Laparoscopic right hemicolectomy with radical lymph node dissection using the no-touch isolation technique for advanced colon cancer

Influence of the no-touch isolation technique on oncologic outcomes for patients with colon cancer undergoing curative surgery: A systematic review and meta-analysis

OBJECTIVE

To explore the influence of the no-touch isolation technique (NTIT) on oncologic outcomes for patients with colon cancer (CC) undergoing curative surgery.

BACKGROUND

Although several studies have investigated this topic, there have been no meta-analyses exploring the influence of NTIT on oncologic outcomes for these patients.

METHODS

We performed a comprehensive electronic literature search of studies published prior to March 2022 to identify those that compared oncologic outcomes for patients with CC who did or did not undergo NTIT. We conducted a meta-analysis using a random-effects model to calculate risk ratio (RRs) and 95% confidence intervals (CIs), analyzing heterogeneity using I2 statistics.

RESULTS

Four studies involving a total of 2885 patients with CC who underwent curative surgery met the inclusion criteria for this meta-analysis. The 5-year overall survival (OS) rate was 76.6% for patients with CC who underwent NTIT and 77.2% for those who did not. A meta-analysis of the 3 studies that reported 5-year OS revealed no significant difference between groups (RR, 0.84; 95% CI, 0.62-1.16; P = 0.30; I2 = 70%). In addition, there were no significant differences in 5-year recurrence-free survival (RR, 1.17; 95% CI, 0.93-1.48; P = 0.19; I2 = 45%), and 5-year liver recurrence-free survival (RR, 0.95; 95% CI 0.62, 1.46; P = 0.82; I2 = 65%).

CONCLUSIONS

The use of NTIT has no significant influence on oncologic outcomes for patients with CC undergoing curative surgery.

"Caudal to cranial" versus "medial to lateral" approach in laparoscopic right hemicolectomy with complete mesocolic excision for the treatment of stage II and III colon cancer: perioperative outcomes and 5-year prognosis

The purpose of this study was to compare the "caudal to cranial" (CC) versus "medial to lateral" (ML) approach for laparoscopic right hemicolectomy. Pertinent data from all patients with stage II and III between January 2015 and August 2017 were entered into a retrospective database. A total of 175 patients underwent the ML (N = 109) or CC approach (N = 66). Patient characteristics were equivalent between groups. The CC group showed a shorter surgical time 170.00 (145.00, 210.00) vs. (206.50 (178.75, 226.25) min) than the ML group (p < 0.001). The time to oral intake was shorter in the CC group than in the ML group ((3.00 (1.00, 4.00) vs. 3.00 (2.00, 5.00) days; p = 0.007). For the total harvested lymph nodes, there was no statistical significance between the CC group 16.50 (14.00, 21.25) and the ML group 18.00 (15.00, 22.00) (p = 0.327), and no difference was found in the positive harvested lymph nodes (0 (0, 2.00) vs. 0 (0, 1.50); p = 0.753). Meanwhile, no differences were found in other perioperative or pathological outcomes, including blood loss and complications. For 5-year prognosis, overall survival rates were 75.76% in the CC group and 82.57% in the ML group (HR 0.654, 95% CI 0.336-1.273, p = 0.207); disease-free survival rates were 80.30% in the CC group and 85.32% in the ML group (HR 0.683, 95% CI 0.328-1.422, p = 0.305). Both approaches were safe and feasible and resulted in excellent survival. The CC approach was beneficial in terms of the surgical time and time to oral intake.

An Orthotopic Resection Surgical Technique Using an Inferior Infracolic Approach for Laparoscopic Pancreaticoduodenectomy

The no-touch isolation technique has been widely used in cancer surgery as a strategy to prevent cancer cells from spreading; however, it is difficult to apply in laparoscopic pancreaticoduodenectomy (LPD). Here, we describe an orthotopic resection surgical technique that applies a no-touch principle for LPD and can help with the in situ resection of tumors. In implementing this surgical strategy, Kocher's maneuver was not performed first. Instead, after the exploration of the abdominal cavity, the distal stomach and the pancreatic neck were transected. Then, the dissection of the uncinate process of the pancreas, the duodenum, and the superior mesenteric vein and artery is carried out via an inferior infracolic approach. Finally, the pancreatic head and duodenum were removed in situ. Among the 41 patients who underwent this technique, two (4.9%) required conversion to open surgery due to uncontrolled bleeding. The average operative time was 335 min (248-1055 min). The mean estimated blood loss was 300 mL (50-1250 mL). Two patients (4.9%) underwent combined PV resection and reconstruction; six patients (14.6%) required a blood transfusion; two patients (4.9%) suffered from postoperative bleeding; two patients (4.9%) suffered from Grade B pancreatic fistulas; one patient (2.4%) suffered from bile leakage; and three patients (7.3%) suffered from abdominal fluid collection. No patients died during the perioperative period. Therefore, orthotopic LPD using an inferior infracolic approach is safe and feasible for patients with malignant pancreatic head and periampullary tumors. However, further investigations are required to elucidate its oncological benefits.

Management of Superficial Esophageal Squamous Cell Carcinoma and Early Gastric Cancer following Non-Curative Endoscopic Resection

According to the European and Japanese guidelines, additional treatment is recommended for cases of superficial esophageal squamous cell carcinoma (ESCC) and early gastric cancer (EGC) that do not meet the curability criteria for endoscopic resection (ER), i.e., non-curative ER, owing to the risk of lymph node metastasis (LNM). However, the rates of LNM in such cases were relatively low (e.g., 8% for EGC). Several recent advances have been made in this field. First, pathological risk stratification for metastatic recurrence following non-curative ER without additional treatment was developed for both superficial ESCC and EGC. Second, the pattern of metastatic recurrence and prognosis after recurrence following non-curative ER without additional treatment was found to be considerably different between superficial ESCC and EGC. Third, a combination of ER and selective chemoradiotherapy was developed as a minimally invasive treatment method for clinical T1b-SM ESCC. These findings may help clinicians decide the treatment strategy for patients following non-curative ER; however, for optimal therapeutic decision-making in such patients, it is also important to predict the prognosis other than SESCC or EGC and impaired quality of life. Thus, a novel algorithm that considers these factors, as well as metastatic recurrence, should be developed.

Circulating Tumor Cells and the Non-Touch Isolation Technique in Surgery for Non-Small-Cell Lung Cancer

Circulating tumor cells (CTCs) are dislodged from the primary tumor into the bloodstream, travel within the bloodstream to distant organs, and finally extravasate and proliferate as epithelial metastatic deposits. The relationship between the existence of CTCs and tumor prognosis has been demonstrated by many researchers. In surgery for malignancies, the surgical manipulation of tumors and tissues around the tumor may lead to the release of CTCs into the bloodstream. The non-touch isolation technique (NTIT) has been advocated to prevent the release of CTCs during surgery. The concept of NTIT is the prevention of intraoperative increment of CTCs from the primary tumor by the early blockade of outflow vessels, and ‘pulmonary vein (PV)-first lobectomy’ during surgery for non-small-cell lung cancer (NSCLC) corresponds to this technique. The concept of PV-first lobectomy is well known among thoracic surgeons, but evidence of its efficacy for preventing the increase of intra- and postoperative CTCs and for improving postoperative prognosis is still uncertain. Our study summarizes evidence regarding the relationship between NTIT and CTCs in NSCLC and suggests the need for further research on CTCs and CTC-detecting modalities.

What is the best surgical procedure of transverse colon cancer? An evidence map and minireview

Colorectal cancers comprise a large percentage of tumors worldwide, and transverse colon cancer (TCC) is defined as tumors located between hepatic and splenic flexures. Due to the anatomy and embryology complexity, and lack of large randomized controlled trials, it is a challenge to standardize TCC surgery. In this study, the current situation of transverse/extended colectomy, robotic/ laparoscopic/open surgery and complete mesocolic excision (CME) concept in TCC operations is discussed and a heatmap is conducted to show the evidence level and gap. In summary, transverse colectomy challenges the dogma of traditional extended colectomy, with similar oncological and prognostic outcomes. Compared with conventional open resection, laparoscopic and robotic surgery plays a more important role in both transverse colectomy and extended colectomy. The CME concept may contribute to the radical resection of TCC and adequate harvested lymph nodes. According to published studies, laparoscopic or robotic transverse colectomy based on the CME concept was the appropriate surgical procedure for TCC patients.

Surgical management of adenocarcinoma of the transverse colon: What should be the extent of resection?

Transverse colon, owing its origin to midgut and hindgut and harbouring a flexure at both ends, continues to pose a surgical challenge. When compared to the rest of the colon, transverse colon adenocarcinoma is relatively uncommon. These cancers usually present late and lie in close proximity to the stomach, omentum, and pancreas. Adequate lymphadenectomy entails dissection around and ligation of the middle colic vessels. Hence, resectional surgery for transverse colon carcinoma is considered difficult. This is more so because of the variation of arterial and venous anatomy. From this perspective, the surgeon is tempted to perform a more radical operation like extended right or left hemicolectomy to secure an adequate lymphadenectomy. Such a cancer has also been dealt with a more limited transverse colectomy with colo-colic anastomosis. For all these reasons, patients with transverse colon adenocarcinoma were excluded from randomised trials which compared laparoscopic resection with traditional open operation. Surgical literature is yet to establish a definite operation for transverse colon cancer and the exact procedure is often dictated by surgeon's preference. This is primarily because this is an uncommon cancer. The rapid adoption of laparoscopic operation favoured extended colectomy as transverse colectomy can be difficult by minimally invasive technique. However, in the recent past, cohort studies and meta-analyses have shown equivalent oncological outcome between transverse colectomy and extended colectomy. It is time to resurrect transverse colectomy and consider it equivalent to its radical counterpart for cancers around the mid-transverse colon.

D2 VS D3 LYMPH NODE DISSECTION FOR RIGHT COLON CANCER (review)

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"Top down no-touch" technique in robotic complete mesocolic excision for extended right hemicolectomy with intracorporeal anastomosis

BACKGROUND

Proper identification of the mesocolic vessels is essential for achieving complete mesocolic excision (CME) in cases of colon cancer requiring an extended right hemicolectomy. In robotic procedures, we employed a "top down technique" to allow early identification of the gastrocolic trunk and middle colic vessels. The aim of our study was to illustrate the details of this technique in a series of 12 patients.

METHODS

The top down technique consists of two steps. First, the omental bursa was entered to identify the right gastroepiploic vein. Tracing down this vein as a landmark, the gastrocolic trunk was exposed, branches of this trunk and the middle colic vessels were divided. Second, dissection was directed to the ileocolic region and proceeded in an inferior-to-superior direction along the superior mesenteric vein to divide the ileocolic and right colic vessels consecutively. The ileotranverse anastomosis was created intracorporeally.

RESULTS

There were 8 males and 4 females with a mean age of 64.8 ± 16.9 years and a mean body mass index of 25.6 ± 3.7 kg/m². All the procedures were completed successfully. No conversions occurred. The mean operative time and blood loss were 312.1 ± 93.9 min and 110.0 ± 89.9 ml, respectively. The mean number of harvested lymph nodes was 45.2 ± 11.1. The mean length of hospital stay was 7.6 ± 4.7 days. Two patients had intraoperative complications and two had postoperative complications. There was no disease recurrence at a mean follow-up period of 10.4 ± 7.1 months.

CONCLUSIONS

The top down technique appears to be useful in robotic CME for an extended right hemicolectomy. Early identification of the gastrocolic trunk and middle colic vessels via this technique may prevent inadvertent vascular injury at the mesenteric root of the transverse colon.

Comparison between different approaches applied in laparoscopic right hemi-colectomy: A systematic review and network meta-analysis

AIM

Several different operative approaches have been applied nowadays in laparoscopic right hemi-colectomy. This study aims to evaluate the potential benefits of different approaches by conducting a network meta-analysis (NMA).

METHOD

A comprehensive literature research of the PubMed, Embase, Medline, the Cochrane Central Library, Wan Fang and China National Knowledge Infrastructure (CNKI) databases was performed. Original articles comparing two of three different approaches including medial to lateral (MtL) approach, lateral to medial (LtM) approach and cranial to caudal (CtC) approach of laparoscopic right colon resection for patients with both neoplastic and benign diseases were included.

RESULTS

3 RCTs and 3 NRCTs with a total of 571 patients were included in this NMA. The result revealed that LtM approach needs shorter postoperative flatus recovery time than both MtL approach with a WMD of 1.40 (95% CI: 0.13 to 2.67, P < 0.05) and CtC approach (WMD = -1.25, 95% CI: -1.90 to -0.61, P < 0.05). The length of hospital stay of LtM approach is shorter than that of MtL approach (WMD = 0.29, 95% CI: 0.08 to 0.50, P < 0.05). CtC approach can achieve less postoperative complications (OR = 3.37, 95% CI: 1.06 to 10.70, P < 0.05) compared with MtL approach.

CONCLUSION

All three approaches are safe and acceptable in laparoscopic right hemi-colectomy since the pooled evidence revealed that most aspects of different approaches are comparable in general. The postoperative flatus recovery time and hospitalization time of LtM approach is shorter compared with MtL approach. And CtC approach may have slight superiority in postoperative complications compared with MtL approach.

Long-term oncological outcomes of submucosal manipulation during non-curative endoscopic submucosal dissection for submucosal invasive gastric cancer: a multicenter retrospective study in Japan

BACKGROUND

Sufficient information is not available on the extent to which lymph node metastasis (LNM) and prognosis are affected by submucosal manipulation during endoscopic submucosal dissection (ESD) for submucosal invasive gastric cancer (SMGC). We aimed to identify the effects of submucosal manipulation during ESD on LNM and prognosis in patients with SMGC.

METHODS

From 19 institutions in Japan, 2526 patients who failed to meet the current curative criteria for ESD between 2000 and 2011 were recruited. After exclusion, 1969 patients were remained. Based on the treatment strategy after ESD, 1064 patients underwent additional radical surgery. A total of 890 of 1064 patients with SMGC, LNM and cancer recurrence, and prognosis were retrospectively reviewed.

RESULTS

The median follow-up duration was 67 months. A total of 214 patients had SM1 (depth of tumor invasion from the muscularis mucosae <500 μm) invasive cancer and 676 patients had SM2 (depth of tumor invasion from the muscularis mucosae ≥500 μm) invasive cancer. LNM was found in 84 patients (9.4%), and 14 patients (1.6%) developed cancer recurrence. The 3-year and 5-year overall survival rates were 96.1 and 91.7%, respectively. The 3-year and 5-year disease-specific survival rates were 99.3 and 98.5%, respectively.

CONCLUSIONS

The rates of LNM and cancer recurrence, and prognosis of patients who underwent additional radical surgery after non-curative ESD for SMGC were excellent. Submucosal manipulation during ESD for SMGC does not seem to enhance the risk for LNM or worsen the prognosis compared to surgical series.

No-touch isolation techniques for pancreatic cancer

The rate of recurrence, including liver metastasis is high in pancreatic cancer, even when complete surgical resection is performed as a curative treatment. In patients with pancreatic cancer, the handling and grasping of the pancreas during surgery may increase the risk of liver metastasis, as squeezing may spread cancer cells via the portal vein. A no-touch isolation technique might prevent the spread of cancer cells via the hematogenous metastatic route in patients with pancreatic cancer. However, while no-touch isolation techniques are simple, feasible and, in theory, ideal procedures for the surgical treatment of pancreatic cancer, there have been no randomized controlled prospective studies to validate their advantages and their efficacy remains controversial. It is, therefore, worth investigating the use of no-touch isolation techniques in pancreatic cancer.

Cranially approached radical lymph node dissection around the middle colic vessels in laparoscopic colon cancer surgery

PURPOSE

Laparoscopic lymph node (LN) dissection around the middle colic vessels is technically demanding, thus raising controversy regarding the role of laparoscopic surgery for transverse colon cancer. We herein describe a cranial approach method to perform radical LN dissection around the middle colic vessels. The key characteristic of this approach is early division of middle colic vessels prior to mobilization of the colon.

METHODS

From April 2010 to September 2013, 27 patients with colon cancer received laparoscopic LN dissection around the middle colic vessels using this cranial approach. Their surgical and short-term outcomes were reviewed.

RESULTS

The mean number of harvested LNs was 29 (range, 6-50). The mean operative time and intraoperative blood loss were 274 min (range, 160-362 min) and 42 mL (range, 3-247 mL), respectively. There were no serious intraoperative complications or conversions to open surgery. There were two patients with stage 0, 7 with stage I, 12 with stage II, and 6 with stage III. No recurrent case was observed with a median follow-up period of 30 months (range, 9-48 months).

CONCLUSIONS

We consider this approach feasible and useful for radical LN dissection around the middle colic vessels during laparoscopic colon cancer surgery.

A systematic review and meta-analysis evaluating the role of laparoscopic surgical resection of transverse colon tumours

OBJECTIVES

A meta-analysis of published literature comparing outcomes after laparoscopic resection (LR) with open resection (OR) for transverse colon tumours.

METHODS

Medline, PubMed, CINAHL, EMBASE and Cochrane were searched from inception to October 2013. The text words "minimally invasive", "keyhole surgery" and "transverse colon" were used in combination with the medical subject headings "laparoscopy" and "colon cancer". Outcome variables were chosen based upon whether the included articles reported results. A meta-analysis was performed to obtain a summative outcome.

RESULTS

Six comparatives involving 444 patients were analysed. Of them 245 patients were in the LR group and 199 in the OR group. There was a significant increase in operative time in the LR group compared with the OR group [random effects model: SMD = -0.65, 95% CI (-1.01, -0.30), z = -3.60, p < 0.001] but there was significant heterogeneity amongst trials (Q = 15.51, df = 5, p = 0.008, I(2) = 68). There was less blood loss in the LR group [fixed effects model: SMD = 0.70, 95% CI (0.47, 0.93), z = 6.01, p < 0.001] and patients returned to oral diet earlier [random effects model: SMD = 0.78, 95% CI (0.40, 1.16), z = 4.01, p < 0.001] and had a reduced time to functioning bowel [fixed effects model: SMD = 0.86, 95% CI (0.60, 1.11), z = 6.63, p < 0.001]. No difference was seen for overall morbidity (p = 0.76) or mortality (p = 0.58).

CONCLUSIONS

LR of transverse colon tumours is a safe and effective technique. Although there is an increase in operating time, operative and clinical outcomes of intraoperative blood loss and faster recovery are seen with laparoscopic procedures.

Comparative study of oncologic outcomes for laparoscopic vs. open surgery in transverse colon cancer

Purpose

Laparoscopic resection for transverse colon cancer is a technically challenging procedure that has been excluded from various large randomized controlled trials of which the long-term outcomes still need to be verified. The purpose of this study was to evaluate long-term oncologic outcomes for transverse colon cancer patients undergoing laparoscopic colectomy (LAC) or open colectomy (OC).

Methods

This retrospective review included patients with transverse colon cancer who received a colectomy between January 2006 and December 2010. Short-term and five-year oncologic outcomes were compared between these groups.

Results

A total of 131 patients were analyzed in the final study (LAC, 84 patients; OC, 47 patients). There were no significant differences in age, gender, body mass index, tumor location, operative procedure, or blood loss between groups, but the mean operative time in LAC was significantly longer (LAC, 246.8 minutes vs. OC, 213.8 minutes; P = 0.03). Hospital stay was much shorter for LAC than OC (9.1 days vs. 14.5 days, P < 0.01). Postoperative complication rates were not statistically different between the two groups. In terms of long-term oncologic data, the 5-year disease-free survival and overall survival were not statistically different between both groups, and subgroup analysis according to cancer stage also revealed no differences.

Conclusion

LAC for transverse colon cancer is feasible and safe with comparable short- and long-term outcomes.

Laparoscopic colectomy for transverse colon carcinoma: a surgical challenge but oncologically feasible

AIM

The aim of the study was to assess the safety and feasibility of laparoscopic surgery for transverse colon cancer and to compare the clinicopathological outcome with that of conventional open surgery.

METHOD

From March 1998 to December 2009, 1253 patients with colorectal tumours were operated on, 564 laparoscopically. There were 154 cases of transverse colon cancer, 86 of which were included in the study. Details were collected on age, sex, body mass index (BMI), operation time, blood loss, time to first flatus, time to resume a liquid diet, postoperative length of hospital stay, complications, TNM stage, tumour size, distal resection margin, proximal resection margin, number of nodes harvested and surgical procedure. Laparoscopic and open surgical removal was compared.

RESULTS

No significant differences were found between laparoscopic and conventional groups in age, sex, BMI, operation time or postoperative length of hospital stay. The mean blood loss during the operations was significantly less in the laparoscopic group (105.9 ± 140.9 ml vs 305.7 ± 325.3 ml; P = 0.05). The time to the first flatus was shorter (2.1 ± 0.3 days vs 3.8 ± 3.0 days; P = 0.043) and diet was started earlier (3.1 ± 1.4 days vs 3.4 ± 1.5 days) in the laparoscopic group. No significant differences in tumour size, proximal resection margin or number of lymph nodes were observed. The mean distal resection margin was not statistically different (10.3 ± 4.5 cm vs 8.8 ± 4.9 cm). At a mean follow up of 33 ± 2.3 months, nonport-site metastases occurred in eight patients and locoregional recurrence occurred in three, with no significant difference between the groups. The 3-year cumulative overall survival rate was 78%, and the disease-free survival rate was 69%.

CONCLUSION

There was no difference in the outcome of laparoscopic and open surgery for transverse colon cancer, including the cancer-specific outcome.

Laparoscopic right hemicolectomy

Over the past 20 years, laparoscopic colectomy has become a well-established technique in the surgical armamentarium of colorectal operations, with proven reductions in postoperative pain, time to return of bowel function, and length of hospital stay. After early concerns over its oncologic effects, large prospective, multicenter trials have proven its safety in colorectal adenocarcinoma, with equivalence in nodal harvest, recurrence rates, disease-free survival, and overall survival. Laparoscopic right hemicolectomy in particular is a relatively accessible technique which may be performed by a single surgeon and an assistant/camera operator; this operation serves as an excellent method to develop laparoscopic skills for more complicated colorectal procedures. In this article, we describe the technical aspects of our approach to laparoscopic right hemicolectomy, which utilizes a medial-to-lateral, no-touch technique and either an intracorporeal or extracorporeal anastomosis.

Intracorporeal versus extracorporeal anastomosis during laparoscopic right hemicolectomy - systematic review and meta-analysis

BACKGROUND

Since 2005, after an initial scanty spreading, the vast majority of surgeons advice against the intracorporeal ileocolic anastomosis following right hemicolectomies. In the subsequent years, greater interest was re-discovered for the intracorporeal ileocolic anastomosis formed after video-assisted right hemicolectomies

OBJECTIVE

The aim of this systematic review is to compare the intra-abdominal versus extra-abdominal anastomosis after right laparoscopic colectomy.

DATA SOURCES

A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central and the Science Citation Index.

STUDY SELECTION

A total of 191 publications were identified; seven non-randomized studies published between 2004 and 2012 with a total of 945 patients, who underwent laparoscopic right colectomy for malignant and benign disease, were included in this systematic review.

INTERVENTION

Intra-abdominal versus extra-abdominal confectioning of ileo-coloc anastomosis after right laparoscopic colectomy.

MAIN OUTCOME MEASURES

Anastomotic leak, overall post-operative morbidity and overall 30-days post-operative mortality.

RESULTS

Anastomotic leak rate resulted similar in IA (1.13%) and EA (1.84%) group (P=0.81, OR of 0.90, 95% CI 0.24-3.10) (Chi(2)=3.90, P=0.42, I(2)=0%). The mortality rate was lower in the IA group (0.34% versus 1.32%), although no statistically difference was demonstrated between the two groups (P = 0.48, OR of 0.52 95% CI 0.09-3.10). It was not possible to conduct a meta-analysis of post-operative morbidity as the data reported in the included studies were too heterogeneous.

LIMITATIONS

The weakness in our results was due to the lack of evidence in current published literature.

CONCLUSIONS

The present systematic review of literature and meta-analysis failed to solve the controversies between intracorporeal and extracorporeal anastomosis after laparoscopic right hemicolectomy. Future randomized, controlled trials are needed to further evaluate different surgical anastomosis after laparoscopic right hemicolectomy.

Is laparoscopic right colectomy more effective than open resection? A meta-analysis of randomized and nonrandomized studies

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.

Curative resection of transverse colon cancer via minilaparotomy

Minilaparotomy has been reported to be a minimally invasive alternative to laparoscopically assisted surgery. We retrospectively evaluated the usefulness of minilaparotomy for the resection of transverse colon cancer, which has generally been considered difficult to resect laparoscopically. Patients for whom curative resection was attempted for transverse colon cancer (n = 21) or sigmoid colon cancer (n = 81) via minilaparotomy (skin incision, < or = 7cm) were analyzed. The 2 groups did not significantly differ in terms of success rate of minilaparotomy (90.5% versus 97.5%), age, sex, pathologic stage, body mass index, operative time (mean, 133.5 minutes versus 122.5 minutes), blood loss (119.7 mL versus 92.4 mL), number of lymph nodes harvested, incidence of postoperative complications (9.5% versus 12.3%), postoperative length of stay, and 5-year disease-free survival rate (86.6% versus 79.6%). Minilaparotomy is feasible, safe, and favorable in terms of early oncologic outcome in patients with transverse colon cancer as well as those with sigmoid colon cancer.

Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer

INTRODUCTION

The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented.

METHODS

Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve.

RESULTS

No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results.

CONCLUSION

The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results.

REGISTRATION NUMBER

ISRCTN74883561 (http://www.controlled-trials.com).

Retrospective, matched case-control study comparing the oncologic outcomes between laparoscopic surgery and open surgery in patients with right-sided colon cancer

PURPOSE

The short- and long-term outcomes of laparoscopic surgery for right-sided colon cancer remain largely uninvestigated. This study was undertaken to compare the morbidity and mortality after either a laparoscopic right hemicolectomy (LRHC) or an open right hemicolectomy (ORHC) for this type of tumor.

METHODS

The study group included 100 patients who underwent an LRHC and 100 patients who underwent an ORHC for right-sided colon cancer from 1990 through 2004. The two groups were retrospectively well matched with respect to sex, age (+/-5 years), and pathological tumor-node-metastasis (TNM) stage.

RESULTS

The median follow-up period was 83 months in the LRHC group and 105 months in the ORHC group. The LRHC group had a lower volume of intraoperative bleeding (P < 0.001), a lower rate of wound infection (P = 0.019) or postoperative intestinal obstruction (P = 0.013), and a shorter hospital stay (P < 0.001) than the ORHC group. The rate of recurrence did not differ significantly between the LRHC group (19%) and the ORHC group (22%). In patients with TNM stage I or II, the disease-free survival (DFS) rate (94.9% vs 95.1%) and overall survival (OS) rate (95.8% vs 95.0%) did not differ significantly between the two groups. A similar tendency was observed in patients with stage III with the rates for DFS (71.3% vs 60.4%) and OS (73.6% vs 64.1%), respectively.

CONCLUSIONS

An LRHC for right-sided colon cancer has the advantage over an ORHC of better short-term outcomes, and both groups have similar long-term oncologic outcomes. An LRHC is thus an acceptable alternative to an ORHC for the treatment of this type cancer.

Laparoscopic colectomy: medial versus lateral approach

BACKGROUND

Laparoscopic colectomy can be performed using 2 approaches: lateral or medial. However, it is unknown if one of these techniques provides better results. Thus, the object of the present study is to assess whether one of the approaches has any potential benefits over the other.

METHODS

A comparative, retrospective study was performed that included all patients scheduled for left and right laparoscopic colon resection for both neoplastic and benign diseases between June 2000 and June 2006. The following factors were assessed: operation time, recovery variables (bowel sounds, passage of gases, intake of liquids and solids), length of hospital stay, and morbidity and mortality rates. The population was divided into 4 groups: right colectomy using a lateral approach (RL); right colectomy using a medial approach (RM); left colectomy using a lateral approach (LL); and left colectomy using a medial approach (LM).

RESULTS

A total of 202 patients were evaluated: RL: 16 (8%); RM: 37 (18.3%); LL: 110 (54.4%); LM: 39(19.3%). No differences in recovery parameters were observed between the right colectomies. However, the presence of bowel sounds and solid intake was significantly earlier in the patients subjected to left colectomies using a medial approach. A tendency toward a higher conversion rate was observed in left colectomies with lateral approach (LL: 18 vs. LM: 1, P=0.052). The operation time was significantly shorter when a medial approach was used for both right and left colectomies (RL: 185.6 min vs. RM: 148.6 min, P=0.009; LL: 205.5 min vs. LM: 139.9 min, P<0.0001). No differences in the morbidity and mortality rates were found between lateral and medial approach in both types of colectomy.

CONCLUSIONS

The use of a medial approach in a laparoscopic colectomy provides short-term benefits compared with a lateral approach.

A comparative study on the short-term clinicopathologic outcomes of laparoscopic surgery versus conventional open surgery for transverse colon cancer

BACKGROUND

The long-term oncologic stability of laparoscopic surgery for colon cancer was established, and laparoscopic surgery was accepted as an alternative to conventional open surgery for colon cancer. However, transverse colon cancer was excluded from the majority of the previous prospective studies. As a result, debate on laparoscopic surgery for transverse colon cancer continues. This study aimed to compare the clinicopathologic outcome of laparoscopic surgery with that of conventional open surgery for transverse colon cancer.

METHODS

From August 2004 to December 2007, 106 cases of transverse colon cancer were managed by resection at our institution, and 89 of these cases were included in this study. Age, sex, body mass index (BMI), operation time, blood loss, time to first flatus, time to start of diet, hospital stay, complications, tumor size, distal resection margin, proximal resection margin, and number of nodes harvested were compared between the two groups.

RESULTS

No significant differences were found between the laparoscopic and conventional groups in terms of age, sex, BMI, operation time, or hospital stay. The mean blood loss during the operations was significantly less in the laparoscopic group (113.8 +/- 128.9 ml) than in the conventional group (278.8 +/- 268.7 ml; p < 0.05). Moreover, the time to the first flatus was shorter (2.8 +/- 0.9 days vs. 4.4 +/- 2.0 days; p < 0.00) and the diet was started earlier (3.9 +/- 1.7 days vs. 5.4 +/- 1.9 days; p < 0.00) in the laparoscopic group. No intergroup differences in tumor size, proximal resection margin, or number of lymph nodes were observed. The mean distal resection margin was longer in the laparoscopic group (12.5 +/- 4.1 cm vs. 9.2 +/- 6.2 cm; p < 0.05).

CONCLUSION

Laparoscopic and conventional open surgeries were found to have similar clinical outcomes in transverse colon cancer, and the oncologic quality of laparoscopic surgery was found to be acceptable compared with conventional open surgery.

Laparoscopy-assisted combined resection for synchronous gastric and colorectal cancer: report of three cases

In gastric cancer patients, the most common form of synchronous cancer is colorectal cancer. To reduce the invasiveness of the resection, a laparoscopy-assisted combined resection was performed in three patients with synchronous gastric and colorectal cancer. Although all gastric lesions were in the early stages, two colorectal lesions were advanced cases. In all cases, the laparoscopic gastric resection and reconstruction was performed first, followed by the colorectal resection. In the case of right-side colon cancer in addition to gastric cancer, it was relatively easy to perform the combined resection with lymph node dissection sharing the same ports used for the gastrectomy, although we needed an additional port. In one case, in which rectal cancer was present in addition to gastric cancer located in the upper portion of the stomach, a totally laparoscopic proximal gastrectomy was combined with a laparoscopy-assisted low anterior resection, leaving only a lower abdominal minilaparotomy wound. All patients quickly returned to normal activity without remarkable complications, with the exception of a wound infection in one patient. With a mean follow-up of 30.7 months, all patients survived without any sign of recurrence. This procedure represents a feasible option for minimally invasive treatment of synchronous gastric and colorectal cancer.

Surgical and pathological outcomes of laparoscopic surgery for transverse colon cancer

PURPOSE

Several multi-institutional prospective randomized trials have demonstrated short-term benefits using laparoscopy. Now the laparoscopic approach is accepted as an alternative to open surgery for colon cancer. However, in prior trials, the transverse colon was excluded. Therefore, it has not been determined whether laparoscopy can be used in the setting of transverse colon cancer. This study evaluated the peri-operative clinical outcomes and oncological quality by pathologic outcomes of laparoscopic surgery for transverse colon cancer.

MATERIALS AND METHODS

Analysis of the medical records of patients who underwent laparoscopic colorectal resection from August 2004 to November 2007 was made. Computed tomography, barium enema, and colonoscopy were performed to localize the tumor preoperatively. Extended right hemicolectomy, transverse colectomy, and extended left hemicolectomy were performed for transverse colon cancer. Surgical outcomes and pathologic outcomes were compared between transverse colon cancer (TCC) and other site colon cancer (OSCC).

RESULTS

Of the 312 colorectal cancer patients, 94 patients underwent laparoscopic surgery for OSCC, and 34 patients underwent laparoscopic surgery for TCC. Patients with TCC were similar to patients with OSCC in age, gender, body mass index, operating time, blood loss, time to pass flatus, start of diet, hospital stay, tumor size, distal resection margin, proximal resection margin, number of lymph nodes, and radial margin. One case in TCC and three cases in OSCC were converted to open surgery.

CONCLUSIONS

Laparoscopic surgery for transverse colon cancer and OSCC had similar peri-operative clinical and acceptable pathological outcomes.

Open right colectomy is still effective compared to laparoscopy: results of a randomized trial

OBJECTIVE

The primary goal of this study was to clarify whether a laparoscopic (LPS) approach could be considered the dominant strategy in patients undergoing right colectomy.

SUMMARY BACKGROUND DATA

Because few nonrandomized or small sized studies have been carried out so far, definitive conclusions about the role of LPS right colectomy cannot be drawn.

METHODS

Two hundred twenty-six patients, candidates for right colectomy, were randomly assigned to LPS (n = 113) or open (n = 113) resection. The postoperative care protocol was the same for both groups. Trained members of the surgical staff who were not involved in the study registered postoperative morbidity. Follow-up was carried out for 30 days after hospital discharge. The following costs were calculated: surgical instruments, operative room occupation, routine care, postoperative morbidity, and hospitalization.

RESULTS

Conversion rate in the LPS group was 2.6% (3 of 113). Operative time (in minutes) was longer in the LPS group (131 vs. 112, P = 0.01). Postoperative morbidity rate was 18.6% in the open group and 13.3% in the LPS group (P = 0.31). Postoperative stay was one day longer in the open group (P = 0.002). No difference was found in postoperative quality of life. The additional operative charge in the LPS group was euro980 per patient randomized (euro821 for surgical instruments and euro159 for longer operative time). The savings in the LPS group was euro390 per patient randomized (euro144 for shorter length of hospital stay and euro246 for the lower cost of postoperative morbidity). The net balance resulted in a euro590 extra charge per patient randomly allocated to the LPS group.

CONCLUSION

LPS slightly improved postoperative recovery. This translated into a savings that covered only 40% of the extra operative charge. Therefore, open right colectomy could be still considered an effective procedure.

Laparoscopic medial-to-lateral approach for the curative resection of right-sided colon cancer

INTRODUCTION

Our previous randomized clinical trial comparing the laparoscopic medial-to-lateral dissection with the more classic lateral-to-medial approach for resection of rectosigmoid cancer showed that the medial approach reduces the operative time and the postoperative proinflammatory response. Besides the oncologic advantages of an early vessel division and a "no-touch" dissection, we feel that the longer the lateral abdominal wall attachments of the colon are preserved, the better the exposure and the easier the dissection. Encouraged by the above-mentioned positive findings, we therefore further conduct this phase II clinical trial to examine the feasibility and surgical outcomes regarding the utilization of this medial-to-lateral laparoscopic dissection approach for the curative resection of right-sided colon cancer.

METHODS

A total of 104 patients (from December 2000 to January, 2005) with advanced right-sided colon cancer (TNM stage II: n = 56; stage III: n = 48) requiring a curative right hemicolectomy were subjected to the laparoscopic medial-to-lateral approach that included initial exploration and ligation of ileocolic, right colic, and middle colic vessels in no-touch isolation fashion, subsequent medial-to-lateral extension of retroperitoneal dissection along Gerota fascia, opening of lesser sac by transection of gastrocolic ligament, and the final mobilization of hepatic flexure and lateral attachments of ascending colon (Fig. 1). This study was approved by the institutional review committee of National Taiwan University Hospital. The surgical details were shown in the video. Postoperatively, adjuvant chemotherapy with Mayo Clinic Regimen was given in patients with stage III diseases. The functional recovery and surgical outcomes were prospectively evaluated.

RESULTS

The laparoscopic medial-to-lateral approach for a curative right hemicolectomy can be preformed with acceptable operation time (192.6 +/- 32.8 min, mean +/- standard deviation) and little blood loss (48.4 +/- 14.4 ml) through a small wound (6.0 +/- 0.8 cm). The number of dissected lymph node was 16.0 +/- 2.8. The operative complications represented 5.7% of all cases, including anastomotic leakage in two cases (1.9%) and wound infection in four cases (3.8%). The patients have quick functional recovery, as evaluated by the length of postoperative ileus (60.0 +/- 12.0 h), hospitalization (9.0 +/- 1.5 days) and degree of postoperative pain (4.0 +/- 0.5, visual analogue scale). Besides the expenses covered by the National Bureau of Health Insurance in Taiwan, the patient had to pay an extra-expenses of NT$ 25,000.0 +/- 2,800.0 (1.0 US$ = 32.0 NT$). During the follow-up periods (median: 30 months, range 6-55 months), recurrence of tumor developed in 6 (10.7%) of stage II and 10 (20.8%) of stage III patients, with liver metastasis in six patients, lung metastasis in 4, liver and lung metastasis in 1, intraperitoneal recurrence in 2, bone metastasis in 1, brain metastasis in 1, and port-site recurrence in 1.

CONCLUSIONS

By medial-to-lateral dissection method, the laparoscopic right hemicolectomy can be performed with technical efficiency, short convalescence, and acceptable short-term oncologic results. We therefore encourage the use of this approach for patients requiring a curative laparoscopic right hemicolectomy.

What is a meant when a laparoscopic surgical procedure is described as “safe”?

BACKGROUND

The literature on laparoscopic surgery contains many studies concluding that a procedure is "safe." This study aimed to review systematically articles from the past 10 years that judged a laparoscopic technique for colon resection and anastomosis to be "safe."

METHODS

The authors searched the Medline database from January 1995 to August 2005 using the search terms "laparoscopic," "colon," and "safe," selecting studies of laparoscopic colon resection or laparoscopic techniques of colonic anastomosis. They calculated exact 95% confidence intervals around estimates of the risk for death reported in the studies to determine the upper limit of the possible risk for death in a study reporting no deaths.

RESULTS

Of 135 studies matching the search criteria, 41 (30%) described operations involving laparoscopic colonic resection or anastomosis. These studies enrolled a mean number of 233 subjects. There were 26 retrospective studies, 12 prospective studies, 2 randomized control trials, and 1 case report. The estimated upper 95% confidence limits for studies reporting mortality ranged from 1.66% to 97.5%. Of the studies that reported mortality and concluded that laparoscopic colon surgery is "safe," 77.8% could not exclude a mortality rate higher than 5%.

CONCLUSION

Many studies concluding that laparoscopic colon surgery is "safe" could not exclude a high risk of operative mortality. The term "safe" is not a useful descriptor of the relative safety of laparoscopic surgical procedures, and statements about the safety of a surgical procedure should be justified with precise estimates and confidence intervals of the risk for adverse events.

Laparoscopic versus open right hemicolectomy with curative intent for colon carcinoma

AIM: Laparoscopic surgery, especially laparoscopic rectal surgery, for colorectal cancer has been developed considerably. However, due to relatively complicated anatomy and high requirements for surgery techniques, laparoscopic right colectomy develops relatively slowly. This study was designed to compare the outcomes of laparoscopic right hemicolectomy (LRH) with open right hemicolectomy (ORH) in the treatment of colon carcinoma.

METHODS: Between September 2000 and February 2003, 30 patients with colon cancer who underwent LRH were compared with 34 controls treated by ORH in the same period. All patients were evaluated with respect to surgery-related complications, postoperative recovery, recurrence and metastasis rate, cost-effectiveness and survival.

RESULTS: Among 30 LRH, 2 (6.7%) were converted to open procedure. No significant differences were observed in terms of mean operation time, blood loss, post-operative complications, and hospital cost between LRH and ORH groups. Mean time for bowel movement, hospital stay, and time to resume early activity in the LRH group were significantly shorter than those in the ORH group (2.24±0.56 vs 3.25±1.29 d, 13.94±6.5 vs 18.25±5.96 d, 3.94±1.64 vs 5.45±1.82 d respectively, P<0.05). As to the lymph node yield, the specimen length and total cost for operation and drugs, there was no significant difference between the two groups. Local recurrence rate and metachronous metastasis rate had no marked difference between the two groups. Cumulative survival probability at 40 mo in LRH group (76.50%) was not obviously different compared to the ORH group (74.04%).

CONCLUSION: LRH in patients with colon cancer has statistically and clinically significant advantages over ORH. Thus, LRH can be regarded as a safe and effective procedure.