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Sarno G, Simancas-Racines D, Gargiulo A, Tedesco A, Iacone B, Reytor-González C, Parise-Vasco JM, Iguago JA, Sarno S, Frias-Toral E, Bracale U. Impact of obesity on postoperative complications in colorectal cancer surgery: A systematic review and meta-analysis. Semin Cancer Biol 2025; 113:176-189. [PMID: 40412491 DOI: 10.1016/j.semcancer.2025.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2025] [Revised: 04/30/2025] [Accepted: 05/21/2025] [Indexed: 05/27/2025]
Abstract
BACKGROUND Obesity has been increasingly recognized as a factor that influences postoperative outcomes in colorectal cancer surgery. However, its impact on surgical complications, mortality, and oncological outcomes remains controversial. This systematic review and meta-analysis aimed to evaluate the association between obesity and postoperative complications in colorectal cancer surgery. METHODS A comprehensive search was conducted in MEDLINE/PubMed, Scopus, and Embase, including studies evaluating body mass index (BMI) in relation to postoperative complications such as infections, anastomotic leakage, postoperative ileus, bleeding, reoperation, and mortality. Data synthesis involved a qualitative analysis of all eligible studies and a meta-analysis when applicable. The quality of the studies included was assessed using the Newcastle-Ottawa Scale, while the certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS Twenty-nine studies were included in the qualitative analysis and 17 were eligible for the meta-analysis. Compared to BMI < 30 kg/m², patients with BMI ≥ 30 kg/m² showed significantly higher risk of any type of surgical site infection (OR=1.49; 95 % CI: 1.37-1.70; low certainty). No significant differences were found in mortality (OR=1.23; 95 % CI: 0.72-2.11; very low certainty), hemorrhage (OR=1.05; 95 % CI: 0.97-1.14; very low certainty), or gastrointestinal complications (OR=1.10; 95 % CI: 0.96-1.26; very low certainty). CONCLUSION Obesity significantly increases the risk of surgical site infections in colorectal cancer surgery. Although its impact on mortality and gastrointestinal complications remains unclear, implementing preoperative optimization protocols specifically aimed at obesity management could mitigate these surgical risks. The certainty of evidence ranges from low to very low, highlighting the need for high-quality prospective studies with standardized BMI criteria and surgical protocols.
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Affiliation(s)
- Gerardo Sarno
- General Surgery and Kidney Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, Salerno 84131, Italy; General and Emergency Surgery Unit, Department of Medicine, Surgery and Dentistry, "Salerno Medical School", San Giovanni di Dio e Ruggi d'Aragona University Hospital, Scuola Medica Salernitana, University of Salerno, Faculty of Medicine and Surgery, Campus di Baronissi (SA), "Gaetano Fucito" Facility, Mercato San Severino, Salerno, SA, Italy.
| | - Daniel Simancas-Racines
- Universidad UTE, Facultad de Ciencias de la Salud Eugenio Espejo, Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC), Quito 170527, Ecuador
| | - Antonio Gargiulo
- General and Emergency Surgery Unit, Department of Medicine, Surgery and Dentistry, "Salerno Medical School", San Giovanni di Dio e Ruggi d'Aragona University Hospital, Scuola Medica Salernitana, University of Salerno, Faculty of Medicine and Surgery, Campus di Baronissi (SA), "Gaetano Fucito" Facility, Mercato San Severino, Salerno, SA, Italy
| | - Anna Tedesco
- General and Emergency Surgery Unit, Department of Medicine, Surgery and Dentistry, "Salerno Medical School", San Giovanni di Dio e Ruggi d'Aragona University Hospital, Scuola Medica Salernitana, University of Salerno, Faculty of Medicine and Surgery, Campus di Baronissi (SA), "Gaetano Fucito" Facility, Mercato San Severino, Salerno, SA, Italy
| | - Biancamaria Iacone
- General and Emergency Surgery Unit, Department of Medicine, Surgery and Dentistry, "Salerno Medical School", San Giovanni di Dio e Ruggi d'Aragona University Hospital, Scuola Medica Salernitana, University of Salerno, Faculty of Medicine and Surgery, Campus di Baronissi (SA), "Gaetano Fucito" Facility, Mercato San Severino, Salerno, SA, Italy
| | - Claudia Reytor-González
- Universidad UTE, Facultad de Ciencias de la Salud Eugenio Espejo, Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC), Quito 170527, Ecuador
| | - Juan Marcos Parise-Vasco
- Universidad UTE, Facultad de Ciencias de la Salud Eugenio Espejo, Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC), Quito 170527, Ecuador
| | - Jaime Angamarca Iguago
- Universidad UTE, Facultad de Ciencias de la Salud Eugenio Espejo, Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC), Quito 170527, Ecuador
| | - Sabrina Sarno
- Operating Unit of Oncological Hematology, Corp-S Department of Research and Assistance of Onco-Hematology, Mesenchymal and Musculoskeletal Neoplasms of the Adult and Innovative Diagnostics. IRCCS National Cancer Institute "G. Pascale", Italy
| | - Evelyn Frias-Toral
- Universidad Espíritu Santo, Escuela de Medicina, Samborondón 0901952, Ecuador; Division of Research, Texas State University, 601 University Dr, San Marcos, TX 78666, United States
| | - Umberto Bracale
- General and Emergency Surgery Unit, Department of Medicine, Surgery and Dentistry, "Salerno Medical School", San Giovanni di Dio e Ruggi d'Aragona University Hospital, Scuola Medica Salernitana, University of Salerno, Faculty of Medicine and Surgery, Campus di Baronissi (SA), "Gaetano Fucito" Facility, Mercato San Severino, Salerno, SA, Italy
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Wong C, Beaumont M, Klassen T, McCavour A, Rendon R, Shayegan B. The far-reaching impact of robotic-assisted surgery on healthcare systems. Healthc Manage Forum 2025; 38:156-165. [PMID: 40268877 DOI: 10.1177/08404704251327561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2025]
Abstract
The use of Robotic-Assisted Surgery (RAS) in Canada continues to grow and evolve, demonstrating improvements in patient and clinical outcomes across a wide range of surgical procedures. Global studies show how implementing a RAS program can also increase hospital capacity, drive benefits in health human resources, and improve overall health system efficiency. Despite the evidence of these positive results, Canada lags behind other developed nations in adopting RAS. Drawing on the experience of surgeons and health leaders from across Canada, this article focuses on the benefits of adopting RAS and discusses the challenges organizations face in successfully funding and implementing RAS programs. This includes the innovative approaches health leaders are taking to support equitable access to RAS for patients and offers evidence-informed strategies that can help unlock the full potential of RAS-beyond the operating room-to improve overall quality of care and the sustainability of the Canadian healthcare system.
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Affiliation(s)
- Connie Wong
- Intuitive Surgical Canada, Halifax, Nova Scotia, Canada
| | - Martin Beaumont
- Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, Canada
- Université de Montréal, Montreal, Quebec, Canada
| | | | - Amy McCavour
- Horizon Health Network, Fredericton, New Brunswick, Canada
| | - Ricardo Rendon
- Queen Elizabeth II Hospital, Halifax, Nova Scotia, Canada
- Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Canadian Urological Association, Dorval, Quebec, Canada
- Canadian UroOncology Group, Toronto, Ontario, Canada
| | - Bobby Shayegan
- Canadian Urological Association, Dorval, Quebec, Canada
- Canadian UroOncology Group, Toronto, Ontario, Canada
- St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- McMaster Institute of Urology, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
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3
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Gahunia S, Wyatt J, Powell SG, Mahdi S, Ahmed S, Altaf K. Robotic-assisted versus laparoscopic surgery for colorectal cancer in high-risk patients: a systematic review and meta-analysis. Tech Coloproctol 2025; 29:98. [PMID: 40198499 PMCID: PMC11978707 DOI: 10.1007/s10151-025-03141-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Accepted: 03/08/2025] [Indexed: 04/10/2025]
Abstract
BACKGROUND Evidence of superiority of robotic-assisted surgery for colorectal resections remains limited. This systematic review and meta-analysis aims to compare robotic-assisted and laparoscopic surgical techniques in high-risk patients undergoing resections for colorectal cancer. METHODS Systematic searches were performed using Pubmed, Embase and Cochrane library databases from inception until December 2024. Randomised and non-randomised studies reporting outcomes of robotic-assisted or laparoscopic resections in the following high-risk categories were included: obesity, male gender, the elderly, low rectal cancer, neoadjuvant chemoradiotherapy and previous abdominal surgery. Comparative meta-analyses for all sufficiently reported outcomes were completed. Risk of bias was assessed using the ROBINS-I and RoB 2 tools for non-randomised and randomised studies, respectively. RESULTS 48 studies, including a total of 34,846 patients were eligible for inclusion and 32 studies were utilised in the comparative meta-analyses. Conversion to open rates were significantly lower for robotic-assisted surgery in patients with obesity, male patients and patients with low rectal tumours (obese OR 0.41 [CI 0.32-0.51], p < 0.00001); male gender (OR 0.28 [CI 0.22-0.34], p < 0.00001); low tumours OR 0.10 [CI 0.02-0.58], p = 0.01). Length of stay was significantly reduced for robotic-assisted surgery in patients with obesity (SMD 0.25 [CI - 0.41 to - 0.09], p = 0.002). Operative time was significantly longer in all subgroups (obesity SMD 0.57 [CI 0.31-0.83], p < 0.0001; male gender SMD 0.77 [CI 0.17-1.37], p = 0.01; elderly SMD 0.50 [CI 0.18-0.83], p = 0.002; low rectal tumours SMD 0.48 [CI 0.12-0.84], p = 0.008; neoadjuvant chemoradiotherapy SMD 0.72 [CI 0.34-1.09], p = 0.0002; previous surgery SMD 1.55 [CI 0.05-3.06], p = 0.04). When calculable, blood loss, length of stay, complication rate and lymph node yield were comparable in all subgroups. CONCLUSIONS This review provides further evidence of non-inferiority of robotic-assisted surgery for colorectal cancer and demonstrates conversion rates are superior in specific, technically challenging operations.
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Affiliation(s)
- S Gahunia
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK.
| | - J Wyatt
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L1 8JX, UK
| | - S G Powell
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L1 8JX, UK
| | - S Mahdi
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
| | - S Ahmed
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
| | - K Altaf
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
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McKechnie T, Khamar J, Chu C, Hatamnejad A, Jessani G, Lee Y, Doumouras A, Amin N, Hong D, Eskicioglu C. Robotic versus laparoscopic colorectal surgery for patients with obesity: an updated systematic review and meta-analysis. ANZ J Surg 2025; 95:675-689. [PMID: 39876627 PMCID: PMC11982662 DOI: 10.1111/ans.19319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Revised: 11/06/2024] [Accepted: 11/08/2024] [Indexed: 01/30/2025]
Abstract
BACKGROUND Obesity poses significant challenges in colorectal surgery, affecting operative difficulty and postoperative recovery. The choice of minimally invasive approach for this patient population remains a challenge during preoperative planning. This review aims to provide an updated synthesis of studies comparing laparoscopic and robotic approaches for adult patients with obesity undergoing colorectal surgery. METHODS MEDLINE, Embase and CENTRAL were searched up to August 2023. Articles were included if they compared laparoscopic and robotic colorectal surgery outcomes in adults with obesity (BMI ≥30 kg/m2). Outcomes included overall postoperative morbidity, conversion to laparotomy, and operative time. Inverse variance random-effects meta-analyses were used to pool effect estimates. RESULTS After screening 2187 citations, 10 observational studies were included with 3281 patients with obesity undergoing robotic surgery (mean age: 58.1 years, female: 43.9%) and 11 369 patients with obesity undergoing laparoscopic surgery (mean age: 58 years, female: 53.2%). Robotic surgery resulted in longer operative times (MD 46.71 min, 95% CI 33.50-59.92, p < 0.01, I2 = 93.79%) with statistically significant reductions in conversions to laparotomy (RR 0.50, 95% CI 0.39-0.65, p < 0.01, I2 = 67.15%). No significant differences were seen in postoperative morbidity (RR 0.94, 95% CI 0.82-1.08, p = 0.40, I2 = 36.08%). CONCLUSION These data suggest that robotic colorectal surgery in patients with obesity may reduce the risk for conversion to laparotomy, but at the expense of increased operative times and with no overt benefits in postoperative outcomes. Further high quality randomized controlled trials assessing the utility of robotic surgery in patients with obesity undergoing colorectal surgery are warranted.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Jigish Khamar
- Division of General Surgery, Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
| | - Christopher Chu
- Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Amin Hatamnejad
- Division of Ophthalmology, Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
| | - Ghazal Jessani
- Department of Family MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Yung Lee
- Division of General Surgery, Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
- Harvard T.H. Chan School of Public HealthHarvard UniversityBostonMassachusettsUSA
| | - Aristithes Doumouras
- Division of General Surgery, Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
- Division of General Surgery, Department of SurgerySt. Joseph's HealthcareHamiltonOntarioCanada
| | - Nalin Amin
- Division of General Surgery, Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
- Division of General Surgery, Department of SurgerySt. Joseph's HealthcareHamiltonOntarioCanada
| | - Dennis Hong
- Division of General Surgery, Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
- Division of General Surgery, Department of SurgerySt. Joseph's HealthcareHamiltonOntarioCanada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
- Division of General Surgery, Department of SurgerySt. Joseph's HealthcareHamiltonOntarioCanada
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Ingham AR, McSorley ST, McMillan DC, Mansouri D, Chong D, MacKay GJ, Wrobel A, Kong CY, Alani A, Nicholson G, Roxburgh CSD. Does robotic assisted surgery mitigate obesity related systemic inflammatory response and clinical outcomes in left sided colorectal cancer resections? J Robot Surg 2025; 19:98. [PMID: 40042780 PMCID: PMC11882609 DOI: 10.1007/s11701-025-02261-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Accepted: 02/23/2025] [Indexed: 03/09/2025]
Abstract
Obesity (BMI > 30 kg/m2) is rapidly increasing worldwide with 26% of the UK population being obese and 38% being overweight. Obesity is intimately related to several life-limiting conditions including colorectal cancer (CRC). Obese patients have a higher degree of perioperative systemic inflammatory response (SIR) and an increased risk of perioperative complications. The aim of this current study was to investigate whether robotic-assisted surgery mitigates the effects of obesity in left sided CRC resections on the SIR and clinical outcomes. All patients undergoing left-sided colorectal cancer resections from May 2021 to May 2023 were, prospectively, entered into a database with patient characteristics and perioperative short-term outcomes recorded. CRP was considered a surrogate for SIR. The relationship between obesity and complications were examined using Chi Square for linear association, Kruskal-Wallis for continuous data and multivariate binary logistic regression model. 221 patients who underwent RAS for left-sided CRC were analysed. Obesity was associated with more comorbidity (ASA, p < 0.01) and SSI (p < 0.05) but not with age, sex, procedure or pathology. POD3 CRP < 150 mg/l was also associated with obesity (p < 0.01). In turn, greater comorbidity was associated with age (p < 0.001), site of resection (p < 0.05), SSI (p < 0.05), postoperative blood transfusion (p < 0.01) and LOS (p < 0.001). On multivariate analysis, only greater ASA (p < 0.05) and surgical procedure (p < 0.01) were associated with the development of an SSI independently. Greater comorbidity but not obesity was independently associated with postoperative SIR and clinical outcomes in patients undergoing RAS. These results support the use of RAS for left sided CRC resections, particularly in the obese.
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Affiliation(s)
- Abigail R Ingham
- Academic Unit of Surgery and School of Cancer Sciences, Glasgow, Scotland.
| | - Stephen T McSorley
- Academic Unit of Surgery and School of Cancer Sciences, Glasgow, Scotland
| | - Donald C McMillan
- Academic Unit of Surgery and School of Cancer Sciences, Glasgow, Scotland
| | - David Mansouri
- Academic Unit of Surgery and School of Cancer Sciences, Glasgow, Scotland
| | - David Chong
- Academic Unit of Surgery and School of Cancer Sciences, Glasgow, Scotland
| | - Graham J MacKay
- Academic Unit of Surgery and School of Cancer Sciences, Glasgow, Scotland
| | - Aleksandra Wrobel
- Academic Unit of Surgery and School of Cancer Sciences, Glasgow, Scotland
| | - Chia Yew Kong
- Academic Unit of Surgery and School of Cancer Sciences, Glasgow, Scotland
| | - Ahmed Alani
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, Scotland
| | - Gary Nicholson
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, Scotland
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Vitiello A, Berardi G, Calabrese P, Spagnuolo M, Calenda F, Salzillo G, Peltrini R, Pilone V. Retrospective matched case-control comparison of Totally Robotic Sleeve Gastrectomy (RSG) during the learning curve with Laparoscopic Sleeve Gastrectomy (LSG): why is operative time different? Updates Surg 2025:10.1007/s13304-025-02087-3. [PMID: 39812955 DOI: 10.1007/s13304-025-02087-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2024] [Accepted: 01/07/2025] [Indexed: 01/16/2025]
Abstract
Robotic approach is slowly rising in metabolic surgery, and laparoscopy is still considered the gold standard for Sleeve Gastrectomy. Aim of our study was to assess and compare outcomes of RSG through a matched comparison with LSG. Retrospective search of prospectively maintained database of our surgical department was carried out find all consecutive patients who underwent RSG from April 2023 to August 2024. Each subject who underwent RSG was matched one-to-one with a patient treated with LSG in the same period. Operative time (docking + console time for the robotic procedures), length of stay, need for rescue drugs, and perioperative complications were recorded calculated and compared. A total number of 50 patients (25 RSG and 25 LSG) were included in the present analysis. Operative time in the LSG group was significantly shorter than in the RSG group (57.8 ± 12.3 VS 80.6 ± 16.6 min, p < 0.01), but it was comparable to console time (57.8 ± 12.3 VS 56.9 ± 19.6, p = 0.85). Mean docking time was 23.7 ± 11 min. Length of stay, readmissions, conversion to laparoscopy/open surgery, early complications, and rescue drugs administration were comparable between the two groups. Age, sex, and BMI were not good predictors neither of laparoscopic nor robotic operative time. RSG during the learning curve proved as safe as LSG, but it was associated with longer operative time due to the duration of the docking step. Operation length may become comparable once the learning curve plateau is reached. Age, BMI, and sex are not good criteria of choice between the two approaches.
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Affiliation(s)
- Antonio Vitiello
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5, 80131, Naples, Italy.
| | - Giovanna Berardi
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5, 80131, Naples, Italy
| | - Pietro Calabrese
- Clinical Medicine and Surgery Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5, 80131, Naples, Italy
| | - Maria Spagnuolo
- Clinical Medicine and Surgery Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5, 80131, Naples, Italy
| | - Fabrizia Calenda
- Clinical Medicine and Surgery Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5, 80131, Naples, Italy
| | - Giuseppe Salzillo
- Clinical Medicine and Surgery Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5, 80131, Naples, Italy
| | - Roberto Peltrini
- Public Health Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5, 80131, Naples, Italy
| | - Vincenzo Pilone
- Public Health Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5, 80131, Naples, Italy
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7
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Bistre-Varon J, Gunter R, Del Rio RS, Elhadi M, Gandhi S, Robins B, Popeck S, LeFave JP, Haas EM. Is the NICE procedure the great equalizer for patients with high BMI undergoing resection for diverticulitis? Surg Endosc 2024; 38:7518-7524. [PMID: 39285037 DOI: 10.1007/s00464-024-11226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 08/22/2024] [Indexed: 01/03/2025]
Abstract
BACKGROUND By 2030, projections indicate that nearly half of USS adults will be obese, with 29 states exceeding a 50% obesity rate. High Body Mass Index (BMI) presents particular challenges in treating diverticulitis, including worsened symptoms and increased risk of surgical complications. The Robotic Natural orifice Intracorporeal Anastomosis with Transrectal Extraction (NICE) procedure has been developed for colorectal surgeries to tackle these challenges. This study evaluates the efficacy of the Robotic NICE procedure in achieving comparable surgical outcomes in patients with both high and normal BMI. METHODS This retrospective cohort study assessed the outcomes of robotic-assisted colectomy utilizing the NICE technique in patients with diverticulitis, dividing them into two groups based on BMI: high BMI (≥ 30 kg/m^2) and non-high BMI (< 30 kg/m^2). RESULTS Among the 194 patients analyzed, the incidence of complicated diverticulitis was significantly higher in the high BMI group (60.5%) compared to the non-high BMI group (39%; p = 0.003).The high BMI group had higher ASA scores, indicating sicker patients. The high BMI group also had a significantly higher rate of unplanned operations within 30 days (7.9% vs. 1.7%, p = 0.034). However, no significant differences were observed in the length of hospital stay, time to first flatus, or ICU admission rates between the two groups. Binary logistic regression highlighted the length of stay as a significant predictor of postoperative complications (Odds Ratio: 1.9686, 95% CI: 1.372-2.825, p < 0.001). Other factors, including age, operative time, and gender, did not significantly predict complications. CONCLUSION The findings suggest that the Robotic NICE procedure can mitigate some of the challenges typically associated with conventional minimally invasive surgery in which abdominal wall incision is made, providing consistent outcomes regardless of BMI. Further research is needed to explore long-term benefits, aiming to establish this approach as a standard for managing diverticulitis in our patient population.
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Affiliation(s)
- Jacques Bistre-Varon
- Houston Colon Foundation, Houston, TX, USA
- Healthcare Gulf Coast Division, Houston, TX, 77030, USA
| | | | | | | | | | | | | | | | - Eric M Haas
- Houston Colon Foundation, Houston, TX, USA.
- Healthcare Gulf Coast Division, Houston, TX, 77030, USA.
- Houston Methodist Hospital, 6560 Fannin St Ste E1404, Houston, TX, 77030, USA.
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8
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Smalbroek BP, Geitenbeek RTJ, Dijksman LM, Khan J, Denost Q, Rouanet P, Hompes R, Consten ECJ, Smits AB. Laparoscopic and robotic total mesorectal excision in overweight and obese patients: multinational cohort study. Br J Surg 2024; 111:znae259. [PMID: 39417595 DOI: 10.1093/bjs/znae259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 09/19/2024] [Accepted: 09/20/2024] [Indexed: 10/19/2024]
Affiliation(s)
- Bo P Smalbroek
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Ritch T J Geitenbeek
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Lea M Dijksman
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jim Khan
- Department of Surgery, Portsmouth Hospitals University NHS Trust and the University of Portsmouth, Portsmouth, UK
| | - Quentin Denost
- Department of Surgery, Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Philippe Rouanet
- Department of Surgery, Montpellier Cancer Institute (ICM), Univ. Montpellier, Montpellier, France
| | - Roel Hompes
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anke B Smits
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
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9
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Fujimoto T, Tamura K, Nagayoshi K, Mizuuchi Y, Goto F, Matsuda H, Horioka K, Shindo K, Nakata K, Ohuchida K, Nakamura M. Simple pelvimetry predicts the pelvic manipulation time in robot-assisted low and ultra-low anterior resection for rectal cancer. Surg Today 2024; 54:1184-1192. [PMID: 38548999 DOI: 10.1007/s00595-024-02820-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/19/2024] [Indexed: 09/21/2024]
Abstract
PURPOSE This study explored the difficulty factors in robot-assisted low and ultra-low anterior resection, focusing on simple measurements of the pelvic anatomy. METHODS This was a retrospective analysis of the clinical data of 61 patients who underwent robot-assisted low and ultra-low anterior resection for rectal cancer between October 2018 and April 2023. The relationship between the operative time in the pelvic phase and clinicopathological data, especially pelvic anatomical parameters measured on X-ray and computed tomography (CT), was evaluated. The operative time in the pelvic phase was defined as the time between mobilization from the sacral promontory and rectal resection. RESULTS Robot-assisted low and ultra-low anterior resections were performed in 32 and 29 patients, respectively. The median operative time in the pelvic phase was 126 (range, 31-332) min. A multiple linear regression analysis showed that a short distance from the anal verge to the lower edge of the cancer, a narrow area comprising the iliopectineal line, short anteroposterior and transverse pelvic diameters, and a small angle of the pelvic mesorectum were associated with a prolonged operative time in the pelvic phase. CONCLUSION Simple pelvic anatomical measurements using abdominal radiography and CT may predict the pelvic manipulation time in robot-assisted surgery for rectal cancer.
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Affiliation(s)
- Takaaki Fujimoto
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Koji Tamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Fumika Goto
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hironao Matsuda
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kohei Horioka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Shindo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kenoki Ohuchida
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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Chen H, Wang X, Zhang Y, Liu W, Zhou C, Zheng D. Effect of dexmedetomidine on pulmonary function in obese patients undergoing laparoscopic surgery. Perioper Med (Lond) 2024; 13:42. [PMID: 38755633 PMCID: PMC11100160 DOI: 10.1186/s13741-024-00396-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVE This research aimed to ascertain the effect of dexmedetomidine on pulmonary function in obese patients undergoing laparoscopic surgery. METHODS Obese patients undergoing laparoscopic surgery under general anesthesia were separated into the control group (group C) and the dexmedetomidine group (group D) (n = 30). Patients in group D were infused with dexmedetomidine (1 μg/kg) intravenously for 10 min and then at a rate of 0.5 mg/kg h until 30 min before the end of the surgery, and those in group C were infused with an equal volume of saline. The surgery time points were divided into: before anesthesia induction (T0), 5 min after intubation (T1), 30 min after pneumoperitoneum (T2), 10 min after pneumoperitoneum release (T3), at the time of extubation (T4), 3 min after extubation (T5), and 24 h after surgery (T6). Arterial blood was collected for blood gas analysis to record arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2). Dynamic lung compliance (Cdyn), oxygenation index (OI), alveolar-arterial oxygen partial pressure difference (A-aDO2), and respiratory index (RI) were calculated. The time of surgery, anesthesia, CO2 pneumoperitoneum, eye-opening, and time from the end of surgery to extubation were recorded. Plasma IL-8 and IL-10 levels were measured from T0 to T6. RESULTS The time of surgery, anesthesia, CO2 pneumoperitoneum, eye-opening, and time from the end of surgery to extubation in group D were not statistically significant when compared with those in group C. Versus at the T1 time point, A-aDO2 and RI were higher and Cdyn and OI were lower in both groups at T2 and T3 time points. Versus group C, group D had higher Cdyn and OI and lower A-aDO2 and RI at T2 and T3 time points. Versus at the T0 time point, at each time point from T1 to T6, IL-8 and IL-10 levels were higher in both groups. Versus group C, group D had lower IL-8 and higher IL-10 levels at each time point from T1 to T6. CONCLUSION In obese patients undergoing laparoscopic surgery under general anesthesia, the use of dexmedetomidine can improve the lung compliance and OI of the patients, inhibit the inflammatory response of the lungs of the patients and thus have a certain protective effect on the lung function.
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Affiliation(s)
- Huan Chen
- Department of Anesthesiology, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Xin Wang
- Department of Anesthesiology, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Yawen Zhang
- Department of Anesthesiology, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Wei Liu
- Department of Anesthesiology, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Changhao Zhou
- Department of Anesthesiology, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Deli Zheng
- Department of Anesthesiology, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China.
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11
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Chen ZL, Du QL, Zhu YB, Wang HF. A systematic review and meta-analysis of short-term outcomes comparing the efficacy of robotic versus laparoscopic colorectal surgery in obese patients. J Robot Surg 2024; 18:167. [PMID: 38592362 DOI: 10.1007/s11701-024-01934-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/24/2024] [Indexed: 04/10/2024]
Abstract
This meta-analysis was conducted to evaluate and contrast the effectiveness of robotic-assisted and laparoscopic colorectal surgery in the treatment of obese patients. In February 2024, we carried out an exhaustive search of key global databases including PubMed, Embase, and Google Scholar, limiting our focus to studies published in English and Chinese. We excluded reviews, protocols lacking published results, articles derived solely from conference abstracts, and studies not relevant to our research objectives. To analyze categorical variables, we utilized the Cochran-Mantel-Haenszel method along with random-effects models, calculating inverse variances and presenting the outcomes as odds ratios (ORs) along with their 95% confidence intervals (CIs). Statistical significance was determined when p values were less than 0.05. In our final meta-analysis, we included eight cohort studies, encompassing a total of 5,004 patients. When comparing the robotic surgery group to the laparoscopic group, the findings revealed that the robotic group experienced a longer operative time (weighted mean difference (WMD) = 37.53 min, 95% (CI) 15.58-59.47; p = 0.0008), a shorter hospital stay (WMD = -0.68 days, 95% CI -1.25 to -0.10; p = 0.02), and reduced blood loss (WMD = -49.23 mL, 95% CI -64.31 to -34.14; p < 0.00001). No significant differences were observed between the two groups regarding overall complications, conversion rates, surgical site infections, readmission rates, lymph node yield, anastomotic leakage, and intestinal obstruction. The results of our study indicate that robot-assisted colorectal surgery offers benefits for obese patients by shortening the length of hospital stay and minimizing blood loss when compared to laparoscopic surgery. Nonetheless, it is associated with longer operation times and shows no significant difference in terms of overall complications, conversion rates, rehospitalization rates, and other similar metrics.
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Affiliation(s)
- Zhi-Long Chen
- Department of Vascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
| | - Qiu-Lin Du
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yan-Bin Zhu
- Department of Vascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Hai-Fei Wang
- Department of Vascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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12
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Avramidou E, Terlemes K, Lymperopoulou A, Katsanos G, Antoniadis N, Kofinas A, Vasileiadou S, Karakasi KE, Tsoulfas G. Minimally Invasive Surgery in Liver Transplantation: From Living Liver Donation to Graft Implantation. LIVERS 2024; 4:119-137. [DOI: 10.3390/livers4010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2024] Open
Abstract
Since the end of the 20th century and the establishment of minimally invasive techniques, they have become the preferred operative method by many surgeons. These techniques were applied to liver surgery for the first time in 1991, while as far as transplantation is concerned their application was limited to the living donor procedure. We performed a review of the literature by searching in Pubmed and Scopus using the following keywords: Liver transplantation, Minimally invasive surgery(MIS) living liver donor surgery. Applications of MIS are recorded in surgeries involving the donor and the recipient. Regarding the recipient surgeries, the reports are limited to 25 patients, including combinations of laparoscopic, robotic and open techniques, while in the living donor surgery, the reports are much more numerous and with larger series of patients. Shorter hospitalization times and less blood loss are recorded, especially in centers with experience in a large number of cases. Regarding the living donor surgery, MIS follows the same principles as a conventional hepatectomy and is already the method of choice in many specialized centers. Regarding the recipient surgery, significant questions arise mainly concerning the safe handling of the liver graft.
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Affiliation(s)
- Eleni Avramidou
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
| | - Konstantinos Terlemes
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
| | - Afroditi Lymperopoulou
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
| | - Georgios Katsanos
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
| | - Nikolaos Antoniadis
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
| | - Athanasios Kofinas
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
| | - Stella Vasileiadou
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
| | - Konstantina-Eleni Karakasi
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
| | - Georgios Tsoulfas
- Department of Transplant Surgery, Center for Research and Innovation in Solid Organ Transplantation Aristotle University of Thessaloniki School of Medicine, 54642 Thessaloniki, Greece
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Massala-Yila EF, Ali M, Yu W, Wang W, Ren J, Wang D. Evaluating body mass index's impact on Da Vinci Robotic rectal cancer surgery, a retrospective study. J Robot Surg 2024; 18:22. [PMID: 38217775 DOI: 10.1007/s11701-023-01774-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/14/2023] [Indexed: 01/15/2024]
Abstract
Robotic surgery addresses laparoscopic shortcomings and yields comparable results for low and high body mass index (BMI) patients. However, the impact of BMI on postoperative complications in robotic colorectal surgery remains debated. This study assessed the implications of BMI on short outcomes and postoperative complications, highlighting its unique role in the outcomes. Retrospective analysis of 119 patients who underwent robotic-assisted surgery for rectal cancer (January 2022 to March 2023). Patients grouped by BMI: normal weight (BMI < 23.9 kg/m2), overweight (BMI ≥ 23.9 kg/m2 and BMI < 27.9 kg/m2), and obese (BMI ≥ 27.9 kg/m2). Investigated BMI's impact on surgical outcomes and postoperative complications. Statistically significant differences (P < 0.05) in Clavien-Dindo, ASA scores. The obese group had a longer time to flatus (P = 0.002) and a higher re-operation rate than other groups (P = 0.01). The overweight group had a higher anastomotic fistula rate than the obese group. Overall complications showed no significant differences among BMI cohorts (P = 0.0295). There were no significant differences in TNM stages and comorbidities. BMI had no significant impact on overall postoperative complications in robotic surgery for rectal cancer. However, higher BMI correlated with a longer time to flatus and increased re-operation rate.
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Affiliation(s)
- Emilienne Fortuna Massala-Yila
- Medical College of Yangzhou University, Yangzhou, China
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Muhammad Ali
- Medical College of Yangzhou University, Yangzhou, China
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Wenhao Yu
- Medical College of Yangzhou University, Yangzhou, China
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Wei Wang
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Jun Ren
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Daorong Wang
- Medical College of Yangzhou University, Yangzhou, China.
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu, China.
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China.
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Yamada K, Imaizumi J, Kato R, Takada T, Ojima H. Streamlining robotic-assisted abdominoperineal resection. World J Surg Oncol 2023; 21:392. [PMID: 38124092 PMCID: PMC10731883 DOI: 10.1186/s12957-023-03260-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Robot-assisted surgery has proven to be a safe and feasible approach for the management of rectal cancer, including abdominoperineal resection (APR). However, it often incurs longer operative times and higher costs. This study aimed to overcome these limitations by adopting a synchronous approach utilizing an optimized team composition. METHODS Data on patients who underwent robot-assisted APR at our facility between June 2022 and June 2023 were analyzed. The key points of the optimized approach included the following: At the start of the surgery, the surgeon performed an anococcygeal ligament resection from the perineal side while the bedside assistants set up the ports. Then, through console manipulation, the presacral fascia, elevated by previously placed gauze, was easily and safely incised, providing access to the perineal region. RESULTS A total of nine patients were included in this study. The median operation time was 231 min, and the intraoperative blood loss was 170 ml. The operation time was reduced to 167.5 min, and the blood loss was 80.5 ml in cases without a trainee. Surgical site infections, classified as Clavien-Dindo grade II complications, were observed in two cases, but no obvious urinary or erectile dysfunction was observed. CONCLUSION The study results indicate that the challenges associated with APR can be efficiently addressed without requiring additional personnel by streamlining team composition and the synchronous approach. This optimization strategy minimizes the need for a larger surgical team, while maximizing the utilization of surgical time and resources.
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Affiliation(s)
- Kazunosuke Yamada
- Department of Gastroenterological Surgery, Gunma Prefectural Cancer Center, 617-1, Nishimachi, Oota-Shi, Gunma, 373-0828, Japan.
| | - Jun Imaizumi
- Department of Gastroenterological Surgery, Gunma Prefectural Cancer Center, 617-1, Nishimachi, Oota-Shi, Gunma, 373-0828, Japan
| | - Ryuji Kato
- Department of Gastroenterological Surgery, Gunma Prefectural Cancer Center, 617-1, Nishimachi, Oota-Shi, Gunma, 373-0828, Japan
| | - Takahiro Takada
- Department of Gastroenterological Surgery, Gunma Prefectural Cancer Center, 617-1, Nishimachi, Oota-Shi, Gunma, 373-0828, Japan
| | - Hitoshi Ojima
- Department of Gastroenterological Surgery, Gunma Prefectural Cancer Center, 617-1, Nishimachi, Oota-Shi, Gunma, 373-0828, Japan
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