Background
Laparoscopic right hemicolectomy is a commonly performed procedure. Little is known on how to perform the enterotomy closure after stapled side-to-side intracorporeal anastomosis.
Method
A ...multicentric case-controlled study has been designed to compare different ways to fashion enterotomy closure: double layer versus single layer, sewn versus stapled, and robotic versus laparoscopic approach. Furthermore, additional characteristics including sutures’ materials, interrupted versus running suture and the presence of deep corner suture has been investigated.
Results
We collected data for 1092 patients who underwent right hemicolectomy at ten centers. We analyzed 176 robotic against 916 laparoscopic anastomosis: no significant differences were found in terms of bleedings (
p
= 0.455) and anastomotic leak (
p
= 0.405). We collected data from 126 laparoscopic sewn single-layer versus 641 laparoscopic sewn double-layer anastomosis: a significant reduction was recorded in terms of leaks in double-layer group (
p
= 0.02). About double-layer characteristics, we found a significant reduction of bleedings (
p
= 0.008) and leaks (
p
= 0.017) with a running suture; similarly, a reduction of bleedings (
p
= 0.001) and leaks (
p
= 0.005) was observed with the usage of deep corner closure. The presence of a barbed suture thread seemed to significantly reduce both bleedings (
p
= 0.001) and leaks (
p
= 0.001). We found no significant differences in terms of bleedings (
p
= 0.245) and anastomotic leak (
p
= 0.660) comparing sewn versus stapled anastomosis.
Conclusions
Fashioning a stapled ileocolic intracorporeal anastomosis, we can recommend the adoption of a double-layer enterotomy closure using a running barbed suture in the first layer. Totally, stapled closure and robotic assistance have to be considered a non-inferior alternative.
Aim The aim of this systematic review was to compare laparoscopic and/or laparoscopic‐assisted right colectomy (LRC) with open right colectomy (ORC). Many randomized clinical trial have shown that ...laparoscopic colectomy benefits patients with improved short‐term outcomes and comparable overall survival in respect to the open approach. These results, however, could not be applied to right colectomy owing to its wide range of resection and more complicated vascular regional anatomy.
Method We performed a meta‐analysis of the literature in order to compare LRC vs ORC by examining 21 end‐points including operative and recovery outcomes, early postoperative mortality and morbidity, and oncological parameters. A subgroup analysis of patients undergoing right colectomy for cancer was carried out. The meta‐analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) statement. The search strategies were developed using the following electronic databases: PubMed, EMBASE, OVID, Medline, Cochrane Database of Systematic Reviews, EBM reviews and CINAHL until March 2011. We included randomized and non randomized studies that compared the LRC vs ORC for benign disease and malignant neoplasm irrespective of publication status. Only studies in English, French, German, Spanish and Italian languages were considered for inclusion. Emergency right colectomies were excluded. To perform the statistical analysis we used the odds ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. An intention‐to‐treat analysis was performed.
Results Seventeen studies, 15 nonrandomized clinical trials and two randomized clinical trials, involving a total of 1489 patients, were identified. The mean operative time was longer in the group of patients undergoing LRC weighted mean difference (WMD) = 37.94, 95% CI: 25.01 to 50.88; P < 0.00001. Intra‐operative blood loss (WMD = −96.61; 95% CI: −150.68 to −42.54; P = 0.0005), length of hospital stay (WMD = −2.29; 95% CI: −3.96 to −0.63; P = 0.007) and short‐term postoperative morbidity (OR = 0.64; 95% CI: 0.49 to 0.83; P = 0.0009) were significantly in favour of LRC.
Conclusion Laparoscopic‐assisted right colectomy results in less blood loss, a shorter length of hospital stay and lower postoperative short‐term morbidity compared with ORC.
Background
Sphincter-saving surgery for the treatment of middle and low rectal cancer has spread considerably when total mesorectal excision became standard treatment. In order to reduce ...leakage-related complications, surgeons often perform a derivative stoma, a loop ileostomy (LI), or a loop colostomy (LC), but to date, there is no evidence on which is the better technique to adopt.
Methods
We performed a systematic review and meta-analysis of all randomized controlled trials until 2007 and observational studies comparing temporary LI and LC for temporary decompression of colorectal and/or coloanal anastomoses.
Clinically relevant events were grouped into four study outcomes:
general outcome measures: dehydratation and wound infection GOM
construction of the stoma outcome measures: parastomal hernia, stenosis, sepsis, prolapse, retraction, necrosis, and hemorrhage
closure of the stoma outcome measures: anastomotic leak or fistula, wound infection COM, occlusion and hernia
functioning of the stoma outcome measures: occlusion and skin irritation.
Results
Twelve comparative studies were included in this analysis, five randomized controlled trials and seven observational studies. Overall, the included studies reported on 1,529 patients, 894 (58.5%) undergoing defunctioning LI. LI reduced the risk of construction of the stoma outcome measure (odds ratio, OR = 0.47). Specifically, patients undergoing LI had a lower risk of prolapse (OR = 0.21) and sepsis (OR = 0.54). LI was associated with an excess risk of occlusion after stoma closure (OR = 2.13) and dehydratation (OR = 4.61). No other significant difference was found for outcomes.
Conclusion
Our overview shows that LI is associated with a lower risk of construction of the stoma outcome measures.
Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. ...The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach.
This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery.
The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001).
According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.
Aim
Anastomotic leakage is the one of the most serious complications in rectal cancer surgery and is associated with high mortality, morbidity and an increased incidence of local recurrence. Although ...many studies have compared drained and undrained colorectal anastomoses, to date the role of pelvic drainage in extraperitoneal colorectal anastomosis remains undefined.
Method
We carried out a systematic review of the literature, performing an unrestricted search in MEDLINE and Embase up to 30 October 2012. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We performed a meta‐analysis of the data currently available on the incidence of extraperitoneal anastomotic leakage, according to the presence or absence of pelvic drainage.
Results
Overall, eight studies – three randomized clinical trials (RCTs) and five non‐RCTs, comprising a total of 2277 patients – were included in the meta‐analysis. Pelvic drainage was demonstrated to reduce both the leak rate and the rate of reintervention in patients who underwent anterior rectal resection with extraperitoneal colorectal anastomosis (OR = 0.51, 95% CI: 0.36–0.73; and OR = 0.29, 95% CI: 0.18–0.46, respectively) compared with patients without drainage. Overall mortality and infection rates were also evaluated, but a nonsignificant correlation was found with the presence of drainage.
Conclusion
The meta‐analysis shows that the presence of a pelvic drain reduces the incidence of extraperitoneal colorectal anastomotic leakage and the rate of reintervention after anterior rectal resection.
Aim The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer.
Method The following electronic ...databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE.
Results Five nonrandomized studies including a total of 5012 patients were identified. Meta‐analysis suggested that rectal washout significantly reduced the local recurrence rate (P < 0.0001; OR 0.57; 95% CI 0.43–0.74). It was also significantly lower after washout in patients having radical resection only (P = 0.0004; OR 0.54; 95% CI 0.39–0.76), patients treated by a curative resection (P < 0.0001; OR 0.55; 95% CI 0.42–0.72) and those undergoing preoperative radiotherapy (P = 0.04; OR 0.62; 95% CI 0.39–0.98).
Conclusion Taking into account the limitations of the design of the included studies the meta‐analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.
Abstract Aim : The use of robotic technology has proved to be safe and effective, arising as a helpful alternative to standard laparoscopy in a variety of surgical procedures. However the role of ...robotic assistance in laparoscopic rectopexy 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 June 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We meta-analyzed the data currently available regarding the incidence of recurrence rate of rectal prolapse, conversion rate, operative time, intra-operative blood loss, post-operative complications, re-operation rate and hospital stay in robot-assisted rectopexy (RC) compared to conventional laparoscopic rectopexy (LR). Results : Six studies were included resulting in 340 patients. The meta-analysis showed that the RR does not influence the recurrence rate of rectal prolapse, the conversion rate and the re-operation rate, whereas it decreases the intra-operative blood loss, the post-operative complications and the hospital stay. Yet, the RR resulted to be longer than the LR. Post-operative ano-rectal and the sexual functionality and procedural costs could not meta-analyzed because the data from included studies about these issues were heterogeneous and incomplete. Conclusion : The meta-analysis showed that the RR may ensure limited improvements in post-operative outcomes if compared to the LR. However, RCTs are needed to compare RR to LR in terms of short-term and long-term outcomes, specially investigating the functional outcomes that may confirm the cost-effectiveness of the robotic assisted rectopexy.
Abstract Aim Loop ileostomy is a suitable procedure for transitory faecal diversion after low colorectal anastomosis, but it causes relevant morbidities (discomfort, peristomal infections, ...dehydration) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI) that can be removed without surgery. Method The data of 143 consecutive patients, undergoing elective laparoscopic anterior resection of the rectum for adenocarcinoma and low mechanical colorectal anastomosis, 68 with conventional loop ileostomy (CLI) and 75 with TPI, were analyzed. Results Neither intra-operative complications nor deaths occurred during the follow-up period. Clinical anastomotic leakage occurred in 4 patients with CLI and in 1 with TPI ( p = 0.191). The median time required for the emission of gases and faeces through the stoma was respectively 1 and 2.5 days in the CLI group, and 1 and 2 days in the TPI group ( p = 0.259 and p = 0.126). The median post-operative stay was 8 days in the CLI group and 11 days in the TPI group ( p < 0.001). PTIs were removed on the median of 9 days after surgery without major complications, whereas the CLIs were re-canalized in 79.4% of patients on an average of 106 days, with 2 major complications. Conclusion The temporary percutaneous ileostomy seems to be a valid alternative to conventional ileostomy, ensuring optimal faecal diversion and less patient discomfort. It can be easily removed without surgery, allowing patients a better outcome.
Background
Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, ...peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery.
Aims
We analyse the outcomes and the costs of the TPI in protecting low colorectal anastomosis in elderly, compared to the CLI.
Methods
Data of patients underwent elective anterior rectal resection for rectal cancer with extra-peritoneal colorectal anastomosis protected by ileostomy from January 2011 to December 2015 were reviewed. Sixty-one out of 132 patients were older than 70; 35 underwent faecal diversion by TPI and 26 by CLI.
Results
The two groups resulted homogenous about age, sex, operative time, short-term post-operative complications. None of the patients reported anastomotic leakage. The hospital stay and the cost for the first surgical procedure did not show statistically significant differences between TPI and CLI. When comparing the overall hospital stay and costs the differences are statistically significant: the TPI showed a shorter hospital stay (12.4 vs 19.3 days, −35.7%) and a lower cost of hospitalization (7954.0 vs 14,372.1€, −44.7%), compared to CLI.
Discussion
The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of TPI, especially in elderly.
Conclusion
The TPI not only improved the post-operative outcome of the patients, but also allowed a remarkable saving for the National Health System.
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