Hemicolectomy For Colon Cancer Research Articles

Infrapyloric lymph node dissection in right hemicolectomy for colon cancer: Should prophylactic resection be recommended?

Infrapyloric lymph node dissection in right colon cancer patients remains controversial. We aimed to investigate the pattern of infrapyloric lymph node metastasis in right colon cancer patients. Clinical and pathological data of 140 colon cancer patients who underwent radical right hemicolectomy and infrapyloric lymph node dissection were retrospectively examined. Patient characteristics, intraoperative conditions, postoperative recovery information, postoperative pathological findings, and follow-up data were examined. About 19, 44, 73, and 4 patients had tumors located in the cecum, ascending colon, hepatic flexure, and right side of the transverse colon, respectively. The median number of harvested lymph nodes and that of positive lymph nodes were 24 (16-30) and 1 (0-7.75), respectively. The lymph node metastasis rate was 41.43% (58/140). The corresponding values for infrapyloric lymph nodes were 3 (1-4), 0(0-0), and 0.71% (1/140), respectively. The median follow-up duration was 19 (0-65) months in 131 (93.6%) patients. The 5-year overall and disease-free survival rates were 86.3% and 73.5%, respectively. Given the low rate of infrapyloric lymph node metastasis in right colon cancer, lymph node dissection is recommended in patients with locally advanced colon cancer at the hepatic flexure and those with suspected infrapyloric lymph node metastasis.

Intracorporeal anastomosis in right hemicolectomy for colon cancer: short-term outcomes with the DaVinci Xi robot

Intracorporeal anastomosis (IA) may improve outcomes compared with extracorporeal anastomosis (EA) in minimally invasive right colectomy. This is a prospective series of robotic right hemicolectomies (RRC) with IA from one institution. 35 consecutive patients with verified or suspected right colon cancer undergoing RRC with IA, and historic control groups of 22 RRC and 40 laparoscopic right colectomies (LRC), both with EA. Primary outcome measure was length of stay (LOS). Secondary outcome measures were 30-day complication rates, readmissions, pain scores, analgesic consumption, and specimen quality. Median LOS did not differ significantly between the groups (RRC-IA, 4 days; LRC-EA, 4 days; RRC-EA, 5 days). In-hospital surgical complications Clavien–Dindo 3 + were seen in 1, 2, and 0 patients, respectively, and 3, 5, and 3 patients were readmitted to hospital within 30 days. Median pain score was 2 in all groups on postoperative day (POD) 2. Relatively more patients in the RRC-IA group received gabapentin on POD 2 (p = 0.006), but use of other analgetics did not differ between groups. Mean specimen lengths were 31, 25 and 27 cm, respectively (RRC-IA vs. LRC-EA, p = 0.003), but mesentery width, proportion of mesocolic excisions and number of lymph nodes did not differ between the groups. RRC-IA was not associated with shorter LOS, fewer complications or better specimen quality than recent controls undergoing either RRC-EA or LRC-EA.

Association of day of the week with mortality after elective right hemicolectomy for colon cancer: Case analysis from the National Clinical Database.

AimWe aimed to investigate whether later weekdays are related to worse short‐term outcomes after elective right hemicolectomy for colon cancer.MethodsWe retrospectively analyzed adult patients who underwent elective right hemicolectomy for colon cancer between 2012 and 2017. Records lacking details about surgical mortality were excluded, and multiple imputation was performed for other missing data (variables). The primary endpoint was surgical mortality, defined as the sum of 30‐day mortality and in‐hospital deaths within 90 days postoperatively. Using 22 clinical variables, hierarchal logistic regression modeling with clustering of patients from the same institutes was performed.ResultsOf the 112 658 patients undergoing elective right hemicolectomy for colon cancer, the 30‐day mortality and surgical mortality were 0.6% and 1.1%, respectively. Surgery on Friday was less frequent, accounting for 17.1% of all cases. The occurrence of severe postoperative complications, anastomotic leakage, or unadjusted odds ratio for surgical mortality did not show significant differences between weekdays. A hierarchal logistic regression model identified 19 independent factors for surgical mortality. Adjusted odds ratios for surgical mortality were 1.01 (95% confidence interval: 0.83‐1.22, P = .915), 0.86 (95% confidence interval: 0.71‐1.05, P = .144), 0.86 (95% confidence interval: 0.71‐1.05, P = .408), and 0.83 (95% confidence interval: 0.68‐1.03, P = .176) for Tuesday, Wednesday, Thursday, and Friday, respectively, showing no significant differences.ConclusionThis study did not identify an evident difference in surgical mortality between weekdays; a safe elective right hemicolectomy for colon cancer is being offered throughout the week in Japan.

Analysis of appendectomy samples identified dysbiosis in acute appendicitis.

Appendicitis is the most common cause of sudden-onset abdominal pain requiring surgery. Culture-independent techniques have revealed that the complex intestinal bacterial ecology is associated with various diseases. To evaluate differences in patient characteristics and gut microbiota distribution in patients with appendicitis, we enrolled 12 patients who underwent appendectomy for appendicitis (appendicitis group) and 13 patients who underwent ileocecal resection or right hemicolectomy for colon cancer (control group). Microbiota were analyzed using next-generation sequencing of surgical specimens from appendix swab samples collected postoperatively. Overall differences in the structure of the gut microbiota were evaluated using the α- and β-diversity indices, which were calculated using the weighted or unweighted UniFrac distance. Changes in the gut microbial distribution were taxonomically evaluated at the phylum and genus levels. The α-diversity of observed species was significantly different between patients with and without inflammation of the appendix. The appendiceal microbiome of patients with appendicitis exhibited the highest unweighted UniFrac distances. There were no significant differences at the phylum level. Ruminococcus (p=0.02) and f_erysipelotrichaceae_g_clostridium (p=0.005) were increased in the control group compared with the appendicitis group. This pilot study provides the first report of the correlation of the gut microbiota with the pathogenesis of appendicitis evaluated using mucus-origin sampling.

Complete migration of a composite mesh into small bowel incidentally found during laparotomy for colectomy in an asymptomatic patient: a case report

BackgroundComposite meshes are used for incisional hernia repair because they enable intraperitoneal mesh placement due to their dorsal surface, which is made of inert material. We report, for the first time, to our knowledge, a case of composite mesh migration detected incidentally during a laparotomy for colon cancer in an asymptomatic patient.Case presentationOur patient was a 71-year-old South Asian man who underwent ventral mesh repair following a postoperative complication after right hemicolectomy for colon cancer. The patient was diagnosed with a metachronous sigmoid cancer 5 years later, for which he underwent laparotomy. During laparotomy, a migrated mesh was incidentally found and extracted from his proximal ileum without any evidence of abscess or fistula formation.ConclusionTo our knowledge, this is the first report of an incidentally found migrated composite mesh from a bowel lumen in an asymptomatic patient.

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery.

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery.

Complete mesocolic excision for right colon cancer—state of art: a systematic review of the literature

: Complete mesocolic excision (CME) is a new concept of right hemicolectomy for colon cancer (CC) set up to improve oncological outcomes and based on three main points: dissection in the embryological plane, central vascular ligation (CVL) and resection of a sufficient length of bowel. During this last decade, many doubts and questions have been arised about safety and efficacy of CME. We conducted a systematic review of the literature to investigate the safety, quality and survival outcomes of this procedure. Literature search resulted in 659 articles found and after the selection process 21 studies properly fulfilling inclusion and exclusion criteria were included. The total number of collected patients was 7,402 (mean age 65.42 years, 51.27% men). The weighted mean number of lymph nodes retrieved was 27.45 and the mean number of metastatic nodes was 1.34. Surgical complication and overall operative mortality rate were 5.5% and 0.5% respectively. Five-year overall survival (OS) and disease-free survival (DFS) rates were 84.3% and 82.8%. Available data from literature have several limitations mostly including non-homogeneous and incomplete reports together with no evidence from randomized control trial (RCT) studies. Therefore, to date, the quality of evidence is low and does not consistently support the superiority of CME over the standard right hemicolectomy, despite a reported trend to improved survival with comparable operative morbidity and mortality. More reliable data from large sample size RCTs are needed before CME can be recommended as the standard of care for right CC.

Clinical outcome of laparoscopic vs open right hemicolectomy for colon cancer: A propensity score matching analysis of the Japanese National Clinical Database.

AimThe advantages of laparoscopic right hemicolectomy over open surgery for colon cancer in general clinical practice are debated, as evidenced by the continued use of open surgery in a significant proportion of patients worldwide. This study aimed to assess and compare the clinical outcome of laparoscopic and open right hemicolectomy for colon cancer using data from the Japanese National Clinical Database.MethodsA total of 72 299 patients who underwent laparoscopic (n = 46 084) and open (n = 26 215) right hemicolectomy for colon cancer between 2014 and 2018 were enrolled in this retrospective study. Short‐term outcome was compared between groups using propensity score matching analysis.ResultsThe incidence of overall postoperative morbidity ≥ Clavien‐Dindo classification grade 3 was significantly higher in the open surgery group than the laparoscopic group (4.7% vs 3.2%, P < .001). The incidence of most individual morbidities, including surgical site infection, anastomotic leakage, and ileus, was higher in the open surgery group. Short‐term outcomes, including intraoperative blood loss, postoperative hospital stay, reoperation rate, 30‐day mortality, and in‐hospital mortality, were superior in the laparoscopic group, except for operative time. Subgroup analyses showed that the incidence of postoperative morbidity was lower in the laparoscopic group for all prespecified subgroups.ConclusionLaparoscopic right hemicolectomy has an advantage over open surgery for colon cancer with respect to short‐term outcome.

A challenging solution to a complex incisional hernia – a video vignette

We present the case of a 76 year old male, whose surgical history included a laparoscopic left hemicolectomy for colon cancer, complicated with anastomotic leakage and multiple interventions for recurrent paraostomal and midline incisional hernias, one of them resulting in intestinal perforation. Secondary wound closure with negative wound pressure therapy and skin grafts had to be applied. The patient was referred to our center as a result of a complex M1-2-3-4-5 W3 (1) incisional hernia with deep skin ulcerations and intestinal exposure.

Extracorporeal versus intracorporeal anastomosis in laparoscopic right hemicolectomy for cancer

Introduction This study aimed at assessing the long-term oncological outcomes of intracorporeal ileocolic anastomosis (ICA) for laparoscopic right hemicolectomy for colon cancer compared with extracorporeal anastomosis (ECA). Material and methods We performed a retrospective analysis of 149 consecutive patients who underwent laparoscopic right hemicolectomy for colon cancer between January 2006 and December 2012. Results Eighty and 69 patients underwent intracorporeal and ECA, respectively. The two groups were demographically comparable. ICA exhibited a significantly shorter operative time (p < .0001), while local relapse and length of hospital stay did not significantly differ among the groups (p = .724 and .310, respectively). There was no significant difference in median number of retrieved lymph node. The overall survival and the disease-free survival at five years did not significantly differ among the groups. Conclusions Intracorporeal ICA can reduce operative time and is associated with similar postoperative and long-term oncological outcomes compared to the ECA technique.

Superior Mesenteric Vein-First Approach for Robotic Salvage Surgery with Indocyanine Green Fluorescence Angiography

Inadequate lymphadenectomy is still a major concern in colon cancer surgery. The superior mesenteric vein (SMV)-first approach is a novel, standardized, reproducible method for robotic complete mesocolic excision surgery. Our aim was to present the application of the SMV-first approach principles to facilitate robotic salvage surgery for recurrent disease within the mesocolon. A 78-year-old female presented with a malignant lymph node deposit within residual right mesocolonic tissue, approximately 3months following a laparoscopic right hemicolectomy for colon cancer. Dissection was initiated with a transverse curvilinear incision along the inferior aspect of the remaining ileocolic pedicle to identify the SMV. Dissection continued along the ventral aspect of the SMV in a cephalad direction to identify and expose the middle colic vessels at their origin. The use of idocyanine green (ICG) confirmed the vascular anatomy, demonstrating the right branch of the middle colic artery traversing the malignant deposit in the residual mesocolon. Following ligation at the origin of the right branch of the middle colic and ileocolic vessels, the retro-mesocolic plane dissection was completed to excise the malignant deposit and the residual mesocolon. The patient was discharged home the following day. The pathological specimen confirmed metastatic poorly differentiated adenocarcinoma in one of nine lymph nodes, and the vascular pedicle resection margin was negative for tumor. Following the SMV-first approach principles provides a safe plane for dissection, and, in conjunction with ICG, facilitates the delineation of the vascular anatomy, to enable robotic salvage surgery to be performed.1-3.

End-to-side versus side-to-side anastomosis after laparoscopic right hemicolectomy for colon cancer: Short-term outcomes of a randomized controlled trial.

27 Background: A standard anastomotic configuration after right hemicolectomy is not well established, although short-term benefits of end-to-side anastomosis have been reported. This study was designed to assess the superiority of end-to-side anastomosis compared to side-to-side anastomosis after laparoscopic right hemicolectomy for colon cancer under an enhanced recovery program. Methods: Between September 2016 and August 2019, 130 patients (18–80 years) scheduled for laparoscopic right hemicolectomy were randomly assigned (1:1) to undergo end-to-side ( n = 65) or side-to-side ( n = 65) anastomosis. All patients underwent an enhanced recovery program with early diet and mobilization. The primary outcome was the cumulative recovery rate 7 days after surgery, defined as the percentage of patients who met all of the following recovery criteria: tolerated diet for 24h, analgesic-free, safe ambulation, and afebrile status without major complications. Results: The cumulative recovery rate did not differ between end-to-side (92.3%, 60/65) and side-to-side anastomosis (92.3%, 60/65) ( P = 1.000). Both approaches had similar cumulative recovery rates at 4, 5, and 6 days (end-to-side vs. side-to-side: 41.5% vs. 35.4%, P = 0.589; 73.8% vs. 63.1%, P = 0.257; 86.2% vs. 81.5%, P = 0.634; respectively) The median recovery time [interquartile range (IQR)] in the end-to-side and side-to-side groups was 105 [90-124] hours and 113 [84-139] hours, respectively ( P = 0.474), showing no significant difference. Length of stay [IQR] was similar in the end-to-side and side-to-side groups (5 [5–7] vs. 6 [5–7] days; P = 0.376). The 30-day complication rate (16.9% vs. 12.3%, P = 0.620), enhanced recovery program failure rate (10.8% vs. 7.7%, P = 0.763), and 30-day readmission rate (4.6% vs. 3.1%; P = 1.000) were not significantly different between the groups. Conclusions: This is the first randomized controlled trial showing that end-to-side anastomosis is not superior to side-to-side anastomosis in terms of short-term outcomes after laparoscopic right hemicolectomy. Clinical trial information: NCT02897531.

Preoperative instructions and postoperative care in the 21st century

The preoperative and postoperative management of patients undergoing right hemicolectomy for colon cancer has undergone significant change in the 20th century. From a time where a postoperative stay of 10 days was not uncommon, patients are now routinely discharged on postoperative day 2–3, and same day colectomy is also practiced in some centers. Enhanced recovery programs are standard practice and their guidelines are developed from a strong evidence base around perioperative management and recovery. The preoperative visit is increasingly important and is used to identify modifiable risk factors such as malnutrition, anemia, smoking, and alcohol abuse. Detailed counselling and preoperative education should also be undertaken so patients are psychologically prepared for their cancer surgery and have clear expectations and goals for their recovery. Nausea and vomiting postoperatively is a common cause of delayed discharge. Patients at risk should be identified preoperatively and treated prophylactically. Prehabilitation is an exciting field in colorectal surgery but its role in right hemicolectomy for colon cancer is limited due the necessary short interval between diagnosis and surgery. Patients should be fasting for the minimal amount of time preoperatively and should be allowed clear carbohydrate containing fluids up until 2 hours before surgery. The intraoperative use of opioids should be minimized and high risk patients should have goal-directed fluid therapy (GDFT). As the majority of right colectomies are performed laparoscopically, TAP blocks should be used instead of epidural analgesia for postoperative pain relief. The routine use of nasogastric tubes or abdominal drains should be avoided. Patients should be mobilized the evening after surgery and diet advanced early to prevent postoperative ileus. In modern colorectal practice, regular audits should be undertaken in the unit to ensure adherence to enhanced recovery programs and to identify areas for improvement.

A phase II study of PD-1 inhibition for the prevention of colon adenomas in patients with Lynch syndrome and a history of partial colectomy.

TPS1587 Background: Colon cancers and adenomas that are associated with Lynch syndrome (LS) often display microsatellite instability (MSI), a characteristic that is associated with increased response to treatment with PD-1 inhibitors. Because LS patients with a history of colon cancer are at increased risk of having a second primary colon cancer or high-risk adenoma, preventive measures are of particular interest in this population. We hypothesize that a maintenance schedule of nivolumab can be safely administered to LS patients with a history of treated colon cancer with remaining colon at risk in order to decrease the incidence of adenomas, advanced adenomas and second primary colon cancers. Methods: OSU 17198 is a phase II multi-center, single-arm study of nivolumab in patients with germline MLH1 or MSH2 mutations and a history of hemicolectomy for colon cancer at least one year prior to study entry. Subjects must have completed any adjuvant therapy at least 6 months prior to study participation and may not have received prior therapy with a PD-1 inhibitor. Nivolumab is given at 240mg IV every 3 months for two years, and colonoscopies will be performed prior to study entry, after the fourth dose, after the eighth dose, and one year after the eighth dose. Subjects will be monitored for auto-immune adverse effects. The primary endpoint is incidence of adenomas at three years, and secondary endpoints are safety, incidence of advanced adenomas, and incidence of colon and non-colon cancers at three years. Approximately 104 subjects will be enrolled to obtain 94 evaluable subjects. This study is currently open for enrollment at the Ohio State University and at various stages of activation at seven additional sites in the United States. Enrollment of this study is anticipated to be completed in 2020, and data collection is anticipated to be complete in 2023. This study has undergone safety review by the FDA and the Ohio State University Institutional Review Board. Clinical trial information: NCT03631641.

Intrabiliary growth type of metastasis from colon cancer, 12\u2009years after curative colectomy: a case report

BackgroundLiver is a common location of colorectal metastasis, but intrabiliary growth of liver metastasis is not well recognized. Furthermore, intrabiliary metastasis that discovered over 10 years after excision has rarely been described.Case presentationAn 80-year-old man was admitted due to the presence of a liver mass in segment 5 (S5) concomitant with elevated carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19–9. He underwent right hemicolectomy for colon cancer 12 years prior. Enhanced computed tomography (CT) showed dilated bile ducts with periductal enhancement in S5; hence, cholangiocarcinoma was suspected. Upon anterior segmentectomy, we observed that the cut surface of the specimen exhibited a yellowish-white tumor within the bile ducts. Histologically, the tumor formed within the papillary process, extended along the lumen, and replaced the normal bile duct epithelium. Immunohistochemical studies showed that the liver tumor and primary colon cancer were negative for cytokeratin (CK) 7 and positive for CK20 and Caudal-type homeobox transcription factor 2 (CDX-2). In addition, both tumors showed a same KRAS mutation. We diagnosed the liver tumor as liver metastasis recurrence from colon cancer.ConclusionIntrabiliary growth type of metastasis (IGM) is difficult to distinguish from cholangiocarcinoma, and sometimes develops long after surgery; thus, careful examination of a patient’s history is needed in such cases.

Safety of Anastomoses in Right Hemicolectomy for Colon Cancer.

Introduction: Colorectal cancer is one of the most common malignant tumor of the digestive system, the incidence of this cruel disease has been increasing at a constant rate. Materials and methods: 236 patients diagnosed with right colon cancer were retrospectively reviewed. For all patients included in this study, right hemicolectomy or extended right hemicolectomy with ileo-colonic anastomosis was performed. Patients were divided in two groups, as follows: study group including patients which developed anastomotic leakage, and control group including patients without anastomotic leak. There were compared clinical, surgical, postoperative and anastomotic leakage (AL) related data within the two groups.The study investigates possible risk and protective factors for developing anastomotic leakage, furthermore the relationship between anastomotic leakage and mortality was analyzed. Results: risk factors for AL as advanced age, tumors of the right 1/3 of transvers colon, emergencysurgery, mechanical suture, S-E anastomosis, late start of bowel motility were identified during the current research. S-S anastomotic technique were identified as protective factor in the development of fistula. Conclusion: According to the results of the present research, in right colon tumors S-S anastomotic technique should be used, being linked with the lowest chances of anastomotic leakage.

Effects of anastomotic technique on early postoperative outcome in open right-sided hemicolectomy.

BackgroundDespite recent improvements in colonic cancer surgery, the rate of anastomotic leakage after right hemicolectomy is still around 6–7 per cent. This study examined whether anastomotic technique (handsewn or stapled) after open right hemicolectomy for right‐sided colonic cancer influences postoperative complications.MethodsPatient data from the German Society for General and Visceral Surgery (StuDoQ) registry from 2010 to 2017 were analysed. Univariable and multivariable analyses were performed. The primary endpoint was anastomotic leakage; secondary endpoints were postoperative ileus, complications and length of postoperative hospital stay (LOS).ResultsA total of 4062 patients who had undergone open right hemicolectomy for colonic cancer were analysed. All patients had an ileocolic anastomosis, 2742 handsewn and 1320 stapled. Baseline characteristics were similar. No significant differences were identified in anastomotic leakage, postoperative ileus, reoperation rate, surgical‐site infection, LOS or death. The stapled group had a significantly shorter duration of surgery and fewer Clavien–Dindo grade I–II complications. In multivariable logistic regression analysis, ASA grade and BMI were found to be significantly associated with postoperative complications such as anastomotic leakage, postoperative ileus and reoperation rate.ConclusionHandsewn and stapled ileocolic anastomoses for open right‐sided colonic cancer resections are equally safe. Stapler use was associated with reduced duration of surgery and significantly fewer minor complications.

Comparative analysis of postoperative complications of right versus left hemicolectomy for colon cancer in elderly patients

Objectives To compare and analyze the postoperative complications of right versus left hemicolectomy for colon cancer in elderly patients aged 65 years and over. Methods 365 elder patients with colon cancer aged 65 years and over received first surgery in Beijing Hospital during January 2013 to June 2016, and were pathologically diagnosed with colon adenocarcinoma.The right hemicolectomy(RC)was with an ileocolic anastomosis, and the left hemicolectomy(LC)with a colocolic or colorectal anastomosis.The data of patients were analyzed retrospectively, and the incidence rate of postoperative complications was compared between the two groups. Results 181(49.6%)patients underwent RC, and 184(50.4%)received LC.The proportion of males was lower in RC group than in LC(49.2% vs.59.2%, χ2=3.726, P=0.048). The average age was higher in RC patients than in LC(75.6 vs.73.6 years, t=3.048, P=0.002). RC had a longer average length of postoperative hospital stay than LC(13.6±14.07)days vs.(10.7±8.07)days, t=2.386, P=0.018). RC had a higher incidence rate of postoperative complication than LC(33.1% vs.21.7%, χ2=5.972, P=0.015). According to the Clavien-Dindo classification of postoperative complications, the incidence rate of complications at level I was higher in RC than in LC(10.5% vs.4.9%, χ2=4.049, P=0.044). Conclusions For elderly patients with colon cancer, the age is more advanced in RC patients and has a longer length of postoperative hospital stay, and has more postoperative complications, especially level I postoperative complications. Key words: Colorectal neoplasms; Postoperative complications

Postoperative mortality and morbidity in older patients undergoing emergency right hemicolectomy for colon cancer.

Even with the advances in surgical technique and perioperative care, morbidity and mortality after colorectal cancer surgery remain considerable, and patients (pt) who present as an emergency have an even higher mortality and morbidity rate. A total of 35 pt with caecum or ascending colon cancer between January 2007 and June 2015, three departments in Italy and in Poland, were included in the study. The intention of surgery in all cases was curative resection with ileo-colic anastomosis. Comparative statistical analysis was performed. Acute bowel obstruction was the major complication of CRC that led to an emergency hemicolectomy. Postoperative mortality and morbidity rates were in total 12.5 and 28.1%, respectively. All the deaths happened in Poland. Of the pt, 42.8% had morbidity in Poland and 16.6% in Italy. Out of the pt, 25% presenting with perforation: 25% died, 25% had wound dehiscence, 12.5% had pulmonary oedema, and 12.5% had an intra-abdominal abscess. The mean age of the pt with complications in Poland and in Italy was 79.3 and 72.0years, respectively. We observed that particularly lethal combination is older age, perforation with peritonitis and advanced stage of the cancer.

Intracorporeal versus extracorporeal anastomosis in right hemicolectomy: a systematic review and meta-analysis

BackgroundLaparoscopic right hemicolectomy for colon cancer is associated with substantial morbidity despite the introduction of enhanced recovery protocols and laparoscopic surgery. Laparoscopic right hemicolectomy with an intracorporeal anastomosis (IA) is less invasive than laparoscopic assisted hemicolectomy, possibly leading to further decrease in post-operative morbidity and faster recovery. The current standard technique includes an extracorporeal anastomosis with mobilization of the colon, mesenteric traction and a extraction wound located in the mid/upper abdomen with relative more post-operative morbidity compared to extraction wounds located in the lower abdomen.MethodsA systematic review of PubMed and Embase databases was performed on studies comparing the intracorporeal versus the extracorporeal performed anastomosis in laparoscopic right hemicolectomy. Primary outcomes were mortality, short-term morbidity and length of stay. For quality assessment, the MINORS checklist was used. Meta-analysis was performed using a random-effects model, and a subgroup analysis was performed for data regarding short-term morbidity and length of stay in studies published in 2012≥.ResultsA total of 2692 papers were identified, 12 non-randomized comparative studies were included in the analysis with a total number of 1492 patients. No significant change in mortality was found (OR 0.36, 95 % CI 0.09–1.46; I2 = 0 %). Short-term morbidity decreased significantly in favour of IA (OR 0.68, 95 % CI 0.49–0.93; I2 = 20 %). Length of stay was decreased, but with serious risk of heterogeneity (MD −0.77 days, 95 % CI −1.46 to −0.07; I2 = 81 %). Subgroup analysis for papers published in 2012≥ resulted in an even larger decrease in short-term morbidity (OR 0.65, 95 % CI 0.50–0.85; I2 = 0 %) and a significant decrease in length of stay with low risk of heterogeneity (MD −0.77 days, 95 % CI −1.17 to −0.37; I2 = 4 %).ConclusionIntracorporeal anastomosis in laparoscopic right hemicolectomy is associated with reduced short-term morbidity and decreased length of hospital stay suggesting faster recovery as shown in this meta-analysis.