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Megafu OM. Statistical Fragility in Minimally Invasive Colorectal Surgery Studies: A Review of Randomized Trials. J Laparoendosc Adv Surg Tech A 2024; 34:614-621. [PMID: 38900698 DOI: 10.1089/lap.2024.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
Purpose: The P value has been used as a statistical tool in randomized controlled trials (RCTs) to establish significance but does not provide information on the robustness of a study when used alone. The fragility index (FI) provides a supplemental approach for demonstrating robustness in RCTs that report dichotomous outcomes. This study aims to determine the statistical fragility of RCTs that compare minimally invasive techniques with open techniques in managing benign and malignant colorectal diseases. Methods: Dichotomous outcomes of minimally invasive surgery versus open surgery in RCTs from 2000 to 2023 were assessed. The overall FI and fragility quotient (FQ) of each study were calculated. Results: Of the 1377 screened studies, 50 met the inclusion criteria. In total, 820 outcomes were recorded with 747 outcomes reported as not significant (P ≥ .05) and 73 as significant (P < .05). The overall FI for all studies including all outcomes was 5 (interquartile range [IQR] 4-7) with a FQ of 0.031 (IQR 0.014-0.062). Of the 50 RCTs, 6 (12%) reported a loss to follow-up that was greater than the overall FI of 5. Conclusions: As RCTs are judged increasingly beyond just the P value, practicing colorectal surgeons will benefit from using and interpreting the FI, FQ, and the P value of studies both in analyzing future RCTs and in determining whether or not to make a change in their clinical practice if there is an efficiently true discovery.
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Affiliation(s)
- Olajumoke M Megafu
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Wen ZL, Bai L, Zhou X. Novel stent-assisted ileal bypass is applied to avoid protective stoma and prevent anastomotic leakage for rectal cancer. ANZ J Surg 2024; 94:418-423. [PMID: 37984380 DOI: 10.1111/ans.18781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/30/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE This study aimed to investigate the safety and feasibility of a novel stent-assisted ileal bypass for rectal cancer patients who received sphincter-preserving surgery. METHODS Patients who were diagnosed with rectal cancer and received sphincter-preserving surgery plus a novel stent-assisted ileal bypass were respectively included from January 2022 to January 2023. Biofragmentable ileal stent with diaphragm sheet in the cavity was placed in the terminal ileum using absorbable sutures after anastomosis. At the proximal end of the stent, an intestinal diversion tube was placed in the prefabricated purse-string, through which faeces were drained. The stent completely disintegrated in the body after 3-4 weeks, which protected the anastomosis after surgery and avoided protective stoma. Clinical characteristics and surgical outcomes were collected. RESULTS Eleven patients who successfully received surgery were included. There were seven (63.6%) males and four (36.4%) females. The tumour size was 3.2 ± 1.7 cm and the lower verge of tumour to anal verge was 6.8 ± 1.3 cm. As for surgical outcomes, operation time was 216.4 ± 54.1 min, blood loss was 43.6 ± 64.6 mL, time to first flatus via intestinal diversion tube was 3.2 ± 1.1 days, time to discharge stent was 22.8 ± 3.0 days, and postoperative hospital stay was 21.0 ± 5.4 days. Two patients suffered from postoperative complications including pneumonia and incision infection. CONCLUSION This novel stent-assisted ileal bypass is safe and feasible, it provides a new choice for rectal cancer patients to avoid protective stoma and secondary surgery.
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Affiliation(s)
- Ze-Lin Wen
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Lian Bai
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xiong Zhou
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
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Song Z, Huang X, Dai S, Tong Y, Cai X. A stent-based diverting technique after low anterior resection of rectal cancer: our preliminary experience. Langenbecks Arch Surg 2022; 407:1751-1756. [PMID: 35034165 DOI: 10.1007/s00423-022-02433-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 01/03/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) is a severe complication of rectal cancer low anterior resection (LAR). Ileostomy, the most common method to reduce the severity of AL, is associated with the risk of permanent stoma and an additional operation for stoma reversal. This purpose of this study is to develop a novel protective technique called the stent-based diverting technique (SDT) to protect the anastomosis following LAR. METHODS From March 2020 to December 2020, thirty-four patients treated with LAR followed by SDT were enrolled prospectively at Sir Run Run Shaw Hospital. Demographic characteristics, laboratory test results, surgical outcomes, and oncological features were recorded. RESULTS Overall, the median period of stent degradation was 21 (18-24) days. One patient (2.9%) had anastomotic leakage, and another patient (2.9%) had intestinal obstruction, while no other complications (e.g., intestinal volvulus, perforation, fistula) were observed in this study. CONCLUSIONS The unique SDT may be a novel approach to prevent anastomotic leakage following low anterior resection of rectal cancer.
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Affiliation(s)
- Zhangfa Song
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Laparoscopy, Hangzhou, China
| | - Xuefeng Huang
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Laparoscopy, Hangzhou, China
| | - Sheng Dai
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Laparoscopy, Hangzhou, China
| | - Yifan Tong
- Zhejiang Provincial Key Laboratory of Laparoscopy, Hangzhou, China.,Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Xiujun Cai
- Zhejiang Provincial Key Laboratory of Laparoscopy, Hangzhou, China. .,Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China.
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Shi H, Chen SY, Xie ZF, Huang R, Jiang JL, Lin J, Dong FF, Xu JX, Fang ZL, Bai JJ, Luo B. Peroral traction-assisted natural orifice trans-anal flexible endoscopic rectosigmoidectomy followed by intracorporeal colorectal anastomosis in a live porcine model. World J Gastrointest Endosc 2020; 12:451-458. [PMID: 33269054 PMCID: PMC7677887 DOI: 10.4253/wjge.v12.i11.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/29/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Compared to traditional open surgery, laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain, a shorter hospital stay, and better quality of life. In 2007, Whiteford et al reported the first natural orifice trans-anal endoscopic surgery (NOTES) sigmoidectomy using transanal endoscopic microsurgery. To date, all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms.
AIM To introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model.
METHODS Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection. After preoperative work-up and bowel preparation, general anesthesia combined with endotracheal intubation was achieved. One dual-channel therapeutic endoscope was used. Carbon dioxide insufflation was performed during the operation. The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps: (1) The rectosigmoid colon was tattooed with India ink by submucosal injection; (2) Creation of gastrostomy by directed submucosal tunneling; (3) Peroral external traction using endoloop ligation; (4) Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling; (5) Peroral external traction-assisted dissection of the left side of the colon; (6) Trans-anal rectosigmoid specimen transection, where an anvil was inserted into the proximal segment after purse-string suturing; (7) Intracorporeal colorectal end-to-end anastomosis using a circular stapler by a single stapling technique; and (8) Closure of gastrostomy using endoscopic clips. All animals were euthanized immediately after the procedure, abdominal exploration was performed, and the air-under-water leak test was carried out.
RESULTS The procedure was completed in all three animals, with the operation time ranging from 193 min to 259 min. Neither major intraoperative complications nor hemodynamic instability occurred during the operation. The length of the resected specimen ranged from 7 cm to 13 cm. With the assistance of a trans-umbilical rigid grasper, intracorporeal colorectal, tension-free, end-to-end anastomosis was achieved in the three animals.
CONCLUSION Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.
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Affiliation(s)
- Hong Shi
- Department of Digestive Endoscopy, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
| | - Su-Yu Chen
- Department of Digestive Endoscopy, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
| | - Zhao-Fei Xie
- Department of Digestive Endoscopy, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
| | - Rui Huang
- Department of Digestive Endoscopy, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
| | - Jia-Li Jiang
- Department of Digestive Endoscopy, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
| | - Juan Lin
- Department of Digestive Endoscopy, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
| | - Fang-Fen Dong
- School of Medical Technology and Engineering, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Jia-Xiang Xu
- School of Clinical Medicine, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Zhi-Li Fang
- School of Clinical Medicine, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Jun-Jie Bai
- School of Clinical Medicine, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Ben Luo
- School of Clinical Medicine, Fujian Medical University, Fuzhou 350122, Fujian Province, China
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