Robotic colectomy with CME versus laparoscopic colon resection with or without CME for colon cancer: a systematic review and meta-analysis

INTRODUCTION

This systematic review with meta-analysis aimed to compare the robotic complete mesocolon excision (RCME) to laparoscopic colectomy (LC) with (LCME) or without CME (LC non-CME) in postoperative outcomes, harvested lymph nodes and disease-free survival.

METHODS

We performed a systematic review with meta-analysis according to PRISMA 2020 and AMSTAR 2 guidelines.

RESULTS

The literature search yielded seven comparative studies including 677 patients: 269 patients in the RCME group and 408 in the LC group. The pooled analysis concluded to a lower conversion rate in the RCME group (OR=0.17; 95% CI [0.04, 0.74], p=0.02). There was no difference between the two groups in terms of morbidity (OR=1.03; 95% CI [0.70, 1.53], p=0.87), anastomosis leakage (OR=0.83; 95% CI [0.18, 3.72], p=0.81), bleeding (OR=1.90; 95% CI [0.64, 5.58], p=0.25), wound infection (OR=1.37; 95% CI [0.51, 3.68], p=0.53), operative time (mean difference (MD)=36.32; 95% CI [-24.30, 96.93], p=0.24), hospital stay (MD=-0.94; 95% CI [-2.03, 0.15], p=0.09) and disease-free survival (OR=1.29; 95% CI [0.71, 2.35], p=0.41). In the subgroup analysis, the operative time was significantly shorter in the LCME group than RCME group (MD=50.93; 95% CI [40.05, 61.81], p<0.01) and we noticed a greater number of harvested lymph nodes in the RCME group compared with LC non-CME group (MD=8.96; 95% CI [5.98, 11.93], p<0.01).

CONCLUSIONS

The robotic approach for CME ensures a lower conversion rate than the LC. RCME had a longer operative time than the LCME subgroup and a higher number of harvested lymph nodes than the LC non-CME group.

Artificial intelligence for detection of microsatellite instability in colorectal cancer-a multicentric analysis of a pre-screening tool for clinical application

BACKGROUND

Microsatellite instability (MSI)/mismatch repair deficiency (dMMR) is a key genetic feature which should be tested in every patient with colorectal cancer (CRC) according to medical guidelines. Artificial intelligence (AI) methods can detect MSI/dMMR directly in routine pathology slides, but the test performance has not been systematically investigated with predefined test thresholds.

METHOD

We trained and validated AI-based MSI/dMMR detectors and evaluated predefined performance metrics using nine patient cohorts of 8343 patients across different countries and ethnicities.

RESULTS

Classifiers achieved clinical-grade performance, yielding an area under the receiver operating curve (AUROC) of up to 0.96 without using any manual annotations. Subsequently, we show that the AI system can be applied as a rule-out test: by using cohort-specific thresholds, on average 52.73% of tumors in each surgical cohort [total number of MSI/dMMR = 1020, microsatellite stable (MSS)/ proficient mismatch repair (pMMR) = 7323 patients] could be identified as MSS/pMMR with a fixed sensitivity at 95%. In an additional cohort of N = 1530 (MSI/dMMR = 211, MSS/pMMR = 1319) endoscopy biopsy samples, the system achieved an AUROC of 0.89, and the cohort-specific threshold ruled out 44.12% of tumors with a fixed sensitivity at 95%. As a more robust alternative to cohort-specific thresholds, we showed that with a fixed threshold of 0.25 for all the cohorts, we can rule-out 25.51% in surgical specimens and 6.10% in biopsies.

INTERPRETATION

When applied in a clinical setting, this means that the AI system can rule out MSI/dMMR in a quarter (with global thresholds) or half of all CRC patients (with local fine-tuning), thereby reducing cost and turnaround time for molecular profiling.

Flexible endoscopy is enough diagnostic prior to loop ileostomy reversal

PURPOSE

This study investigates whether contrast enema (CE) and flexible endoscopy (FE) should be performed routinely after low anterior resection (LAR) before ileostomy reversal. Additionally, the impact of previous anastomotic leakage (AL) on diagnostic test accuracy (DTA) was assessed.

METHODS

This is a retrospective analysis of prospectively collected tertiary care data of two centers. Consecutive rectal cancer patients undergoing LAR with loop ileostomy formation were included. Before ileostomy reversal, all patients were assessed by CE and FE. DTA of FE and CE for asymptomatic AL in patients who had previously suffered from clinically relevant AL (group 1) compared with those without apparent AL after LAR (group 0) were assessed separately.

RESULTS

Two hundred ninety-three patients were included in the analysis, 86 in group 1 and 207 in group 0. Overall sensitivity for detection of asymptomatic AL was 76% (FE) and 60% (CE). Specificity was 100% for both tests. DTA of FE was equal or superior to CE in all subgroups. Prevalence of asymptomatic AL at the time of testing was 1.4% in group 0 and 25.6% in group 1.

CONCLUSION

Flexible endoscopy is the more accurate diagnostic test for the detection of asymptomatic anastomotic leaks prior to ileostomy reversal. Contrast enema showed no gain of information. In the group without complications after the initial rectal resection, 104 must be tested to find one leak prior to reversal. In those patients, routine diagnostic testing additional to digital rectal examination may be questioned.

Randomized clinical trial of stapler hepatectomy versus LigaSure™ transection in elective hepatic resection

BACKGROUND

Previous studies have demonstrated stapler hepatectomy and use of various energy devices to be safe alternatives to the clamp-crushing technique in elective hepatic resection. In this randomized trial, the effectiveness and safety of stapler hepatectomy were compared with those of parenchymal transection with the LigaSure™ vessel sealing system.

METHOD

Patients scheduled for elective liver resection at two tertiary-care centres were randomized during surgery to stapler hepatectomy or transection with the LigaSure™ device. Total intraoperative blood loss was the primary efficacy endpoint. Transection time, duration of operation, perioperative complications and length of hospital stay were recorded as secondary endpoints.

RESULTS

A total of 138 patients were analysed, 69 in the LigaSure™ and 69 in the stapler hepatectomy group. Baseline characteristics were well balanced between the groups. Mean intraoperative blood loss was significantly higher in the LigaSure™ group than the stapler hepatectomy group: 1101 (95 per cent c.i. 915 to 1287) versus 961 (752 to 1170) ml (P = 0·028). The parenchymal transection time was significantly shorter in the stapler group (P = 0·005), as was the total duration of operation (P = 0·027). Surgical morbidity did not differ between the groups, nor did the grade of complications.

CONCLUSION

Stapler hepatectomy was associated with reduced blood loss and a shorter duration of operation than the LigaSure™ device for parenchymal transection in elective partial hepatectomy. Registration number: NCT01858987 (http://www.clinicaltrials.gov).

Postoperative course and clinical significance of biochemical blood tests following hepatic resection

BACKGROUND

Hepatic resection continues to be associated with substantial morbidity. Although biochemical tests are important for the early diagnosis of complications, there is limited information on their postoperative changes in relation to outcome in patients with surgery-related morbidity.

METHODS

A total of 835 consecutive patients underwent hepatic resection between January 2002 and January 2008. Biochemical blood tests were assessed before, and 1, 3, 5 and 7 days after surgery. Analyses were stratified according to the extent of resection (3 or fewer versus more than 3 segments).

RESULTS

A total of 451 patients (54·0 per cent) underwent resection of three or fewer anatomical segments; resection of more than three segments was performed in 384 (46·0 per cent). Surgery-related morbidity was documented in 258 patients (30·9 per cent) and occurred more frequently in patients who had a major resection (P = 0·001). Serum bilirubin and international normalized ratio as measures of serial hepatic function differed significantly depending on the extent of resection. Furthermore, they were significantly affected in patients with complications, irrespective of the extent of resection. The extent of resection had, however, little impact on renal function and haemoglobin levels. Surgery-related morbidity caused an increase in C-reactive protein levels only after a minor resection.

CONCLUSION

Biochemical data may help to recognize surgery-related complications early during the postoperative course, and serve as the basis for the definition of complications after hepatic resection.

Leucocyte-depleted blood transfusion is an independent predictor of surgical morbidity in patients undergoing elective colon cancer surgery-a single-center analysis of 531 patients

BACKGROUND

Leukocyte-depleted packed red blood cells (PRBC) were introduced to reduce potential immunomodulatory effects and transfusion-associated morbidity. It has, however, remained unclear, if leucocyte depletion prevents negative side effects of blood transfusion. The aim of this analysis was to examine the effects of leukocyte-depleted PRBC on surgical morbidity after elective colon cancer surgery.

METHODS

Data were prospectively collected from 531 consecutive patients undergoing elective colon cancer surgery at a single high-volume center (University Hospital) from 2002 to 2008. Potentially predictive factors for surgical morbidity were tested on univariate and multivariate analysis.

RESULTS

A total of 531 patients with colon cancer were included. A curative (R0) resection was performed in 497 patients (94%). The mortality rate, overall morbidity rate, and surgical morbidity rate were 1.1, 33, and 21%, respectively. Some 135 patients (25%) received perioperative transfusion of PRBCs. On multivariate analysis age (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02-1.06; P = 0.001), BMI (OR 1.08, 95% CI 1.03-1.13; P = 0.003), and PRBC transfusion (2.4, 1.41-4.11; P = 0.001) were revealed as independent predictors of surgical morbidity. The risk of surgical complications increased continuously with the amount of transfused PRBCs. The adverse impact of PRBC transfusion was neither restricted to the timepoint of transfusion (intraoperative or postoperative), nor to the kind of complication (infectious vs noninfectious complication).

CONCLUSION

Perioperative transfusion of leukocyte-depleted PRBCs has a significantly negative effect on surgical morbidity of patients undergoing elective colon cancer surgery. The use of perioperative blood transfusions in these patients should be avoided, whenever possible.

Emergency liver transplantation after umbilical hernia repair: a case report

We report a rare case of acute liver failure due to embolization of the liver after an umbilical hernia repair in a patient with Child B liver cirrhosis and status posttransjugular intrahepatic portosystemic shunt (TIPSS). This patient initially presented with a symptomatic umbilical hernia. His umbilical vein was open (Cruveilhier-Baumgarten syndrome). After hernia repair the patient developed thrombosis of the umbilical vein with consequent partial embolization to, and acute failure of, the liver. The patient underwent successful emergency liver transplantation. This disease needs close collaboration among surgeons, gastroenterologists, hepatologists, radiologists, nutritionists, and transplant teams to establish an effective treatment plan.

[Open appendectomy. When do we still need it?]

Acute appendicitis is the most common emergency visceral surgical procedure in Germany with 130,000 appendectomies. The question of which operational procedure should be used must therefore be discussed at regular intervals. In many centers of minimal invasive surgery, laparoscopic appendectomy (LA) is the standard procedure. Nearly 30 years after introduction of LA, it is believed that open appendectomy (OA) is needed only on rare occasions, but the actual percentage of OAs carried out in 2006 was 46% of all appendectomies. This high percentage documents that OA is still the standard procedure in many German hospitals. A review of the literature shows that there are still some situations in which OA is superior to LA. Infants younger than 5 years old have a more difficult basic requirement for LA due to the small abdominal cavity, therefore OA is the procedure of choice in most cases. During pregnancy OA has a lower risk for the fetus than LA. Cost analyses show that OA is less expensive for the hospital in material costs, whereas LA is the better economic choice due to an earlier return to work. In summary, there are only marginal differences between the two procedures since both offer a fast patient recovery. Advantages in favor of both LA and OA exist in subgroup analyses and the possible subgroups that can benefit from OA are discussed in this article.

Surgical treatment of sigmoid diverticulitis--analysis of predictive risk factors for postoperative infections, surgical complications, and mortality

BACKGROUND AND AIMS

Sigmoid diverticular disease has great clinical importance due to its increasing incidence in the Western world and a broad spectrum of clinical features with potential fatal complications after surgery. The definition of risk factors associated with postoperative infections, surgical complications and mortality could be helpful in clinical decision-making and optimizing perioperative treatment.

MATERIALS AND METHODS

Based on a prospective database, 168 consecutive patients undergoing surgery for sigmoid diverticulitis were included in this study. The association of different potential risk factors such as age, Hinchey classification, type and duration of operation, surgeons' experience, blood loss, comorbidities, and hospital course with perioperative complications and mortality were tested by univariate and multivariate analysis.

RESULTS

Of the 168 patients enrolled in this study, there were 84 male and 84 female. A third of patients were operated as emergency cases (within 24 h after surgical evaluation); 62% underwent open surgery, 35% were treated laparoscopically with a conversion rate of 3%. A blood transfusion received 14% of patients, a surgical infection occurred in 20%, surgical complications appeared in 24% with a necessity for re-exploration in 9.5%. Leakage of the primary anastomosis was seen in 3.3%, whereas a leakage of the Hartmann's stump occurred in 4.3%. Overall in-hospital mortality was 4.1%. Multivariate analysis demonstrated Hinchey classification and intraoperative blood transfusion to be independently associated with postoperative infections, complications and mortality.

CONCLUSION

Hinchey classification and intraoperative blood transfusion are independently associated with a worse perioperative outcome in patients undergoing surgery for sigmoid diverticular disease. While Hinchey classification cannot be influenced per se by the surgeon, outcome might be influenced by reducing the need for intraoperative blood transfusion.

Can laparoscopically assisted sigmoid resection provide uncomplicated management even in cases of complicated diverticulitis?

BACKGROUND

Laparoscopically assisted sigmoid resection has become an accepted method for treating uncomplicated diverticulitis. This prospective study aimed to compare the results of laparoscopic sigmoid resection for uncomplicated and complicated sigmoid diverticular disease used to check the indication for the complicated stages of diverticulitis.

METHODS

All patients who underwent laparoscopic resection for sigmoid diverticulitis at the authors' hospital between 1999 and 2005 were divided into two groups: group 1 (uncomplicated diverticular disease) and group 2 (complicated diverticular disease). The exclusion criteria specified generalized peritonitis, signs of sepsis, and extensive previous abdominal surgery.

RESULTS

Of the 203 patients (108 men and 95 women) who underwent laparoscopically assisted resection during the examination period, 112 were assigned to group 1 and 91 to group 2. Differences in favor of group 1 were found for the duration of surgery (154 vs 166 min), the conversion rate (1.8% vs 9.9%), the postoperative wound infections (2.7% vs 13.2%), and the postoperative hospitalization period (12.3 +/- 3.9 vs 15.0 +/- 5.6 days). No significant differences were seen in any other areas such as completion of nutritional buildup (4.6 vs 5.0 days) or time until the first postoperative bowel movement (2.8 vs 3.3 days). Total postoperative morbidity (16.1% vs 26.4%; p = 0.10) tended to be increased in group 2, but this difference was not statistically significant.

CONCLUSIONS

Laparoscopic sigmoid resection can be performed for patients who have complicated diverticulitis without significantly increasing their overall morbidity. This group of patients could benefit from the advantages of the minimally invasive procedure despite a longer operating time and a higher conversion rate.