicenter RCT

PURPOSE

Previous studies have shown that intracorporeal anastomosis (ICA) in minimally invasive right colectomy may improve postoperative recovery compared with extracorporeal anastomosis (ECA). It has been hypothesized that creating the anastomosis extracorporeally may cause mesenteric traction and compromised intestinal perfusion. The purpose of this study was to investigate the effect of either ICA or ECA on intestinal perfusion.

METHOD

This was a substudy to a multicenter, triple-blind randomized clinical trial comparing ICA with ECA in patients undergoing robotic right colectomy for colonic cancer. Videos from intraoperative Indocyanine Green (ICG) fluorescence imaging were analyzed with quantitative ICG perfusion assessment (q-ICG). q-ICG was performed by extracting perfusion metrics from a time-intensity curve generated from an image analysis software: F_MAX: maximal fluorescence intensity, T_MAX: time until maximal fluorescent signal, T_1/2MAX: time until half-maximal fluorescent signal, time ratio (T_1/2MAX/T_MAX) and slope.

RESULTS

A total of 68 patients (33 ICA and 35 ECA) were available for analysis. Demographics were similar between the groups, except for mean arterial blood pressure at the time of ICG infusion, which was significantly lower in the ICA group. We found a significantly steeper slope in the ICA group compared to the ECA group (6.3 vs. 4.7 AU/sec, P = .048). There were no significant differences in F_MAX, T_MAX, T_1/2MAX, and time ratio.

CONCLUSION

We found evidence of an improved intestinal perfusion following ICA compared with ECA. This finding may be related to patient outcomes and should be explored further in the future.

TRIAL REGISTRATION

CLINICALTRIALS

gov NCT03130166.

Extracorporeal versus intracorporeal anastomosis for right colon cancer surgery

Laparoscopic right colectomy is currently considered the standard treatment for right colon cancer. After excision of the right colon, minimally invasive options for ileocolonic anastomosis include extracorporeal anastomosis (EA) and intracorporeal anastomosis (IA). However, the choice of anastomotic technique remains debated. As the entire IA is performed in the abdominal cavity, it is known for its advantages of a faster intestinal recovery and small incision. However, IA is time-consuming and technically difficult, limiting its widespread use. Recently, the robotic approach has increased the adoption of intracorporeal anastomotic techniques owing to the benefits of endowrist-articulated instruments and staplers. Except for a small incision and faster bowel recovery, the outcomes of the two anastomoses methods are inconsistent. To date, there has been no clear conclusion regarding whether IA or EA should be used to treat right colon cancer. This review aimed to investigate the current evidence relating to intraoperative outcomes and short-term postoperative results between both anastomotic approaches.

A multicentre, prospective cohort study of handsewn versus stapled intracorporeal anastomosis for robotic hemicolectomy

AIM

Robotic right hemicolectomy is gaining in popularity due to the recognized technical benefits associated with the robotic platform. However, there is a lack of standardization regarding the optimal anastomotic technique in this cohort of patients, namely stapled or handsewn intra- or extra-corporeal anastomosis. The ergonomic benefit associated with the robotic platform lends itself to intracorporeal anastomosis (ICA). The aim of this study was to compare the short-term clinical outcomes of stapled versus handsewn ICA.

METHOD

A multicentre prospective cohort study was undertaken across four high-volume robotic centres in France between September 2018 and December 2020. All adult patients undergoing an elective robotic right hemicolectomy with an ICA performed and a minimum postoperative follow-up of 30 days were included. The primary endpoint of our study was anastomotic leak within 30 days postoperatively.

RESULTS

A total of 144 patients underwent robotic right hemicolectomy: 92 (63.8%) had a stapled ICA and 52 (36.1%) a handsewn ICA. The operative indication was adenocarcinoma in 90% with a stapled ICA compared with 62% in the handsewn ICA group (p < 0.001). The overall operating time was longer in the handsewn ICA group compared with the stapled ICA group (219 min vs. 193 min; p = 0.001). The anastomotic leak rate was 3.3% in stapled ICA and 3.8% in handsewn ICA (p = 1.00). There was no difference in the rate or severity of postoperative morbidity.

CONCLUSION

ICA robotic hemicolectomy is technically safe and is associated with low rates of anastomotic leak overall and equivalent clinical outcomes between the two techniques.

Bowel recovery after intra- vs extra-corporeal anastomosis for oncologic laparoscopic right hemicolectomy within an ERAS protocol: a retrospective study

OBJECTIVE

Restoring bowel continuity after laparoscopic right hemicolectomy with an intra-corporeal (IC) rather than an extra-corporeal (EC) ileocolic anastomosis may offer advantages in post-operative recovery. The aim of this study was to compare bowel function recovery between these two techniques, in a context of complete mesocolic excision within an enhanced recovery after surgery (ERAS) protocol.

METHODS

All consecutive patients who underwent oncologic laparoscopic right hemicolectomy from January 2012 to February 2021 in our institution were included in the study. Data were gathered from the prospectively maintained official ERAS (EIAS) database and completed through our institution's electronic health records. The primary endpoint was prolonged post-operative ileus (PPOI), defined as the need to insert a nasogastric tube, or refractory nausea VAS > 4, on or after the third post-operative day. Secondary endpoints were post-operative pain, morbidity and length of hospital stay (LoS). Groups were compared before and after propensity score matching based on age, gender, ASA score, use of epidural analgesia and post-operative complications.

RESULTS

A total of 108 patients met the inclusion criteria, 36 (30%) had IC and 72 (70%) EC anastomosis. In the unmatched population, baseline characteristics were similar except for more frequent use of epidural analgesia in the EC group (62 (72.9%) vs. 17 (47.2), p = 0.007). PSM analysis was carried out. Operative time was longer in the IC group (197 min (176-223) vs. 160 (140-189), p < 0.001). The rate of PPOI was similar (2 (5.6%) patients in the IC group vs. 10 (11.6%) in the EC group (p = 0.306)), but time to frist passage of flatus and stool was shorter in the IC group. There was no difference in morbidity but patients after IC anastomosis had lower pain VAS scores at 24 h (p = 0.004) and a trend for a shorter LoS (6 (5-8) days vs 7 (5-10) in the EC group, p = 0.054). After PSM, there were 36 patients in each group. PPOI, time to first flatus and stool, morbidity and LoS were not significantly different although there was a trend for better recovery outcomes in the IC group. Patients in the IC group had significantly longer operative times but less pain at 24 h.

CONCLUSIONS

Although IC anastomosis was not significantly associated to lower rates of PPOI, it showed trends of faster recovery and significantly less post-operative pain at the expense of longer operating times.

Short-term outcomes of intracorporeal versus extracorporeal anastomosis after laparoscopic colectomy: a propensity score-matched cohort study from a single institution

PURPOSE

To compare the postoperative short-term results of intracorporeal anastomosis (IA) using overlap anastomosis (OLA), with those of extracorporeal anastomosis (EA) using functional end-to-end anastomosis (FEEA) or hand-sewn anastomosis (HSA), after laparoscopic colectomy (LAC).

METHODS

The subjects of this retrospective study were 208 patients with colon cancer who underwent OLA, FEEA, or HSA after LAC at our institution, between 2018 and 2021. The short-term results of the OLA group were compared with those of the FEEA and HSA groups, respectively, using a propensity score-matching method.

RESULTS

The mean operative time for anastomosis was longer in the OLA group than in the FEEA and HSA groups (p < 0.0001). The mean blood loss volume was less in the OLA group than in the FEEA and HSA groups (p = 0.0344 and p = 0.0002, respectively). The mean skin incision size was smaller in the OLA group than in the FEEA and HSA groups (p < 0.0001 and p = 0.0031, respectively). None of the patients in the OLA group had surgical site infections. Three to five patients were required for the surgeon to plateau on the learning curve.

CONCLUSION

Although IA required more time than EA, the skills appeared to improve with experience and the short-term results were superior to those of EA.

Robotic versus laparoscopic right colectomy for colon cancer: a nationwide cohort study

PURPOSE

On a national level, the minimally invasive approach is widely adopted in Denmark. The adoption of robotic colorectal surgery is increasing; however, the advantage of a robotic approach in right colectomy is still uncertain. The purpose of this study was to compare robotic right colectomy with laparoscopic right colectomy on a national level.

METHODS

This was a nationwide database study based on data from the Danish Colorectal Cancer Group database. Patients from all colorectal centers in Denmark in the period 2014-2018 treated with curative intend in an elective setting with either robotic or laparoscopic right colectomy were identified. Propensity score matching was performed to adjust for confounding, and the groups were compared on demographics, disease characteristics, operative data, and postoperative and pathology outcomes. Reporting was done in accordance with the STROBE statement.

RESULTS

In total, 4002 patients were available for analysis. Propensity score matching in ratio 2:1 identified 718 laparoscopic and 359 robotic cases. After matching, we found a higher lymph node yield in the robotic group compared to the laparoscopic group, (32.5 vs. 28.4, P < 0.001), while radicality, plane of dissection, and pathological disease stages showed no differences. There were no statistical differences in morbidity and mortality. Intracorporeal anastomosis (23.7% vs. 4.5%, P < 0.001) was more commonly performed with a robotic approach.

CONCLUSIONS

Robotic approach was associated with a significant higher lymph node yield and with similar postoperative morbidity compared to a laparoscopic approach for right colectomy.