Is laparoscopic right colectomy more effective than open resection? A meta-analysis of randomized and nonrandomized studies

A meta-analysis of the risk factors for surgical site infection in patients with colorectal cancer

The purpose of the meta-analysis was to evaluate and compare the surgical site infection (SSI) risk factors in patients with colorectal cancer (CC). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random or fixed-effect models. For the current meta-analysis, 23 examinations spanning from 2001 to 2023 were included, encompassing 89 859 cases of CC. Clean-contaminated surgical site wounds had significantly lower infections (OR, 0.36; 95% CI, 0.20-0.64, p < 0.001) compared to contaminated surgical site wounds in patients with CCs. Males had significantly higher SSIs (OR, 1.18; 95% CI, 1.12-1.24, p < 0.001) compared to females in patients with CC. American Society of Anesthesiology score ≥3 h had a significantly higher SSI (OR, 1.42; 95% CI, 1.18-1.71, p < 0.001) compared to <3 score in patients with CCs. Body mass index ≥25 had significantly higher SSIs (OR, 1.54; 95% CI, 1.11-2.14, p = 0.01) compared to <25 in patients with CCs. The presence of stoma creation had a significantly higher SSI rate (OR, 2.28; 95% CI, 1.37-3.79, p = 0.001) compared to its absence in patients with CC. Laparoscopic surgery had significantly lower SSIs (OR, 0.68; 95% CI, 0.59-0.78, p < 0.001) compared to open surgery in patients with CC. The presence of diabetes mellitus had a significantly higher SSI rate (OR, 1.24; 95% CI, 1.15-1.33, p < 0.001) compared to its absence in patients with CCs. No significant difference was found in SSI rate in patients with CCs between <3 and ≥3 h of operative time (OR, 1.07; 95% CI, 0.75-1.51, p = 0.72), between the presence and absence of blood transfusion (OR, 1.60; 95% CI, 0.69-3.66, p = 0.27) and between the presence and absence of previous laparotomies (OR, 1.47; 95% CI, 0.93-2.32, p = 0.10). The examined data revealed that contaminated wounds, male sex, an American Society of Anesthesiology score ≥3 h, a body mass index ≥25, stoma creation, open surgery and diabetes mellitus are all risk factors for SSIs in patients with CC. However, operative time, blood transfusion and previous laparotomies were not found to be risk factors for SSIs in patients with CC. However, given that several comparisons had a small number of chosen research, consideration should be given to their values.

Early outcomes from the Minimally Invasive Right Colectomy Anastomosis study (MIRCAST)

BACKGROUND

The impact of method of anastomosis and minimally invasive surgical technique on surgical and clinical outcomes after right hemicolectomy is uncertain. The aim of the MIRCAST study was to compare intracorporeal and extracorporeal anastomosis (ICA and ECA respectively), each using either a laparoscopic approach or robot-assisted surgery during right hemicolectomies for benign or malignant tumours.

METHODS

This was an international, multicentre, prospective, observational, monitored, non-randomized, parallel, four-cohort study (laparoscopic ECA; laparoscopic ICA; robot-assisted ECA; robot-assisted ICA). High-volume surgeons (at least 30 minimally invasive right colectomy procedures/year) from 59 hospitals across 12 European countries treated patients over a 3-year interval The primary composite endpoint was 30-day success, defined by two measures of efficacy-absence of surgical wound infection and of any major complication within the first 30 days after surgery. Secondary outcomes were: overall complications, conversion rate, duration of operation, and number of lymph nodes harvested. Propensity score analysis was used for comparison of ICA with ECA, and robot-assisted surgery with laparoscopy.

RESULTS

Some 1320 patients were included in an intention-to-treat analysis (laparoscopic ECA, 555; laparoscopic ICA, 356; robot-assisted ECA, 88; robot-assisted ICA, 321). No differences in the co-primary endpoint at 30 days after surgery were observed between cohorts (7.2 and 7.6 per cent in ECA and ICA groups respectively; 7.8 and 6.6 per cent in laparoscopic and robot-assisted groups). Lower overall complication rates were observed after ICA, specifically less ileus, and nausea and vomiting after robot-assisted procedures.

CONCLUSION

No difference in the composite outcome of surgical wound infections and severe postoperative complications was found between intracorporeal versus extracorporeal anastomosis or laparoscopy versus robot-assisted surgery.

Intracorporeal Versus Extracorporeal Anastomoses in Laparoscopic Right Hemicolectomy: A Single-Center Experience

BACKGROUND

Right hemicolectomy is a commonly performed procedure for both benign and malignant diseases of the right colon. However, there is marked technical variation in the anastomosis technique used. In our hospital, both intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) are performed. Our study aimed to assess and compare the short-term outcomes following laparoscopic right hemicolectomies, particularly in regard to the anastomosis technique.

METHODS

All consecutive adult (>18 years of age) patients who underwent elective right hemicolectomy from January 2020 to April 2023 at St Richards Hospital, Chichester, University Hospitals Sussex NHS Foundation Trust, UK, were included in our retrospective study. Data, including age at operation, body mass index, American Society of Anesthesiologists (ASA) score, pathology, type of procedure, type of anastomosis, technique of anastomosis, post-operative high-dependency unit (HDU) stay, hospital length of stay, post-operative ileus, anastomotic leak, return to theater, and in-hospital mortality, were extracted. Patients who did not get an ileocolic anastomosis, had a stoma formation, and had an open procedure or conversion to open procedure were excluded. The cases that fulfilled the criteria were shortlisted for analysis. These cases were then divided into two groups: patients who had an IA and those who had an EA.

RESULTS

From January 2020 to April 2023, 152 patients underwent right hemicolectomy. A total of 139 patients fulfilled our eligibility criteria and were included in our final analysis. The overall mortality rate was 0.7% (1/139), the return to theater rate was 0.7% (1/139), and no anastomotic leaks were recorded. The overall ileus rate was 16.5% (23/139). The hospital length of stay was significantly longer in the EA group as compared to the IA group (p<0.004). A higher proportion (18.75%, n=21) of the patients had a recorded ileus in the EA group as compared to 7.4% (n=2) in the IA group, but this difference was not statistically significant (p=0.24).

CONCLUSIONS

We found that the patients who had IA had reduced hospital length of stay. The IA group also had clinically significant reduced rates of post-operative ileus, but this was not statistically significant. However, other short-term outcomes that were measured were similar in both groups.

Laparoscopic vs. open colectomy for T4 colon cancer: A meta-analysis and trial sequential analysis of prospective observational studies

Background

To evaluate short- and long-term outcomes of laparoscopic colectomy (LC) vs. open colectomy (OC) in patients with T4 colon cancer.

Methods

Three authors independently searched PubMed, Web of Science, Embase, Cochrane Library, and Clinicaltrials.gov for articles before June 3, 2022 to compare the clinical outcomes of T4 colon cancer patients undergoing LC or OC.

Results

This meta-analysis included 7 articles with 1,635 cases. Compared with OC, LC had lesser blood loss, lesser perioperative transfusion, lesser complications, lesser wound infection, and shorter length of hospital stay. Moreover, there was no significant difference between the two groups in terms of 5-year overall survival (5y OS), and 5-year disease-free survival (5y DFS), R0 resection rate, positive resection margin, lymph nodes harvested ≥12, and recurrence. Trial Sequential Analysis (TSA) results suggested that the potential advantages of LC on perioperative transfusion and the comparable oncological outcomes in terms of 5y OS, 5y DFS, lymph nodes harvested ≥12, and R0 resection rate was reliable and no need of further study.

Conclusions

Laparoscopic surgery is safe and feasible in T4 colon cancer in terms of short- and long-term outcomes. TSA results suggested that future studies were not required to evaluate the 5y OS, 5y DFS, R0 resection rate, positive resection margin status, lymph nodes harvested ≥12 and perioperative transfusion differences between LC and OC.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022297792.

Comparison of short-term and medium-term outcomes between intracorporeal anastomosis and extracorporeal anastomosis for laparoscopic left hemicolectomy

BACKGROUND

Few studies have evaluated the feasibility and safety of intracorporeal anastomosis (IA) for left hemicolectomy. Here, we aimed to investigate the potential advantages and disadvantages of laparoscopic left hemicolectomy with IA and compare the short- and medium-term outcomes between IA and extracorporeal anastomosis (EA).

METHODS

We retrospectively analyzed 133 consecutive patients who underwent laparoscopic left hemicolectomies from July 2016 to September 2019 and categorized them into the IA and EA groups. Patients with stage 4 disease and conversion to laparotomy or those lost to follow-up were excluded. Postoperative outcomes between IA and EA groups were compared. Short-term outcomes included postoperative pain score, bowel function recovery, complications, duration of hospital stay, and pathological outcome. Medium outcomes included overall survival and disease-free survival for at least 2 years.

RESULTS

After excluding ineligible patients, the remaining 117 underwent IA (n = 40) and EA (n = 77). The IA group had a shorter hospital stay, a shorter time to tolerate liquid or soft diets, and higher serum C-reactive protein level on postoperative day 3. There was no difference between two groups in operative time, postoperative pain, specimen length, or nearest margin. A 2-year overall survival (IA vs. EA: 95.0% vs. 93.5%, p = 0.747) and disease-free survival (IA vs. EA: 97.5% vs. 90.9%, p = 0.182) rates were comparable between two groups.

CONCLUSIONS

Laparoscopic left hemicolectomy with IA was technically feasible, with better short-term outcomes, including shorter hospital stays and shorter time to tolerate liquid or soft diets. The IA group had higher postoperative serum C-reactive protein level; however, no complications were observed. Regarding medium-term outcomes, the overall survival and disease-free survival rates were comparable between IA and EA procedures.

The SAGES MASTERS program presents: the 10 seminal articles for the Laparoscopic Right Colectomy Pathway

BACKGROUND

As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with.

METHODS

Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions.

RESULTS

The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve.

CONCLUSIONS

The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.

Simultaneous or staged resection of synchronous colorectal cancer liver metastases: a 13-year institutional follow-up

BACKGROUND

This study compared postoperative outcomes and survival rates of patients who underwent simultaneous or staged resection for synchronous colorectal cancer liver metastases.

METHODS

Between 2005 and 2018, 126 patients were registered prospectively at a university hospital in Sweden, 63 patients who underwent simultaneous resection were matched against 63 patients who underwent staged resection.

RESULTS

The length of hospital stay was shorter for the simultaneous resection group, at 11 vs 16 days, p = <0.001. Fewer patients experienced recurrence in the simultaneous resection group 39 vs 50 patients, p = 0.012. There were no significant differences in disease-free survival and overall survival between the groups. Age (hazard ratio [HR] 1.72; 95% CI 1.01-2.94; p = 0.049) and Clavien-Dindo score (HR 2.22; 95% CI 1.06-4.67; p = 0.035) had impact on survival.

CONCLUSION

Colorectal cancer with synchronous liver metastases can be resected simultaneously, and enables a shorter treatment time without jeopardizing oncological outcomes.

Short-term outcomes following resection of right colon diverticulitis: a comparison of open and minimally invasive approaches using the NSQIP database

BACKGROUND

Right colon diverticulitis is a rare disease process for which there are no established treatment guidelines, and outcomes following surgical management are underreported in the literature. We sought to describe the demographics of patients undergoing ileocecectomy for right colon diverticulitis and compare short-term postoperative outcomes between open and minimally invasive approaches.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for patients with diverticulitis of the colon who underwent ileocecectomy between 2012 and 2019. Patients with ascites, disseminated cancer, ASA class 5, and patients requiring mechanical ventilation were excluded. Preoperative, intraoperative, and 30-day postoperative outcomes were compared between the groups using both univariable chi-square or t-tests and multivariable logistical regression models.

RESULTS

484 patients met inclusion criteria, 150 (31%) of whom underwent open surgery and 334 (69%) who underwent minimally invasive surgery with an 18% conversion rate. 71% of patients were White, 11% of were Black, 7% were Hispanic, and 5% were Asian. The indication for surgery differed significantly by approach with acute diverticulitis representing 47% of indications for open cases and 25% for MIS cases (p < 0.0001). After adjusting for possible confounders, patients undergoing the open approach had a significantly higher chance of post-operative sepsis (p = 0.009) and ileus (p = 0.04) compared with MIS. Hospital length of stay was also significantly shorter after MIS compared to open (5.9 days vs. 11.5 days; p < 0.0001). Mean operative time was significantly longer in MIS than open (173 min vs. 198 min; p = 0.001).

CONCLUSION

Our analysis demonstrates that minimally invasive surgery is associated with equivalent or improved short-term morbidity and shorter hospital stay despite longer mean operative time. Interestingly, unlike other countries where the prevalence of right colon diverticulitis is higher, a minority of patients requiring operative therapy in our study of patients in the Western hemisphere were of Asian descent.

Laparoscopic right colectomy: changes in surgical technique and perioperative management allow better postoperative results in a comparative series of 361 patients

To compare the short-term outcomes in patients who underwent laparoscopic right colectomy with a traditional minimally invasive approach versus patients who underwent a laparoscopic colectomy with an enhanced perioperative pathway. A retrospective analysis was conducted on a consecutive series of patients who underwent elective laparoscopic right colectomy for neoplastic disease between January 1, 2011 and December 31, 2020. The patients were divided into two groups: the first cohort (FC), who underwent a traditional laparoscopic colectomy, mainly with extracorporeal anastomosis, between January 1, 2011 and December 31, 2015 and the second cohort (SC), who underwent a laparoscopic colectomy with an enhanced intraoperative (intracorporeal anastomosis) and perioperative pathway (ERAS protocol) between January 1, 2016 and December 31, 2020. There were a total of 361 patients, including 177 in the FC and 184 in the SC. In the SC a higher number of intracorporeal anastomoses was performed (91.8% vs. 19.2%, p < 0.001), drains were placed in 42 patients only (22.8% vs. 100% in the FC) and nasogastric tubes were placed in 21 patients only (11.4% vs. 100% in the FC). In the initial period of the SC. the procedures required a slightly longer operative time (median 105 vs. 95 min; p = 0.002), but postoperative surgical complications were lower (12% vs. 17.4%, p = 0.179). Postoperative recovery was faster in SC along with time to discharge (4 vs. 7 days; p < 0.001). Intraoperative anastomosis and enhanced pathways in right laparoscopic colectomy seem to guarantee better results with lower surgical complications and faster postoperative recovery.

Predictors of surgical outcomes of minimally invasive right colectomy: the MERCY study

PURPOSE

The optimal approach for minimally invasive (MIS) right colectomy remains under debate. This study aimed to describe surgical trends in the treatment of nonmetastatic right colon cancer and to identify predictors of short-term surgical outcomes.

METHODS

A retrospective multicenter cohort study of Minimally-invasivE surgery for oncologic Right ColectomY (MERCY) was conducted on patients who underwent laparoscopic or robotic right colectomy between 2014 and 2020. Classification tree approach was used to describe the extracorporeal (EA) or intracorporeal (IA) anastomosis choice. Mixed-model regressions were used to identify patient- and surgery-related factors predictive of postoperative outcomes. A questionnaire was used to evaluate the surgeons' perspectives.

RESULTS

The MERCY database comprised 1870 patients; 87.2% underwent laparoscopy, and 68.1% received an EA. A clear surgical trend was noted, with an increasing rate of IA and robotic procedures after 2017. EA represented 41% of anastomoses in centers equipped with a robotic surgical system. Mixed-model regressions (on 1088 patients) showed that age, sex, BMI, comorbidity, robotics, IA, and conversion to open surgery were predictors of surgical outcomes. In particular, IA was a predictor of a shorter time to regular diet and fewer surgical site infections. Based on the questionnaire, IA was the preferred over EA by 72% of surgeons.

CONCLUSION

MIS continues to evolve, with an increasing number of IA being performed in the recent years and when using a robotic surgical system. Understanding the role of predictors of surgical outcomes may help surgeons personalize decision-making among the different MIS options to manage right colon cancer.

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

PURPOSE

While minimally invasive surgery is the preferred approach for right hemicolectomy, the choice of anastomotic technique is still debated. Both intracorporeal (ICA) and extracorporeal anastomosis (ECA) are described, with conflicting reports on safety and efficacy seen. This study aimed to examine impact of ICA and ECA on outcomes in right hemicolectomy.

METHODS

A meta-analysis of randomized control trials (RCT) was performed. The primary outcome was overall morbidity. The secondary outcomes included both perioperative and post-operative outcomes.

RESULTS

Four RCTs were included incorporating 399 patients (199 patients (49.9%) ICA Vs 200 (50.1%) ECA). There was no significant difference in overall morbidity (RR 0.79, 95% CI 0.43, 1.48, p = 0.47), anastomotic leak (RR 1.34, 95% CI 0.58, 3.13, p = 0.5) or surgical site infections (RR 0.53, 95% CI 0.17, 1.64, p = 0.27). ICA patients had a significantly less post-operative ileus (RR 0.53, 95% CI 0.3-0.94, p = 0.03) quicker return to first flatus (WMD - 0.71, 95% CI - 1.12, 0.31, p = 0.0005), first bowel motion (WMD - 0.53, 95% CI - 0.69, - 0.37, p < 0.00001) and first meal (WMD - 0.68, 95% CI - 1.33, - 0.03, p = 0.04). Pain scores were significantly better for ICA patients on POD 3 (WMD - 0.76, 95% CI - 1.23, - 0.28, p = 0.002), POD 4 (WMD - 0.90, 95% CI - 1.71, - 0.09, p = 0.03) and POD 5 (WMD - 0.67, 95% CI - 1.22, - 0.13, p = 0.01). Length of hospital stay was similar (WMD - 0.46, 95% CI - 1.14, 0.22, p = 0.19).

CONCLUSION

ICA is associated with a quicker return to normal physiological function with equivalent post-operative morbidity. Both ECA and ICA are safe and feasible for restoring normal bowel continuity.

Laparoscopic Versus Open Right Colectomy for Cancer in the Era of Complete Mesocolic Excision with Central Vascular Ligation: Pathology and Short-Term Outcomes

Background: Colectomies performed according to complete mesocolic excision with central vascular ligation (CME-CVL) principles have been associated with enhanced oncologic outcomes. Nonetheless, laparoscopic CME-CVL right hemicolectomy has not been widely adopted. We aimed to compare the perioperative and pathology outcomes of laparoscopic and open CME-CVL right hemicolectomy. Materials and Methods: We compared data from a prospectively collected database regarding patients who underwent either laparoscopic or open CME-CVL right hemicolectomy for nonmetastatic right colon cancer in a University Hospital, between January 2012 and December 2018. Results: A total of 130 consecutive patients were included in the study. Of them, 73 patients underwent laparoscopic and 57 patients open right colectomy, following the CME-CVL principles. The laparoscopic approach was associated with less hospital stay (6.6 versus 9.1 days; P < .001) and septic complications (P = .046), at a cost of an increased operative time (180 versus 125.1 minutes; P < .001). Patients treated with either open or laparoscopic approach presented similar outcomes regarding pathology endpoints. In fact, both groups demonstrated similar R0 resection rate (P = .202), number of harvested and positive lymph nodes (P = .751 and P = .734, respectively), number of harvested lymph nodes at the level of D1 and D2 lymph node dissection (P > .05), rate of vascular (P = .501), and perineural infiltration (P = .956). Furthermore, no difference was found regarding the rate of intact mesocolic plane (P = .799), along with the tumor diameter (P = .154) and the length of specimen (P = .163). Conclusion: Laparoscopic CME-CVL right hemicolectomy appears to offer certain advantages in short-term outcomes compared to open procedure. Pathology outcomes did not differ between the two approaches. Future studies should further evaluate their long-term outcomes.

Feasibility of robotic right colectomy with complete mesocolic excision and intracorporeal anastomosis: short-term outcomes of 161 consecutive patients

Technical and oncological aspects are still debated when dealing with minimally-invasive right colectomy. Main controversial issues still remain about whether the anastomosis should be performed intra- or extracorporeally and if a complete mesocolic excision (CME) should be carried out. We report the feasibility of robotic right colectomy with CME and intracorporeal anastomosis (IA) for right sided colon cancer. Data from patients who underwent robotic right colectomy with IA and CME from January 2015 to April 2020 were prospectively collected and retrospectively analyzed. Intraoperative outcomes and complications (minor I-II and major III-IV according to Clavien-Dindo classification), conversion rate, 30-day postoperative outcomes and pathological outcomes were the variables assessed. A total of 161 patients undergoing robotic right colectomy for cancer met the inclusion criteria. Mean operative time was 185 min, no intraoperative complications were observed, and the conversion rate was 3.7% (6 patients requiring elective conversions). Overall, mean postoperative stay was 4.9 days and the overall 30-day complication rate was 16.1%. 20 patients (12.4%) had minor complications, while major postoperative complications occurred in six patients (3.7%). Anastomotic leak was recorded in one patient (0.6%) and the 30-day re-admission rate was 0.6%. Mean number of harvested lymph nodes was 21.9. Patients requiring conversion experienced two minor complications, with a mean length of stay of 7 days. Robotic right colectomy with CME and IA is feasible and it is associated with good intraoperative and short-term postoperative clinical outcomes.

Update on risk factors of surgical site infection in colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

Surgical site infection (SSI) in colorectal cancer (CRC) has been a serious health care problem due to the delay of postoperative recovery. Our present study aimed to explore the risk factors for SSI in CRC patients.

METHODOLOGY

We have systematically searched these databases: PubMed, Cochrane Library, and EMBASE as of March 2020 for studies on risk factors associated with SSI. Two investigators independently conducted the quality assessment and data extraction. Related risk factors in the studies were recorded, and a meta-analysis was performed.

RESULTS

The search initially provided 2262 hits, 1913 studies were screened by two independent investigators. Finally, 15 studies were identified to be relevant for this meta-analysis. In total, 25 risk factors were eligible. Our meta-analysis indicated that eight factors (obesity, male sex, diabetes mellitus, ASA score ≥ 3, stoma creation, intraoperative complications, perioperative blood transfusion, and operation time ≥ 180 min) were significant risk factors for SSI, and one factor (laparoscopic procedure) was protective for SSI.

CONCLUSIONS

Effective interventions targeting the above factors may reduce the risk of developing postoperative SSI in CRC patients and improve the clinical outcome of patients. Further prospective studies are needed to confirm these findings.

A Case-matched Comparative Study of Laparoscopic Versus Open Right Colonic Resection for Colon Cancer: Developing Country Perspectives

BACKGROUND

The open approach to right hemicolectomy remains the most widely adopted, whereas laparoscopic surgery is technically more demanding with possible loss of benefit for lengthy procedures compared with open surgery. The aim of this study is to compare the outcomes of the laparoscopic versus open surgery for right colon cancer resections.

MATERIALS AND METHODS

Patients who underwent an elective and potentially curative right colectomy for colon cancer between 2015 and 2019 were included and those who underwent emergency surgery, palliative resection, or cytoreductive surgery were excluded. Patients were randomly matched on 1:2 basis for age, disease stage, neoadjuvant chemotherapy, and extent of colectomy (right vs. extended right hemicolectomy, and additional major resection). The analysis was conducted on an intention-to-treat basis. The outcomes were reported as median (range) or percent as appropriate.

RESULTS

Among 160 patients, 18 were excluded. The final matching included 69 patients. The were no significant differences between the groups regarding patients' age and sex distribution, tumor size, and preoperative serum albumin and hemoglobin. There were 2 conversions (8.7%) to open surgery. Although the operating time for laparoscopic surgery was longer (200 vs. 140 min, P<0.001), it was associated with less blood loss (50 vs. 100 mL, P=0.001) and shorter primary and total hospital stay (4.1 vs. 6.0 days, P<0.001). There were no differences in the rates of severe complications (0% vs. 13%), reoperations (0% vs. 4.3%), readmissions (13% vs. 8.7%), mortality (0% vs. 2.2%), R0 resections (95.7% vs. 97.8%), and lymph node retrieval rate (28 in each group).

CONCLUSION

The laparoscopic approach to right colon resection for colon cancer is associated with less operative trauma and quicker recovery compared with open surgery and offers an equivalent oncologic resection.

Robotic ileocolic resection with intracorporeal anastomosis for Crohn's disease

The robotic platform can overcome limitations of the laparoscopic approach, particularly in the facilitation of intracorporeal anastomosis creation. We aim to share our institutional experience with robotic ileocolic resection for Crohn's disease (CD) and compare it to a laparoscopic cohort. We identified patients who underwent ileocolic resection for CD with a purely robotic (R) or laparoscopic (L) approach between February 2015 and 2018. Chart review was performed and preoperative, intraoperative, and postoperative data was collected. A total of 47 patients with a mean age of 35.2 years old were identified and 61% were female. Seventy percent [n = 33, (23 females, 69.6%)] of the cases were performed robotically and 30% of the cases [n = 14, (6 females, 42.8%)] were performed laparoscopically. The groups were well matched for age, gender, BMI as well as disease related factors (CD duration; clinical classification and location), perioperative immunosuppression, and surgical history. Time to bowel function was shorter by about 1 day in the robotic group (R: 1.9 ± 0.88 days vs. L: 2.7 ± 0.8 days, p = 0.003). Mean operative time was longer in the robotic group by 51 min and this difference was significant (p = 0.03), however 30.3% of patients underwent ureteral stent placement, which can account for added time in robotic cases. There were less conversions in the robotic group [R: 1(4.3%) vs. L: 1(7%)], but this was not significant. There were no intraoperative complications in either group. Complication (L: 21.4% vs. R: 15.1%, p = 0.605) and reoperation rates (L: 0% vs. R: 3.03%, p = 0.429) were similar. Robotic ileocolic resection for Crohn's disease is as safe and feasible as the laparoscopic approach. This was accomplished with no leaks, major morbidity or mortality and comparable length of stay, with 1 day shorter return of bowel function, and with a lower overall complication rate. The robotic approach offers advantages in Crohn's disease which should be studied further in prospective studies.

Incisional Hernia After Laparoscopic-Assisted Right Hemicolectomy

BACKGROUND

Different approaches used for laparoscopic right colectomy have different advantages and disadvantages. This study aims to determine the incidence and clinical relevance of IH after LARHC as the preferred technique in an experienced setting and to assess which factors are correlated with the development of IH.

METHODS

Between January 2012 and December 2016, all consecutive patients who underwent LARHC were included. Data were obtained in accordance with the Dutch ColoRectal Audit, and IH was scored based on physical examination and imaging at standard follow-up. Logistic regression analysis was used to identify risk factors for IH.

RESULTS

A total of 170 patients underwent LARHC. In the same period, 64 patients had an open RHC. IH after LARHC was seen in 24 patients after a median time of 7 months (14%). Only four of these patients underwent operative IH repair (2%). Interestingly, a trend for more IH was seen between two surgeons. Multivariable analysis identified BMI [OR 1.08 (95% CI 1.00-1.15) P = 0.043], a history of smoking [OR 2.14 (95% CI 1.03-4.41) P = 0.040], and surgical site infection [OR 2.99 (95% CI 1.28-7.00) P = 0.012] as risk factors for IH.

CONCLUSION

IH incidence after LARHC was considerable, but few were clinically relevant IHs. The IH incidence should be included in shared decision making. The low clinically relevant IH rate does in our opinion not outweigh possible advantages of LARHC.

Minimally invasive right colectomy anastomosis study (MIRCAST): protocol for an observational cohort study of surgical complications using four surgical techniques for anastomosis in patients with a right colon tumor

BACKGROUND

Right colectomy is the standard surgical treatment for tumors in the right colon and surgical complications are reduced with minimally-invasive laparoscopy compared with open surgery, with potential further benefits achieved with robotic assistance. The anastomotic technique used can also have an impact on patient outcomes. However, there are no large, prospective studies that have compared all techniques.

METHODS/DESIGN

MIRCAST is the Minimally-Invasive Right Colectomy Anastomosis Study that will compare laparoscopy with robot-assisted surgery, using either intracorporeal or extracorporeal anastomosis, in a large prospective, observational, multicenter, parallel, four-cohort study in patients with a benign or malignant, non-metastatic tumor of the right colon. Over 2 years of follow-up, the study will prospectively evaluate peri- and postoperative complications, postoperative recovery, hospital stay, and mid-term results including survival, local recurrence, metastases rate, and conversion rate. The primary composite endpoint will be the efficacy of the surgical method regarding surgical wound infections and postoperative complications (Clavien-Dindo grade III-IV complications at 30 days post-surgery). Secondary endpoints include long-term oncologic results, conversion rate, operative time, length of stay, and quality of life.

DISCUSSION

This will be the first large, international study to prospectively evaluate the use of minimally-invasive laparoscopy or robot-assisted surgery during right hemicolectomy and to control for the impact of the anastomotic technique. The research will contribute to current knowledge regarding the medical care of patients with malignant or benign tumors of the right colon, and enable physicians to determine which technique may be the most appropriate for their patients.

TRIAL REGISTRATION

This study was registered on Clinicaltrials.gov (clinicaltrials.gov identifier: NCT03650517 ) on August 28th 2018 (study protocol version CI18/02 revision A, 21 February 2018).

Risk Factors for Surgical Site Infection After Laparoscopic Colectomy: An NSQIP Database Analysis

BACKGROUND

Surgical site infection (SSI) is a common complication after colon surgery. This study aimed to evaluate risk factors for SSI and its types in laparoscopic colectomy patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

MATERIALS AND METHODS

The NSQIP database was queried for patients undergoing laparoscopic colectomy from 2011 through 2017. Univariate analysis and multivariable logistic regression were used to evaluate risk factors associated with any SSI, superficial SSI, deep-incisional SSI, and organ-space SSI.

RESULTS

Of 72,519 patients, 4906 cases of SSI were identified: 2276 superficial SSI, 357 deep-incisional SSI, and 2483 organ-space SSI. Risk factors associated with superficial SSI were admission before procedure (adjusted odds ratio [AOR] = 1.31; 95% confidence interval [CI] 1.17-1.47; P < 0.01), smoking (AOR = 1.29; 95% CI 1.16-1.44; P < 0.01), and higher body mass index (AOR = 1.24 for every 5 kg/m² increase; 95% CI 1.20-1.27; P < 0.01). Deep-incisional SSI was associated with steroid use (AOR = 1.81; 95% CI 1.31-2.49; P < 0.01), admission before procedure (AOR = 1.66; 95% CI 1.30-2.13; P < 0.01), and smoking (AOR = 1.50; 95% CI 1.17-1.94; P < 0.01). Risk factors associated with organ-space SSI were wound class (AOR = 2.45 for class 4 versus ≤ 2; 95% CI 2.16-2.78; P < 0.01), chemotherapy within 90 d (AOR = 1.57; 95% CI 1.33-1.84; P < 0.01), and steroid use (AOR = 1.46; 95% CI 1.29-1.65; P < 0.01). Receipt of an oral antibiotic prep preoperatively was the strongest factor associated with SSI.

CONCLUSIONS

SSI types in patients undergoing laparoscopic colectomy have different risk factors. Modifiable risk factors may provide an opportunity to reduce SSI risk and its associated morbidity.

Randomized clinical trial of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy (IEA trial)

BACKGROUND

Several non-randomized and retrospective studies have suggested that intracorporeal anastomosis (IA) has advantages over extracorporeal anastomosis (EA) in laparoscopic right colectomy, but scientific evidence is lacking. The aim was to compare short-term outcomes and to define the possible benefits of IA compared with EA in elective laparoscopic right colectomy.

METHODS

An RCT was conducted from May 2015 to June 2018. The primary endpoint was duration of hospital stay. Secondary endpoints were intraoperative technical events and postoperative clinical outcomes.

RESULTS

A total of 140 patients were randomized. Duration of surgery was longer for procedures with an IA than in those with an EA (median 149 (range 95-215) versus 123 (60-240) min; P < 0·001). Wound length was shorter in the IA group (median 6·7 (4-9·5) versus 8·7 (5-13) cm; P < 0·001). Digestive function recovered earlier in patients with an IA (median 2·3 versus 3·3 days; P = 0·003) and the incidence of paralytic ileus was lower (13 versus 30 per cent; P = 0·022). Less postoperative analgesia was needed in the IA group (mean(s.d.) weighted analgesia requirement 39(24) versus 53(26); P = 0·001) and the pain score was also lower (P = 0·035). The postoperative decrease in haemoglobin level was smaller (mean(s.d.) 8·8(1·7) versus 17·1(1·7) mg/dl; P = 0·001) and there was less lower gastrointestinal bleeding (3 versus 14 per cent; P = 0·031) in the IA group. IA was associated with a significantly better rate of grade I and II complications (P = 0·016 and P = 0·037 respectively). The duration of hospital stay was slightly shorter in the IA group (median 5·7 (range 2-19) versus 6·6 (2-23) days; P = 0·194).

CONCLUSION

Duration of hospital stay was similar, but IA was associated with less pain and fewer complications. Registration number: NCT02667860 ( http://www.clinicaltrials.gov).

Simultaneous Colon and Liver Laparoscopic Resection for Colorectal Cancer with Synchronous Liver Metastases: A Single Center Experience

Background: The one-stage approach for colorectal cancer (CRC) with synchronous liver metastases (SLM) has demonstrated advantages, when feasible, in terms of oncological radicality and reduction in sanitary costs. The simultaneous laparoscopic approach to both colon cancer and liver metastases joins the advantages of mini-invasiveness to the one-stage approach. Methods: During the period from February 2011 to July 2017, a single surgeon performed 17 laparoscopic colorectal operations with simultaneous liver resection for CRC with SLM. Colorectal procedures included 9 rectal resections, 6 left colectomies, and 2 right colectomies. Associated hepatic resections included 1 left hepatectomy, 1 right posterior sectionectomy, 2 segmentectomies, and 13 wedge resections. We analyzed retrospectively the patient's short-term outcome and operative and oncologic results. Results: There was no conversion to open surgery. Six patients (35%) had minor complications (Clavien-Dindo grade I-II), whereas only 2 patients (12%) had major complications (Clavien-Dindo grade III-IV) and no mortality occurred. The median time of discharge was 8.6 (range 5-36) days. We obtained 94% of R0 resection margin on the liver specimen and 100% of negative distal and circumferential margin in case of rectal resection. An average of 20 lymphnodes were retrieved in the colorectal specimen. Conclusions: Simultaneous mini-invasive colorectal and liver resection is a challenging but feasible procedure. The advantages of treating primary cancer and metastases in the same recovery justify the morbidity rate, especially because the most of the complications are minor and no cases of mortality occurred. Further experience is needed to better understand how to reduce the morbidity rate.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.

RESULTS

Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).

CONCLUSION

These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer: Analysis of Feasibility and Safety from a Single Western Center

BACKGROUND

Colectomies performed according to complete mesocolic excision (CME) principles have demonstrated an improvement in the quality of surgical specimen and a potential improvement of long-term results. Laparoscopic CME right hemicolectomy is considered a demanding procedure and adopted in few centers from the West. The main purpose of this paper is to present a video showing our technique for laparoscopic CME right hemicolectomy and to analyze our short-term results to prove its safety.

METHODS

Data from 38 patients operated on at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between September 2014 and February 2017, were included in the study.

RESULTS

In the present series, 37% of patients were ≥75 years old, 32% of patients were ASA class 3, 46% of patients had ≥2 comorbidities, 30% of patients had BMI >28 and 17% of patients had ≥2 previous abdominal surgeries. Despite these unfavorable clinic characteristics, no mortality was observed, Clavien-Dindo ≥3 complications occurred in 13.1% and redo surgery in 5.3%. Good quality specimens were obtained with a mean (SD) length of 34.5±7.5 cm, a proximal margin of 16.8±9.2 cm and a distal margin of 14.3±6.4 cm. The mean (SD) number of harvested lymph nodes was 24.3 (8.3).

CONCLUSIONS

When implemented in a Western center, laparoscopic CME right hemicolectomy is feasible and safe and allows obtaining good quality specimens.

Pancreatoduodenectomy with colon resection for pancreatic cancer: a systematic review

BACKGROUND

Radical resection of advanced pancreatic cancer may occasionally require a simultaneous colon resection. The risks and benefits of this combined procedure are largely unknown. This systematic review aimed to assess short and long term outcome after pancreatoduodenectomy with colon resection (PD-colon) for pancreatic ductal adenocarcinoma (PDAC).

METHODS

A systematic literature search was performed in PubMed, Embase, and the Cochrane Library for studies published between 1994 and 2017 concerning PD-colon for PDAC.

RESULTS

After screening 2038 articles, 5 articles with a total of 181 patients undergoing PD-colon were eligible for inclusion. Included studies showed a relatively low risk of bias. The pooled complication rate was 73% (95% CI 61-84) including a pooled colonic anastomotic leak rate of 5.5%. Pooled mortality was 10% (95% CI 6-15). Pooled mean survival (data from 86 patients) was 18 months (95% CI 13-23) with pooled 3- and 5-year survival of 31% (95% CI 20-72) and 19% (95% CI 6-38).

CONCLUSION

Based on the available data, PD-colon for PDAC seems to be associated with an increased morbidity and mortality but with survival comparable with standard PD in selected patients. Future large series are needed to allow for better patient selection for PD-colon.

Robotic versus laparoscopic right colectomy with intracorporeal anastomosis: a multicenter comparative analysis on short-term outcomes

BACKGROUND

In literature, most of the comparative studies of robotic (RRC) versus laparoscopic (LRC) right colectomy are biased by the type of the anastomotic technique adopted. With this study, we aim to understand whether there is a role for robotics in performing right colectomies, comparing RRC versus LRC, both performed with intracorporeal anastomosis.

METHODS

In this retrospective cohort study, all consecutive patients who underwent minimally invasive right colectomy (robotic or laparoscopic) with intracorporeal anastomosis in three Italian high-volume centers between February 1, 2007 and December 31, 2017 were included. Patients were grouped according to the method of surgery: RRC or LRC.

RESULTS

A total of 389 patients were included in the study (305 RRC vs. 84 LRC). Patients' baseline characteristics were comparable between the groups. Operative time was significantly longer in RRC (250 min, IQR 209-305) group than LRC group (160 min, IQR 130-200) (p < 0.001). The median number of lymph nodes harvested was 22 (IQR 18-29) in RRC group while it was 19 (IQR 15-27) in LRC one (p = 0.028). No significant differences between the groups were seen in terms of time-to-first flatus, postoperative complications and length of hospital stay. Re-admission rate was significantly higher in LRC (n = 3, 3.6%) group than in RRC group (n = 1, 0.3%) (p = 0.033).

CONCLUSIONS

In conclusion, RRC and LRC are comparable in terms of functional postoperative outcomes and length of hospital stay. RRC requires longer operative time, but the number of lymph nodes harvested may be higher.

Advantages of Robotic Right Colectomy With Intracorporeal Anastomosis

Through retrospective review of consecutive charts, we compare the short-term and long-term clinical outcomes after robotic-assisted right colectomy with intracorporeal anastomosis (RIA) (n=89) and laparoscopic right colectomy with extracorporeal anastomosis (LEA) (n=135). Cohorts were similar in demographic characteristics, comorbidities, pathology, and perioperative outcomes (conversion, days to flatus and bowel movement, and length of hospitalization). The RIA cohort experienced statistically significant: less blood loss, shorter incision lengths, and longer specimen lengths than the LEA cohort. Operative times were significantly longer for the RIA group. No incisional hernias occurred in the RIA group, whereas the LEA group had 5 incisional hernias; mean follow-up was 33 and 30 months, respectively. RIA is effective and safe and provides some clinical advantages. Future studies may show that, in obese and other technically challenging patients, RIA facilitates resection of a longer, consistent specimen with less mesentery trauma that can be extracted through smaller incisions.

A rare case of ascending colon adenocarcinoma incarcerated in an inguinoscrotal hernia: case report and literature review

Background

Inguinal hernias and colorectal cancers are common conditions, but the presentation of a loop of bowel containing cancer within a hernia is rare. Principles of surgery include oncological resection of the involved colonic segment as well as lymphatic drainage. Based on case reports of the last several decades, there have been no reports of a case where the reduction of an inguinoscrotal hernia and oncological colectomy were performed completely laparoscopically. We present the first instance of a completely laparoscopically assisted resection and hernia repair on a patient with T4 ascending colon cancer. A literature search on recent case reports over the last 30 years has also been presented with a focus on trends in treatment.

Case presentation

An 83-year-old man presented for further investigation of his iron deficiency anaemia and was diagnosed with adenocarcinoma of the ascending colon. This was demonstrated radiologically to be found within a large right inguinoscrotal hernia. He underwent a laparoscopically assisted right hemicolectomy and laparoscopic closure of the internal ring and recovered well.

Conclusions

Colorectal cancers within inguinal hernias are rare and can often present with complications such as perforation. As such, treatment has mostly involved an open operation. The last few years have shown feasibility of a laparoscopic approach and can be attempted safely when indicated.

Total intracorporeal anastomosis for right hemicolectomy: Experience from a Canadian center

BACKGROUND

Laparoscopic right hemicolectomy (LRHC) techniques have varied in the approach to anastomosis. We compared outcomes of laparoscopic right hemicolectomy with extracorporeal anastomosis (ECA) versus intracorporeal anastomosis (ICA).

METHODS

We retrospectively reviewed all LRHCs conducted at Richmond Hospital between January 2015 and October 2017. We compared the demographic, pathologic, intraoperative, and postoperative data.

RESULTS

74 LRHCs were included during the study period: 56 ECA and 18 ICA. The groups were comparable in age, gender, tumor staging, and tumor location. Incidence of clinical ileus was significantly less for ICA (0% vs. 21%, p = 0.032). Mean length of stay was significantly shorter for ICA (3.13 vs. 4.82 days, p = 0.003). There was no difference between ICA and ECA in mean operative time (158 vs. 145 min, p = 0.087), surgical site infections (6% vs. 4%, p = 1.0), emergency department visits within 30 days (5% vs. 6%, p = 1.0), and hospital readmission within 30 days (4% vs 0%, p = 1.0). There were no incidences of anastomotic leaks, perioperative deaths, or cardiopulmonary complications in either group.

CONCLUSIONS

An ICA approach to LRHC results in shorter hospital stay and decreased rates of clinical ileus.

Minimally Invasive versus Open Approach for Right-Sided Colectomy: A Study in 12,006 Patients from the Dutch Surgical Colorectal Audit

BACKGROUND

There is ongoing debate whether laparoscopic right colectomy is superior to open surgery. The purpose of this study was to address this issue and arrive at a consensus using data from a national database.

METHODS

Patients who underwent elective open or laparoscopic right colectomy for colorectal cancer during the period 2009-2013 were identified from the Dutch Surgical Colorectal Audit. Complications that occurred within 30 days after surgery and 30-day mortality rates were calculated and compared between open and laparoscopic resection.

RESULTS

In total, 12,006 patients underwent elective open or laparoscopic surgery for right-sided colorectal cancer. Of these, 6,683 (55.7%) underwent open resection and 5,323 (44.3%) underwent laparoscopic resection. Complications occurred within 30 days after surgery in the laparoscopic group in 26.1% of patients and in 32.1% of patients in the open group (p < 0.001). Thirty-day mortality was also significantly lower in the laparoscopic group (2.2 vs. 3.6% p < 0.001).

CONCLUSION

In this non-randomized, descriptive study conducted in the Netherlands, open right colectomy seems to have a higher risk for complications and mortality as compared to laparoscopic right colectomy, even after correction for confounding factors.

Open Colectomies of Shorter Operative Time Do Not Result in Improved Outcomes Compared With Prolonged Laparoscopic Operations

BACKGROUND

Laparoscopic colectomies are associated with reduced perioperative morbidity and mortality compared with open surgery. Nevertheless, many surgeons continue to utilize an open surgical approach due to the perceived benefits of shorter operative times. This study aims to compare the outcomes of laparoscopic versus open colectomies of equal or shorter operative duration.

METHODS

All patients undergoing elective laparoscopic or open colectomy in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) were identified from the years 2005 through 2012. Patients were stratified first by operative procedure including partial colectomy, total colectomy, or low anterior resection. Each surgical group was then divided into 4 groups according to operative time: <90 minutes, ≥90 minutes and <3 hours, ≥3 hours and <6 hours, and ≥6 hours. In total, 30-day outcomes were compared between laparoscopic operations and open procedures of shorter or equivalent durations within each surgical group. Multivariate logistic regression was utilized to account for differences in patient demographics and comorbidities between the surgical groups.

RESULTS

In total, 156,503 patients met inclusion criteria; 112,053 (71.6%) patients underwent a partial colectomy, 13,838 (8.8%) patients underwent a total colectomy, and 30,612 (19.6%) patients underwent a low anterior resection. A laparoscopic approach was used in 34% (37,789 patients) of the partial colectomies performed, 31% (4285 patients) of the total colectomies performed, and 45% (13,850 patients) of the low anterior resections performed. For all procedures, laparoscopic operations <6 hours were associated with superior outcomes compared with shorter open procedures. The benefit of laparoscopic operations was lost when operative time exceeded 6 hours.

CONCLUSIONS

Laparoscopic colectomies are associated with improved outcomes compared with open operations that do not exceed an operative time of 6 hours. Given the potential to improve patient outcomes, consideration should be given to the laparoscopic approach for all colon surgeries expected to be completed in <6 hours.

Robotic right hemicolectomy: Analysis of 108 consecutive procedures and multidimensional assessment of the learning curve

PURPOSE

Surgeons tend to view the robotic right colectomy (RRC) as an ideal beginning procedure to gain proficiency in robotic general and colorectal surgery. Nevertheless, oncological RRC, especially if performed with intracorporeal ileocolic anastomosis confectioning, cannot be considered a technically easier procedure. The aim of this study was to assess the learning curve of the RRC performed for oncological purposes and to evaluate its safety and efficacy investigating the perioperative and pathology outcomes in the different learning phases.

METHODS

Data on a consecutive series of 108 patients undergoing RRC with intracorporeal anastomosis between June 2011 and September 2015 at our institution were prospectively collected to evaluate surgical and short-term oncological outcomes. CUSUM (Cumulative Sum) and Risk-Adjusted (RA) CUSUM analysis were performed in order to perform a multidimensional assessment of the learning curve for the RRC surgical procedure. Intraoperative, postoperative and pathological outcomes were compared among the learning curve phases.

RESULTS

Based on the CUSUM and RA-CUSUM analyses, the learning curve for RRC could be divided into 3 different phases: phase 1, the initial learning period (1st-44th case); phase 2, the consolidation period (45th-90th case); and phase 3, the mastery period (91th-108th case). Operation time, conversion to open surgery rate and the number of harvested lymph nodes significantly improve through the three learning phases.

CONCLUSIONS

The learning curve for oncological RRC with intracorporeal anastomosis is composed of 3 phases. Our data indicate that the performance of RRC is safe from an oncological point of view in all of the three phases of the learning curve. However, the technical skills necessary to significantly reduce operative time, conversion to open surgery rate and to significantly improve the number of harvested lymph nodes were achieved after 44 procedures. These data suggest that it might be prudent to start the RRC learning curve by treating only benign diseases and to reserve the performance of oncological resection to when at least the initial learning phase has been completed.

The impact of bevacizumab in metastatic colorectal cancer with an intact primary tumor: Results from a large prospective cohort study

BACKGROUND

Debate continues regarding the benefits versus risks of initial resection of the primary tumor in metastatic colorectal cancer (mCRC) patients with an asymptomatic primary tumor. Although the benefit of the anti-vascular endothelial growth factor agent bevacizumab alongside first-line chemotherapy in mCRC is established, the impact of bevacizumab on the intact primary tumor (IPT) is less well understood.

METHODS

Data from an Australian mCRC registry were used to assess the impact of bevacizumab-based regimens in the presence of an IPT, to see if this differs from effects in resected primary tumor (RPT) patients and to understand the safety profile of bevacizumab in patients with IPT. Progression-free survival (PFS), overall survival (OS) and safety endpoints were analyzed.

RESULTS

Of 1204 mCRC patients, 826 (69%) were eligible for inclusion. Bevacizumab use was similar in both arms (IPT (64%) versus RPT (70%)); compared with chemotherapy alone, bevacizumab use was associated with significantly longer PFS (IPT: 8.5 months vs 4.7 months, P = 0.017; RPT: 10.8 months vs 5.8 months, P < 0.001) and OS (IPT: 20 months vs 14.8 months, P = 0.005; RPT: 24.4 months vs 17.3 months, P = 0.004)).¹ Bevacizumab use in an IPT was associated with more GI perforations (4.5% vs 1.8%, P = 0.210) but less frequent bleeding (1.5% vs 5.3%, P = 0.050) and thrombosis (1.5% vs 2.7%, P = 0.470), versus chemotherapy alone. Median survival was equivalent between patients that did or did not experience bevacizumab-related adverse events - 20.0 months versus 19.9 months, hazard ratio = 0.98, P = 0.623.¹ CONCLUSIONS: The addition of bevacizumab significantly improved survival outcomes in mCRC with an IPT. The occurrence of bevacizumab-related adverse events did not significantly impact survival outcomes.

Surgical approach to right colon cancer: From open technique to robot. State of art

This work is a topic highlight on the surgical treatment of the right colon pathologies, focusing on the literature state of art and comparing the open surgery to the different laparoscopic and robotic procedures. Different laparoscopic procedures have been described for the treatment of right colon tumors: Totally laparoscopic right colectomy, laparoscopic assisted right colectomy, laparoscopic facilitated right colectomy, hand-assisted right colectomy, single incision laparoscopic surgery colectomy, robotic right colectomy. Two main characteristics of these techniques are the different type of anastomosis: Intracorporeal (for totally laparoscopic right colectomy, single incision laparoscopic surgery colectomy, laparoscopic assisted right colectomy and robotic technique) or extracorporeal (for laparoscopic assisted right colectomy, laparoscopic facilitated right colectomy, hand-assisted right colectomy and open right colectomy) and the different incision (suprapubic, median or transverse on the right side of abdomen). The different laparoscopic techniques meet the same oncological criteria of radicalism as the open surgery for the right colon. The totally laparoscopic right colectomy with intracorporeal anastomosis and even more the single incision laparoscopic surgery colectomy, remain a technical challenge due to the complexity of procedures (especially for the single incision laparoscopic surgery colectomy) and the particular right colon vascular anatomy but they seem to have some theoretical advantages compared to the other laparoscopic and open procedures. Data reported in literature while confirming the advantages of laparoscopic approach, do not allow to solve controversies about which is the best laparoscopic technique (Intracorporeal vs Extracorporeal Anastomosis) to treat the right colon cancer. However, the laparoscopic techniques with intracorporeal anastomosis for the right colon seem to show some theoretical advantages (functional, technical, oncological and cosmetic advantages) even if all studies conclude that further prospective randomized trials are necessary. Robotic technique may be useful to overcome the problems related to inexperience in laparoscopy in some surgical centers.

Clinical outcomes and cost-benefit analysis comparing laparoscopic and robotic colorectal surgeries

BACKGROUND

The introduction of minimally invasive platforms for colorectal surgery-laparoscopy and more recently robotics-allows for smaller incisions, shortened hospital stay, less postoperative pain, and quicker return to normal activity. There exists a lack of evidence-based knowledge comparing the clinical outcomes and cost-benefit analysis of the different types of minimally invasive surgery. The aim of this study was to analyze and compare the short-term clinical outcomes and overall hospital costs between laparoscopic and robotic colorectal surgery.

METHODS

After IRB approval, we conducted a retrospective chart review from 131 patients who underwent laparoscopic colorectal surgery and 96 patients who underwent robotic colorectal surgery. Data analyzed included pertinent patient demographics, operative times (OR times), conversion rates, postoperative pathology, complications, length of hospital stay, 90-day readmission rates, 30-day mortality, and overall hospital costs.

RESULTS

Two hundred and twenty-seven patients were included-laparoscopic (N = 131) and robotic (N = 96) colorectal surgeries. Mean age of patients in the laparoscopic versus robotic cohort was 70.9 vs 63.6 years, (p < 0.001). Around 62 % were operated on for malignant disease. Mean OR time was 113 min for laparoscopy and 109 min for robotics, p = 0.59. Conversion rates were comparable. Mean length of hospital stay (6.6 vs 5.7 days) and postoperative complications (3.2 vs 7 %) were comparable between the laparoscopic and robotic arms. Overall hospital charges were $114,853 for laparoscopy and $107,220 for robotics, and no significant difference was noted (p = 0.448, NS).

CONCLUSION

Robotic colectomies were comparable to laparoscopic colectomies in terms of overall hospital charges and short-term clinical outcomes, including length of stay and conversion rates. Robotic surgery was favored for left-sided colectomy. With shorter learning curves and wider availability, robotic approach offers a safe and economically feasible minimally invasive platform for complex colorectal resections.

Laparoscopic versus robotic right colectomy: technique and outcomes

Minimally invasive surgery has gained worldwide acceptance in the treatment of colonic cancer in the last decades, thanks to its well-known advantages in short-term outcomes. Nevertheless, the penetrance of minimally invasive colorectal surgery still remains low. Few studies and metanalysis, to date, have analyzed the results of robotic versus laparoscopic colorectal surgery, often with conflicting conclusions. The robotic platform, thanks to its technological features, may potentially overcome the limitation of standard laparoscopy, especially when performing a complete mesocolic excision resection and an intracorporeal anastomosis. Robotic surgery could also shorten the learning curve of young novice surgeons, provided that strict protocols of structured training are applied. This paper is an update on the current available outcomes of robotic vs laparoscopic surgery in right colectomy.

Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years

Background

Robotic surgery has been in existence for 30 years. This study aimed to evaluate the overall perioperative outcomes of robotic surgery compared with open surgery (OS) and conventional minimally invasive surgery (MIS) across various surgical procedures.

Methods

MEDLINE, EMBASE, PsycINFO, and ClinicalTrials.gov were searched from 1990 up to October 2013 with no language restriction. Relevant review articles were hand-searched for remaining studies. Randomised controlled trials (RCTs) and prospective comparative studies (PROs) on perioperative outcomes, regardless of patient age and sex, were included. Primary outcomes were blood loss, blood transfusion rate, operative time, length of hospital stay, and 30-day overall complication rate.

Results

We identified 99 relevant articles (108 studies, 14,448 patients). For robotic versus OS, 50 studies (11 RCTs, 39 PROs) demonstrated reduction in blood loss [ratio of means (RoM) 0.505, 95 % confidence interval (CI) 0.408–0.602], transfusion rate [risk ratio (RR) 0.272, 95 % CI 0.165–0.449], length of hospital stay (RoM 0.695, 0.615–0.774), and 30-day overall complication rate (RR 0.637, 0.483–0.838) in favour of robotic surgery. For robotic versus MIS, 58 studies (21 RCTs, 37 PROs) demonstrated reduced blood loss (RoM 0.853, 0.736–0.969) and transfusion rate (RR 0.621, 0.390–0.988) in favour of robotic surgery but similar length of hospital stay (RoM 0.982, 0.936–1.027) and 30-day overall complication rate (RR 0.988, 0.822–1.188). In both comparisons, robotic surgery prolonged operative time (OS: RoM 1.073, 1.022–1.124; MIS: RoM 1.135, 1.096–1.173). The benefits of robotic surgery lacked robustness on RCT-sensitivity analyses. However, many studies, including the relatively few available RCTs, suffered from high risk of bias and inadequate statistical power.

Conclusions

Our results showed that robotic surgery contributed positively to some perioperative outcomes but longer operative times remained a shortcoming. Better quality evidence is needed to guide surgical decision making regarding the precise clinical targets of this innovation in the next generation of its use.

A cost-minimization analysis of first intention laparoscopic compared to open right hemicolectomy for colon cancer

BACKGROUND

The morbidity, mortality and survival following a laparoscopic right hemicolectomy for colon cancer are equivalent to an open operation. However, the cost of a longer operating time and consumables may offset savings from a shorter length of stay (LOS). A cost minimization study was undertaken to compare the relative costs.

METHODS

A retrospective cohort study of consecutive elective right hemicolectomies for colon cancer performed over 5 years by two teams. One team performed an open operation (OG), the other intended to perform all operations laparoscopically (LG). Clinical outcomes and relative costs were evaluated. Results expressed as mean ± SEM.

RESULTS

There were 58 patients in the open group and 56 in the first intention laparoscopic group, of which 77% were completed laparoscopically. There was no difference in age, gender or cancer stage. The complications, mortality and 5-year survival were similar. Anaesthetic (LG = 63 ± 3, OG = 62 ± 2 min) and surgical times (LG = 144 ± 8, OG = 143 ± 5 min) were similar. Consumables cost €571 more and the total theatre cost was €643 ± 256 higher in the laparoscopic group compared with the open group (p = 0.01). The LOS in the laparoscopic group (4.6 ± 0.5 days) was less than in the open group (8.3 ± 1 days, p < 0.01) saving €1960 ± 636 per patient. Overall, first intention laparoscopic right hemicolectomies saved €1316 ± 733 per patient. A probability sensitivity analysis indicated a 62% probability that a laparoscopic right hemicolectomy was cheaper than an open operation.

CONCLUSION

Laparoscopic right hemicolectomy is oncologically equivalent but less costly and should be considered the procedure of choice for right-sided colon cancer unless contraindicated.

Emergent Laparoscopic Colectomy Is an Effective Alternative to Open Resection for Benign and Malignant Diseases: a Meta-Analysis

The aim of this study is to compare the perioperative outcomes between laparoscopic and open resections performed for colonic emergencies. A systematic search of the literature identified previously published comparative studies regarding emergent laparoscopic colectomy (ELC) and emergent open colectomy (EOC). Meta-analysis was performed utilizing a pooled odds ratio (OR) for dichotomous variables and a weighted mean difference (WMD) for continuous variables with 95 % confidence intervals (CIs). Eleven studies involving 752 patients were identified. Although operation time was noted to be significantly shorter for EOC, patients post-ELC had significantly lower overall morbidity (OR 0.44; 95 % CI 0.30, 0.66; P < 0.0001). Meanwhile, recovery time for post-ELC patients was significantly shorter, as was the length of hospital stay (WMD -2.78 days; 95 % CI -3.17, -2.38; P < 0.00001), the time to regular dietary habits (WMD -1.32 days; 95 % CI -2.51, -0.13; P = 0.03), and the time to recover bowel movement (WMD -0.55 days; 95 % CI -0.89, -0.22; P = 0.001). Reoperation rate and mortality were found to be comparable between ELC and EOC. The R0 resection rate and the number of lymph nodes harvested were also comparable between ELC and EOC for malignant diseases. Whether for benign or malignant disease, ELC is a safe and feasible procedure for colonic emergencies compared with EOC, despite being relatively time-consuming.

Open Right Hemicolectomy:Lateral to Medial or Medial to Lateral Approach?

OBJECTIVE

Currently, no published studies have compared the clinical outcomes of the medial-to-lateral approach (MA) and lateral-to-medial approach (LA) for open right hemicolectomy. Thus, the present study aimed to assess whether one of these approaches has any potential benefits over the other.

METHODS

A retrospective study was performed of all patients who underwent open right hemicolectomy with pathologically confirmed disease who met the eligibility criteria between June 2008 and June 2012. The population was divided into an MA group and an LA group by propensity scoring. We compared patient demographic and clinical characteristic variables between the two groups and assessed short-term and long-term outcomes.

RESULTS

A total of 450 patients (MA, n = 150; LA, n = 300) were evaluated. The operation time (MA,138.4 minutesvs.LA,166.2 minutes; P < .05) and blood loss (MA,52.0mL vs. LA,62.6mL; P < .05)were significantly lower in the MA group. No differences in the number of harvested lymph nodes and oncologic outcomes were observed between the two groups. Further subgroup analysis for stage III colon cancer revealed that the MA group had significantly more retrieved lymph nodes (MA,18.8vs. LA,16.0; P = .028). There were no differences in other variables between the two groups.

CONCLUSIONS

The MA reduced operative time and blood loss compared with the LA. We thus concluded that the MA provided short-term benefits compared with the LA in open right hemicolectomy for right-sided colon cancer.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

The uncinate process first approach: a novel technique for laparoscopic right hemicolectomy with complete mesocolic excision

BACKGROUND

Current evidence suggests that complete mesocolic excision (CME) for right-sided colon cancer could be beneficial in terms of long-term survival. However, CME is a considerably more complex operation than standard right hemicolectomy; this is especially true for the laparoscopic approach. Consequently, we have explored a new laparoscopic approach that provides surgical radicality at the mesenteric root on the one hand and maximum safety on the other hand.

METHODS

The key feature of the uncinate process first approach (UFA) is the commencement of the dissection at the fourth part of the duodenum using a medial to lateral approach, thus mobilizing the whole mesenteric root posteriorly before the central parts of the mesenteric vessels are accessed. Twenty-eight selected patients with right-sided colon cancer underwent surgery using the UFA and were compared with 51 patients who underwent an open CME procedure (CON). In 11/28 and 51/51 patients in the UFA and CON groups, respectively, a planimetric assessment of the specimen was performed.

RESULTS

Surgical time was longer (144.8 vs. 202.5 min; p < 0.000) and postoperative stay shorter (8.0 vs. 10.5 days; p < 0.01) for the laparoscopic approach. The area of the resected mesentery (UFA, 15,097 mm(2); CON, 15,788 mm(2); p = 0.47) and the lymph node count (UFA, 59.0; CON, 51.0; p = 0.09) was not significantly different; additionally, no difference was observed regarding anastomotic leakage (both n = 0) and postoperative mortality (UFA, 0/28; CON, 1/51; p = 1.0).

CONCLUSION

Laparoscopic right hemicolectomy with CME using the UFA provides adequate radicality according to the CME principles and seems feasible and as safe as an open technique. However, future trails will have to demonstrate whether the theoretical advantages of the UFA, with a higher degree of mobility and accessibility of the mesenteric root, translate into a significant clinical benefit, especially relative to the other laparoscopic techniques.

Is robot-assisted laparoscopic right colectomy more effective than the conventional laparoscopic procedure? A meta-analysis of short-term outcomes

AIM

The use of robotic technology procedures has proved to be safe and effective, arising as a helpful alternative to standard laparoscopic surgery in a variety of colorectal procedures. However, the role of robotic assistance in laparoscopic right colectomy is still not demonstrated.

METHODS

A systematic review of the literature was carried out performing an unrestricted search in MEDLINE, EMBASE, the Cochrane Library and Google Scholar up to 30th August 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We meta-analyzed the currently available data regarding the incidence of anastomotic leakage, operative time, intra-operative blood loss, conversion rate, retrieved lymphnodes, post-operative hemorrhage, intra-abdominal abscess, time to 1st flatus, post-operative ileus, wound infection, incisional hernia, not-surgical complications, total complications, hospital stay, post-operative mortality, surgery-related costs and total costs, in conventional laparoscopic right colectomy (LRC) compared to robot-assisted laparoscopic right colectomy (RRC).

RESULTS

Overall 8 studies were included, thus resulting in 616 patients. The meta-analysis showed that the RRC decreases the intra-operative blood loss and the time to the 1st flatus, if compared to the LRC. On the other hand, the robotic assistance increases the operative time and the surgery-related costs. No statistically significant differences were found about the other post-operative outcomes.

CONCLUSION

RRC may ensure limited improvements in post-operative outcome, thus increasing procedural costs and without a proved enhanced oncological accuracy to date, if compared to the LRC.

Diverting ileostomy in colorectal surgery: when is it necessary?

PURPOSE

The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice.

METHODS

Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion.

RESULTS

Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion.

CONCLUSIONS

Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.

Robotic right colectomy: A worthwhile procedure? Results of a meta-analysis of trials comparing robotic versus laparoscopic right colectomy

BACKGROUND:

Robotic right colectomy (RRC) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach is worthwhile in enhancing patient recovery and reducing post-operative complications, compared with laparoscopic right colectomy (LRC). Literature is still fragmented and no meta-analyses have been conducted to compare the two procedures. This work aims at reducing this gap in literature, in order to draw some preliminary conclusions on the differences and similarities between RRC and LRC, focusing on short-term outcomes.

MATERIALS AND METHODS:

A systematic literature review was conducted to identify studies comparing RRC and LRC, and meta-analysis was performed using a random-effects model. Peri-operative outcomes (e.g., morbidity, mortality, anastomotic leakage rates, blood loss, operative time) constituted the study end points.

RESULTS:

Six studies, including 168 patients undergoing RRC and 348 patients undergoing LRC were considered as suitable. The patients in the two groups were similar with respect to sex, body mass index, presence of malignant disease, previous abdominal surgery, and different with respect to age and American Society of Anesthesiologists score. There were no statistically significant differences between RRC and LRC regarding estimated blood loss, rate of conversion to open surgery, number of retrieved lymph nodes, development of anastomotic leakage and other complications, overall morbidity, rates of reoperation, overall mortality, hospital stays. RRC resulted in significantly longer operative time.

CONCLUSIONS:

The RRC procedure is feasible, safe, and effective in selected patients. However, operative times are longer comparing to LRC and no advantages in peri-operative and post-operative outcomes are demonstrated with the use of the robotic surgical system.