Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis

BACKGROUND

Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse.

METHODS

A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis.

RESULTS

Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches.

CONCLUSIONS

A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.

Single-incision versus multi-port laparoscopic ileocolic resections for Crohn's disease: Systematic review and meta-analysis

Introduction

The aim of this systematic review and meta-analysis is to compare the outcomes of single-incision laparoscopic surgery (SILS) versus multi-port laparoscopy for ileocolic resection in patients with Crohn's disease (CD).

Patients and Methods

A systematic search of multiple electronic databases was conducted. The peri- and post-operative outcomes were evaluated between Crohn's patients undergoing SILS versus multi-port laparoscopy for ileocolic resection. The primary outcomes included operative time, anastomotic leak rate, post-operative wound infections and length of hospital stay. Analysed secondary outcomes were conversion rates, ileus occurrence, intra-abdominal abscess formation, return to theatre and re-admissions. Revman 5.3 was used to perform the statistical analysis.

Results

Five observational studies with 521 patients (SILS: 211; multi-port: 310) were included in the data synthesis. Patients undergoing SILS had a reduced total operative time compared to multi-port laparoscopy (mean difference [MD]: -16.14, 95% confidence interval: [CI] -27.23 - 5.05, P = 0.004). Post-operative hospital stay was also found to be significantly less in the SILS group (MD: -0.57, 95% CI: -0.73--0.42, P < 0.0001). No significant difference was seen in the anastomotic leak rate (MD: -16.14, 95% CI: 0.18-1.71, P = 0.004) or post-operative wound infections (odds ratio: 0.78, 95% CI: 0.24 - 2.47, P = 0.67) between the two groups. Moreover, all the measured secondary outcomes were comparable.

Conclusion

SILS seems to be a feasible alternative to multi-port laparoscopic surgery for ileocolic resection in patients with CD. Improved outcomes in terms of total operative time and length of hospital stay were observed in patients undergoing SILS surgery. Adopting this procedure into routine clinical practice constitutes the next step in the development of minimally invasive surgery.

Comparison of Midline and Off-midline specimen extraction following laparoscopic left-sided colorectal resections: A systematic review and meta-analysis

Aims

This study aims to evaluate comparative outcomes following midline versus off-midline specimen extractions following laparoscopic left-sided colorectal resections.

Methods

A systematic search of electronic information sources was conducted. Studies comparing 'midline' versus 'off midline' specimen extraction following laparoscopic left-sided colorectal resections performed for malignancies were included. The rate of incisional hernia formation, surgical site infection (SSI), total operative time and blood loss, anastomotic leak (AL) and length of hospital stay (LOS) was the evaluated outcome parameters.

Results

Five comparative observational studies reporting a total of 1187 patients comparing midline (n = 701) and off-midline (n = 486) approaches for specimen extraction were identified. Specimen extraction performed through an off-midline incision was not associated with a significantly reduced rate of SSI (odds ratio [OR]: 0.71; P = 0.68), the occurrence of AL (OR: 0.76; P = 0.66) and future development of incisional hernias (OR: 0.65; P = 0.64) compared to the conventional midline approach. No statistically significant difference was observed in total operative time (mean difference [MD]: 0.13; P = 0.99), intraoperative blood loss (MD: 2.31; P = 0.91) and LOS (MD: 0.78; P = 0.18) between the two groups.

Conclusions

Off-midline specimen extraction following minimally invasive left-sided colorectal cancer surgery is associated with similar rates of SSI and incisional hernia formation compared to the vertical midline incision. Furthermore, there were no statistically significant differences observed between the two groups for evaluated outcomes such as total operative time, intra-operative blood loss, AL rate and LOS. As such, we did not find any advantage of one approach over the other. Future high-quality well-designed trials are required to make robust conclusions.

Outcomes following open versus laparoscopic multi-visceral resection for locally advanced colorectal cancer: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to compare morbidity, mortality, oncological safety, and survival outcomes after laparoscopic multi-visceral resection (MVR) of the locally advanced primary colorectal cancer (CRC) compared with open surgery.

MATERIALS AND METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic and open surgery in patients with locally advanced CRC undergoing MVR were selected. The primary endpoints were peri-operative morbidity and mortality. Secondary endpoints were R0 and R1 resection, local and distant disease recurrence, disease-free survival (DFS), and overall survival (OS) rates. RevMan 5.3 was used for data analysis.

RESULTS

Ten comparative observational studies reporting a total of 936 patients undergoing laparoscopic MVR (n = 452) and open surgery (n = 484) were identified. Primary outcome analysis demonstrated a significantly longer operative time in laparoscopic surgery compared with open operations (P = 0.008). However, intra-operative blood loss (P<0.00001) and wound infection (P = 0.05) favoured laparoscopy. Anastomotic leak rate (P = 0.91), intra-abdominal abscess formation (P = 0.40), and mortality rates (P = 0.87) were comparable between the two groups. Moreover the total number of harvested lymph nodes, R0/R1 resections, local/distant disease recurrence, DFS, and OS rates were also comparable between the groups.

CONCLUSION

Although inherent limitations exist with observational studies, the available evidence demonstrates that laparoscopic MVR in locally advanced CRC seems to be a feasible and oncologically safe surgical option in carefully selected cohorts.

562 Midline Versus Off Midline Extraction Site in Laparoscopic Left Sided Colorectal Resections for Colorectal Malignancy: A Systematic Review and Meta-Analysis

Method

To evaluate comparative outcomes of off-midline and midline extraction sites in laparoscopic left sided colorectal resections.

Method

A systematic search of electronic databases and bibliographic reference lists was conducted, and a combination of free text and controlled vocabulary search was adapted to thesaurus headings, search operators and limits in electronic databases were applied. Studies comparing the outcomes of Off Midline and Midline incisions for specimen extraction in laparoscopic left sided colorectal resections were included. Incisional hernias, surgical site infections, operative time, estimated blood loss, anastomotic leak and length of hospital stay were the evaluated outcome parameters.

Results

We identified 5 comparative studies reporting a total of 1187 patients comparing outcomes of off-midline (n=486) and midline (n=701) incisions for specimen extraction in laparoscopic left colorectal resections. The off-midline approach was associated with lower post operative surgical site infection (OR 0.71, P=0.68), anastomotic leak (OR 0.76,P=0.66), and incisional hernia (MD: 0.65,P=0.64) compared to midline approach, however it was not statistically significant. There was no significant difference in operative time (MD: 0.10, P=0.99), intra-operative blood loss (MD 2.31, P=0.91), and post-operative hospital stay (MD : 0.78, P=0.18) between the two groups.

Conclusions

Off-midline extraction site for left sided colorectal resections have no significant difference in rates of post operative surgical site infection and incisional hernias when compared to midline extraction site. No significant difference was found in operative time, intra-operative blood loss, anastomotic leak and post operative hospital stay in this study. Future higher-level research is required to further evaluate the clinical outcomes.

EP.TH.770Upgrading the level of evidence regarding Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: Meta-analysis of randomised controlled trials

Objectives

To evaluate comparative outcomes of intracorporeal (ICA) and extracorporeal (ECA) anastomosis in laparoscopic right hemicolectomy.

Methods

We conducted a systematic search of electronic databases and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Overall perioperative morbidity, anastomotic leak, surgical site infection (SSI), paralytic ileus, bleeding, postoperative pain within 5 days, conversion to an open procedure, length of incision and procedure time were the evaluated outcome parameters.

Results

We identified 4 randomised controlled trials reporting a total of 399 patients evaluating outcomes of ICA (n = 199) and ECA (n = 200) in laparoscopic right hemicolectomy. The ICA was associated with significantly shorter length of incision (MD:-1.82, P &lt; 0.00001), lower postoperative pain score on day 2 (MD:-0.69, P = 0.0007), day 3 (MD:-0.80, P = 0.02), day 4 (MD:-0.83, P = 0.01) and day 5 (MD:-0.49, P &lt; 0.00001) when compared to ECA. Moreover, it was associated with significantly shorter length of hospital stay (MD:-0.27, p = 0.03). However, there was no significant difference in overall perioperative morbidity (RR:0.79, P = 0.47), anastomotic leak (RR:1.29, P = 0.65), SSI (RR:0.61, P = 0.42), bleeding (RR:0.70, P = 0.71), ileus (RR:0.60, P = 0.45), conversion to open (RD:-0.02, P = 0.45), number of harvested lymph nodes (MD:0.82, p = 0.06), and procedure time (MD:16.04, p = 0.06) between two groups.

Conclusions

The meta-analysis of level 1 evidence demonstrated that ICA and ECA have comparable perioperative outcomes in laparoscopic right colectomy although the former may be associated with less postoperative pain probably due to shorter incision length. Future research may provide stronger evidence in favour of an intervention.

EP.TH.965Use of Oral Antibiotics as Adjunct to Systemic Antibiotics and Mechanical Bowel Preparation for Left Sided Colorectal Surgery. It is the time to trust the best available evidence and change the practice

Aims

To prospectively evaluate the clinical efficacy of oral antibiotics as an adjunct to intravenous antibiotics and mechanical bowel preparation (MBP) in patients undergoing left sided colorectal surgery.

Methods

All participants aged 18 years or older and of any gender undergoing an elective open or laparoscopic left sided colorectal resection for benign or malignant colorectal pathologies were considered. The intervention of interest was oral neomycin 1g every 4 hours combined with oral metronidazole 400mg every 8 hours from 24 hours before the proposed surgery. Surgical site infections (SSIs), anastomotic leak, paralytic ileus, need for intervention, and mortality were the evaluated outcome parameters.

Results

Forty-two consecutive patients received oral antibiotics as an adjunct to intravenous antibiotics and MBP before left sided colorectal surgery. The mean age was 58.8 ± 11.5. There were 23 males (54.8%) and 19 females (45.2%). Use of oral antibiotics was associated with SSI infection rate of 2.4% (1 patient). The rates of clinically significant and non-significant anastomotic leak were 0% and 2.9%, respectively. Moreover, postoperative ileus happened in 11.9% of patients. Furthermore, there was no mortality or need for re-intervention.

Conclusions

Use of oral antibiotics as an adjunct to intravenous antibiotics and MBP in patients undergoing left-sided colorectal surgery was associated with a surprisingly low rate of SSIs and no significant anastomotic leak. It is time to trust the best available evidence and incorporate the use of oral antibiotics as an adjunct to intravenous antibiotics and MBP in colorectal surgery protocols in the UK hospitals.

EP.TH.959Meta-analysis of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer surgery: An ongoing dilemma

Aims

To evaluate comparative outcomes of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection.

Methods

We systematic searched MEDLINE; EMBASE; CINAHL; CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. Overall perioperative complications, anastomotic leak, surgical site infection, ileus and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

Results

We identified 4 studies reporting a total of 436 patients comparing outcomes of temporary loop ileostomy closure during (n = 185) or after (n = 251) adjuvant chemotherapy following colorectal cancer resection. There was no significant difference in overall perioperative complications (OR 1.39; 95% CI 0.82-2.36, p = 0.22), anastomotic leak (OR 2.80; 95% CI 0.47-16.56, p = 0.26), surgical site infection (OR 1.97; 95% CI 0.80-4.90, p = 0.14), ileus (OR 1.22; 95% CI 0.50-2.96, p = 0.66) or length of hospital stay (MD 0.02; 95% CI -0.85-0.89, p = 0.97) between two groups. Between-study heterogeneity was low in all analyses.

Conclusions

The meta-analysis of best, albeit limited, available evidence suggests that temporary loop ileostomy closure during adjuvant chemotherapy following rectal cancer resection may be associated with comparable outcomes to closure of ileostomy after adjuvant chemotherapy. We encourage future research to concentrate on completeness of chemotherapy and quality of life which can determine appropriateness of either approach.

Meta-analysis of laparoscopic mesh rectopexy versus posterior sutured rectopexy for management of complete rectal prolapse

OBJECTIVES

To evaluate comparative outcomes of laparoscopic mesh rectopexy (LMR) and laparoscopic posterior sutured rectopexy (LPSR) in patients with rectal prolapse.

METHODS

We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Recurrence, Cleveland Clinic Incontinence Score (CCIS), Cleveland Clinic Constipation Score (CCCS), surgical site infections, procedure time, and length of hospital stay were the evaluated outcome measures.

RESULTS

We identified 5 comparative studies reporting a total of 307 patients evaluating outcomes of LMR (n=160) or LPSR (n=147) in patients with rectal prolapse. LMR was associated with significantly lower recurrence rate (OR: 0.28, P=0.009) but longer procedure time (MD: 23.93, P<0.0001) compared to LPSR. However, there was no significant difference in CCIS (MD: -1.02, P=0.50), CCCS (MD: -1.54, P=0.47), surgical site infection (OR: 1.48, P=0.71), and length of hospital stay (MD: -1.54, P=0.47) between two groups. No mesh erosion was reported in any of the included studies at maximum follow-up point. Sub-group analyses with respect to ventral mesh rectopexy, posterior mesh rectopexy, randomised studies, and adult patients were consistent with the main analysis.

CONCLUSIONS

LMR seems to be associated with lower recurrence but longer procedure time compared to LPSR. Although no mesh-related complications have been reported by the included studies, no definitive conclusions can be made considering that the included studies were inadequately powered for such outcome. Future high-quality randomised studies with adequate sample size are required.

Meta-analysis of randomised controlled trials comparing intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: upgrading the level of evidence

The need for escalation of level of evidence regarding the comparative outcomes of intracorporeal (ICA) and extracorporeal (ECA) anastomosis in laparoscopic right hemicolectomy has been persistently highlighted by previous meta-analyses of level 2 and 3 evidence. A systematic search of electronic databases and bibliographic reference lists were conducted. Overall perioperative morbidity, anastomotic leak, surgical site infection (SSI), paralytic ileus, bleeding, postoperative pain within 5 days, length of incision, conversion to an open procedure, harvested lymph nodes, procedure time, and length of hospital stay were the evaluated outcome parameters. Four randomised controlled trials reporting a total of 399 patients evaluating outcomes of ICA (n = 199) and ECA (n = 200) in laparoscopic right hemicolectomy were included. The ICA was associated with significantly shorter length of incision (MD - 1.82, p < 0.00001), lower postoperative pain score on day 2 (MD - 0.69, p = 0.0007), day 3 (MD - 0.80, p = 0.02), day 4 (MD - 0.83, p = 0.01) and day 5 (MD - 0.49, p < 0.00001) when compared to ECA. Moreover, it was associated with significantly shorter length of hospital stay (MD - 0.27, p = 0.03). However, there was no significant difference in overall perioperative morbidity (RR 0.79, p = 0.47), anastomotic leak (RR 1.29, p = 0.65), SSI (RR 0.61, p = 0.42), bleeding (RR 0.70, p = 0.71), paralytic ileus (RR 0.60, p = 0.45), conversion to open (RD: - 0.02, p = 0.45), number of harvested lymph nodes (MD 0.82, p = 0.06), and procedure time (MD 16.04, p = 0.06) between two groups. The meta-analysis of level 1 evidence demonstrated that laparoscopic right hemicolectomy with ICA has comparable perioperative morbidity but better postoperative recovery than with ECA. The ICA is safe to be practiced more routinely where technical challenges allow.

Aggressive angiomyxoma of the ischioanal fossa in a post-menopausal woman

Aggressive angiomyxoma is a rare mesenchymal tumour, primarily arising in the soft tissue of the pelvis and perineum in women of reproductive age. There is a paucity of evidence on optimal management because of the rarity of these tumours, but the consensus has been for surgical excision. We present the case of a 65-year-old woman who was admitted with left-sided buttock pain and initially diagnosed with a perianal abscess. She underwent examination under anaesthesia rectum with surgical excision of the lesion, subsequent histopathological and immunochemical analysis was suggestive of aggressive angiomyxoma. To complement our case report, we also present a literature review focusing on aggressive angiomyxoma in the ischioanal fossa (also known as the ischiorectal fossa) with only eight cases of primary aggressive angiomyxoma involving the ischioanal fossa documented to date. The primary aims of this case report and literature review are to familiarise clinicians with the clinical, histopathological and immunochemical features of these tumours, and to increase appreciation that despite the rarity of aggressive angiomyxoma, it might be considered in the differential diagnosis of ischioanal lesions.

Simultaneous versus staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases: a meta-analysis of outcomes and clinical characteristics

OBJECTIVES

To evaluate the comparative outcomes and clinical characteristics of simultaneous and staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases.

METHODS

We conducted a systematic search of electronic information sources, and bibliographic reference lists. Perioperative morbidity and mortality, anastomotic leak, wound infection, bile leak, bleeding, intra-abdominal abscess, sub-phrenic abscess, reoperation, recurrence, 5-year overall survival, procedure time, and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using random-effects model.

RESULTS

We identified 41 comparative studies reporting a total of 12,081 patients who underwent simultaneous (n = 5013) or staged (n = 7068) resections for colorectal cancer with synchronous hepatic metastases. There were significantly lower use of neoadjuvant chemotherapy (p = 0.003), higher right-sided colonic resections (p < 0.00001), and minor hepatic resections (p < 0.00001) in the simultaneous group. The simultaneous resection was associated with significantly lower rate of bleeding (OR 0.60, p = 0.03) and shorter length of hospital stay (MD - 5.40, p < 0.00001) compared to the staged resection. However, no significant difference was found in perioperative morbidity (OR1.04, p = 0.63), mortality (RD 0.00, p = 0.19), anastomotic leak (RD 0.01, p = 0.33), bile leak (OR 0.83, p = 0.50), wound infection (OR 1.17, p = 0.19), intra-abdominal abscess (RD 0.01, p = 0.26), sub-phrenic abscess (OR 1.26, p = 0.48), reoperation (OR 1.32, p = 0.18), recurrence (OR 1.33, p = 0.10), 5-year overall survival (OR 0.88, p = 0.19), or procedure time (MD - 23.64, p = 041) between two groups.

CONCLUSIONS

Despite demonstrating nearly comparable outcomes, the best available evidence (level 2) regarding simultaneous and staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases is associated with major selection bias. It is time to conduct high-quality randomised studies with respect to burden and laterality of disease. We recommend the staged approach for complex cases.

Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer

OBJECTIVES

To evaluate comparative outcomes of transanal total mesorectal excision (TaTME) and laparoscopic TME (LaTME) in patients with rectal cancer.

METHODS

We systematically searched multiple databases and bibliographic reference lists. A combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits were applied. Overall intraoperative complications, overall postoperative complications, anastomotic leak, surgical site infections (SSIs), completeness of mesorectal excision, R0 resection, distal (DRM) and circumferential resection margin (CRM), number of harvested lymph nodes, and procedure time were the evaluated outcome parameters.

RESULTS

We identified 18 comparative studies reporting a total of 2048 patients evaluating outcomes of TaTME (n = 1000) and LaTME (n = 1048) in patients with rectal cancer. TaTME was associated with significantly higher number of R0 resection (OR 1.67, P = 0.01) and harvested lymph nodes (MD 1.08, P = 0.01), and lower rate of positive CRM (OR 0.67, P = 0.04) and conversion to an open procedure (OR 0.17, P < 0.00001) compared with LaTME. However, there was no significant difference in intraoperative complications (OR 1.18, P = 0.54), postoperative complications (OR 0.89, P = 0.24), anastomotic leak (OR 0.88, P = 0.42), SSIs (OR 0.64, P = 0.26), completeness of mesorectal excision (OR 1.43, P = 0.19), DRM (MD 1.87, P = 0.16), CRM (MD 0.36, P = 0.58), and procedure time (MD - 10.87, P = 0.18) between TaTME and LaTME. Moreover, for low rectal tumours, TaTME was associated with significantly lower rate of anastomotic leak and higher number of lymph nodes (MD 2.06, P = 0.002).

CONCLUSIONS

Although the meta-analysis of best available evidence (level 2) demonstrated that TaTME may be associated with better short-term oncological outcomes and similar clinical outcomes compared with LaTME, the differences between the two groups were small questioning their clinical relevance. No solid conclusions can be made due to lack of high quality randomised studies.

Meta-analysis of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection: the dilemma remains

OBJECTIVE

To evaluate comparative outcomes of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection.

METHODS

We systematic searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov , ISRCTN Register and bibliographic reference lists. Overall perioperative complications, anastomotic leak, surgical site infection, ileus and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using fixed effects or random effects models.

RESULTS

We identified 4 studies reporting a total of 436 patients comparing outcomes of temporary loop ileostomy closure during (n = 185) or after (n = 251) adjuvant chemotherapy following colorectal cancer resection. There was no significant difference in overall perioperative complications (OR 1.39; 95% CI 0.82-2.36, p = 0.22), anastomotic leak (OR 2.80; 95% CI 0.47-16.56, p = 0.26), surgical site infection (OR 1.97; 95% CI 0.80-4.90, p = 0.14), ileus (OR 1.22; 95% CI 0.50-2.96, p = 0.66) or length of hospital stay (MD 0.02; 95% CI - 0.85-0.89, p = 0.97) between two groups. Between-study heterogeneity was low in all analyses.

CONCLUSIONS

The meta-analysis of the best, albeit limited, available evidence suggests that temporary loop ileostomy closure during adjuvant chemotherapy following rectal cancer resection may be associated with comparable outcomes to the closure of ileostomy after adjuvant chemotherapy. We encourage future research to concentrate on the completeness of chemotherapy and quality of life which can determine the appropriateness of either approach.

Meta-analysis of medial-to-lateral versus lateral-to-medial colorectal mobilisation during laparoscopic colorectal surgery

OBJECTIVES

To evaluate comparative outcomes of medial-to-lateral and lateral-to-medial colorectal mobilisation in patients undergoing laparoscopic colorectal surgery.

METHODS

We conducted a systematic search of electronic databases and bibliographic reference lists. Perioperative mortality and morbidity, procedure time, length of hospital stay, rate of conversion to open procedure, and number of harvested lymph nodes were the outcome parameters. Combined overall effect sizes were calculated using fixed-effects or random-effects models.

RESULTS

We identified eight comparative studies reporting a total of 1477 patients evaluating outcomes of medial-to-lateral (n = 626) and lateral-to-medial (n = 851) approaches in laparoscopic colorectal resection. The medial-to-lateral approach was associated with significantly lower rate of conversion to open (odds ratio (OR) 0.43, P = 0.001), shorter procedure time (mean difference (MD) - 32.25, P = 0.003) and length of hospital stay (MD - 1.54, P = 0.02) compared to the lateral-to-medial approach. However, there was no significant difference in mortality (risk difference (RD) 0.00, P = 0.96), overall complications (OR 0.78, P = 0.11), wound infection (OR 0.84, P = 0.60), anastomotic leak (OR 0.70, P = 0.26), bleeding (OR 0.60, P = 0.50), and number of harvested lymph nodes (MD - 1.54, P = 0.02) between two groups. Sub-group analysis demonstrated that the lateral-to-medial approach may harvest more lymph nodes in left-sided colectomy (MD - 1.29, P = 0.0009). The sensitivity analysis showed that overall complications were lower in the medial-to-lateral group (OR 0.72, P = 0.49).

CONCLUSIONS

Our meta-analysis (level 2 evidence) showed that medial-to-lateral approach during laparoscopic colorectal resection may reduce procedure time, length of hospital stay and conversion to open procedure rate. Moreover, it may probably reduce overall perioperative morbidity. However, both approaches carry similar risk of mortality, and have comparable ability to harvest lymph nodes. Future high-quality randomised trials are required.

Laparoscopic management of chronic abscess due to spilled gallstones

INTRODUCTION

Bile and gallstones are spilled during 13% to 40% of all laparoscopic cholecystectomies. They can act as a septic focus and cause complications. We present 2 cases of perihepatic abscess formation due to dropped gallstones presenting some years later. Delayed diagnosis resulted in unnecessary investigations and had negative economic consequences.

CASE DESCRIPTION

In 1 patient a posterolateral cutaneous fistula had developed that was initially biopsied by cardiothoracic surgeons before computed tomography showed the cause. The other patient presented with recurrent Pyrexia of unknown origin (PUO) causing repeated absence from work and was diagnosed only after 18 months of medical investigation. Both patients were treated with laparoscopic drainage of the abscess and successful retrieval of all stones.

DISCUSSION

Radiologic and open drainage and retrieval of stones have been well described in these cases. We suggest that a laparoscopic approach is superior because the cavity can be clearly identified and stones visualized and removed under direct vision. The need for a formal laparotomy is avoided. We also highlight the economic burden to both patient and health care professional of delayed diagnosis, as shown in these 2 cases. Spilled gallstones are a recognized complication of laparoscopic cholecystectomy. All stones should be actively sought and removed to avoid complications. Laparoscopic drainage is preferable to open or radiologic drainage. Dropped gallstones should be considered a possible diagnosis in patients who have had a previous cholecystectomy and present with unusual symptoms.

Enhancing the Enhanced Recovery Program in Colorectal Surgery - Use of Extended-Release Epidural Morphine (DepoDur®)

Purpose

DepoDur® is a single-dose extended-release morphine injection into the epidural space. It is not commonly used, but has many advantages over traditional analgesic regimens. We analyzed a number of these advantages in our case series in the context of the colorectal enhanced recovery program (ERP) and aimed to show that the ERP could be further enhanced by using DepoDur®.

Methods

We conducted a prospective audit of all patients undergoing open and laparoscopic colorectal procedures where DepoDur® was used between July 2010 and April 2012. Validated pain scores were used, and primary outcome measures were resting and dynamic pain, mobilization, and need for additional analgesia.

Results

Two hundred eighty patients were included in the case series. Good pain control was seen at 24 and 48 hours. Eighty-one percent of the patients required simple analgesia alone at 24 hours, and 62% required simple analgesia (paracetamol +/- nonsteroidal anti-inflammatory drugs) alone at 48 hours. Only a minority required additional oramorph and patient-controlled analgesia at 24 and 48 hours (19% at 24 hours and 38% at 48 hours). Seventy-nine percent of the patients were mobilized at 24 hours, and 88% of the patients were mobilized at 48 hours.

Conclusion

DepoDur® is an effective alternative to conventional pain management techniques and may have a role in further enhancing the ERP.

Retrospective analysis of pre- and peri-operative imaging in confirmed proximal colonic cancers--possible implications for screening flexible sigmoidoscopy

OBJECTIVE

Faecal occult blood testing is being introduced for population screening in the United Kingdom. Flexible sigmoidoscopy may provide a viable alternative. The outcomes of the flexible sigmoidoscopy trial are awaited but the most obvious disadvantage is that only the lower third of the colon is examined and proximal pathology cannot be excluded. The relationship between proximal pathology and distal findings at flexible sigmoidoscopy is uncertain. The aim of this study was to determine the incidence of distal neoplasia in patients with confirmed proximal cancers of the colon.

METHOD

All confirmed proximal colonic cancers (defined as those proximal to the splenic flexure) were identified from a database of pathology specimens at a single centre between January 1999 and August 2006. A retrospective analysis of preoperative and peri-operative mucosal imaging (contrast enema, colonoscopy and CT colonography) was conducted to identify any distal neoplasia in these patients.

RESULTS

A total of 348 patients were identified. Pre- or peri-operative mucosal imaging was identified in 231 (66%) and 49 (21%) had distal neoplasia. Nineteen (8%) of these patients would have gone on to have a colonoscopy based on the UK flexible sigmoidoscopy trial protocol and 92% of the cohort would not have had a colonoscopy.

CONCLUSION

Nearly 80% of confirmed proximal cancers in our series did not have any demonstrable distal neoplasia. Only 8% of our cohort would have proceeded to colonoscopy. A very significant number of proximal cancers would not have been detected.