The impact of intracorporeal anastomosis in right laparoscopic colectomy in the surgical site infections and the hospital stay: a cohort study

Intracorporeal anastomosis in minimally invasive right hemicolectomy: a nationwide survey of the Korean Society of Coloproctology

Purpose

We investigated the current practices and perceptions of colorectal surgeons in South Korea regarding intracorporeal ileocolic anastomosis (IIA) in minimally invasive right hemicolectomy (RHC).

Methods

Members of the Korean Society of Coloproctology (KSCP) participated in an online survey encompassing demographic information, surgical experiences, methods for IIA, and advantages, barriers, and perceptions of IIA. We performed a statistical analysis of survey results.

Results

Among the 1,074 KSCP members contacted, 178 responded to the survey. Most respondents were males aged 40-49 years with >10 years of experience who were affiliated with a tertiary healthcare facility. One hundred fifty-six respondents had performed <100 colorectal cancer surgeries annually. Fifty-nine respondents reported experiences of the IIA technique in minimally invasive RHC. Most respondents favored the isoperistaltic side-to-side (S-S) anastomosis and stapled S-S anastomosis, hand-sewn closure for the common channel, and the periumbilical area for primary specimen extraction. Respondents with IIA experience emphasized the reduction in postoperative complications as the primary reason for performing IIA, whereas respondents without IIA experience cited the lack of benefits as the main deterrent. Respondents commonly cited concerns regarding anastomotic leakage and intraabdominal contamination as the primary reasons for not performing IIA. Respondents with IIA experience demonstrated a more positive response towards attempting or transitioning to IIA than those without. Respondents with IIA experience prioritized self-sufficiency, whereas respondents without IIA experience prioritized proctorship and discussions of the initial cases.

Conclusion

Measures to standardize the IIA technique and appropriate training programs must be implemented to enhance its use in minimally invasive RHC.

Evaluation of the short-term complications of intracorporeal anastomosis in right-sided colectomy

INTRODUCTION

The benefits of intracorporeal anastomosis in laparoscopic colorectal cancer surgery remain unclear. Therefore, we aimed to investigate the short-term postoperative outcomes of intracorporeal anastomosis.

METHODS

We retrospectively analyzed 87 patients who underwent laparoscopic surgery for right-sided colon tumors using a colon database.

RESULTS

Of the 87 patients, 23 underwent intracorporeal anastomosis and 64 underwent extracorporeal anastomosis. Intraoperative bleeding, wound length, exhaust gas, preoperative white blood cell count, and C-reactive protein (postoperative day 1) were higher in the extracorporeal anastomosis group than in the intracorporeal anastomosis group. The incidence of wound infection was higher in the intracorporeal anastomosis group than in the extracorporeal anastomosis group. In the irrigation water bacterial culture collected after anastomosis, the positive group had a higher white blood cell count on postoperative day 1 and higher C-reactive protein levels on postoperative day 3 than did the negative group. Patients who underwent chemical preparation had lower C-reactive protein levels on postoperative day 1 than did the group who did not undergo chemical preparation.

CONCLUSION

Despite the advantages of intracorporeal anastomosis in terms of wound length and intraoperative bleeding, the risk of infection may increase during the introduction phase. Fever and inflammatory responses are significantly elevated in culture-positive cases.

Clinical Outcomes after Intracorporeal versus Extracorporeal Anastomosis in Patients Undergoing Laparoscopic Right Hemicolectomy for Colon Cancer

Background and Objectives: Laparoscopic right hemicolectomy (LRHC) is commonly performed for patients with colon cancer, selecting between intracorporeal anastomosis (ICA) or extracorporeal anastomosis (ECA). However, the impact of ICA versus ECA on patient outcomes remains debatable. The varying levels of experience among surgeons may influence the outcomes. Therefore, this study sought to compare the short- and long-term outcomes of LRHC using ICA versus ECA. Materials and Methods: This retrospective study extracted patient data from the medical records database of Changhua Christian Hospital, Taiwan, from 2017 to 2020. Patients with colon cancer who underwent LRHC with either ICA or ECA were included. Primary outcomes were post-surgical outcomes and secondary outcomes were recurrence rate, overall survival (OS), and cancer-specific survival (CSS). Between-group differences were compared using chi-square, t-tests, and Fisher's exact tests and Mann-Whitney U tests. Associations between study variables, OS, and CSS were determined using Cox analyses. Results: Data of 240 patients (61 of ICA and 179 of ECA) with a mean age of 65.0 years and median follow-up of 49.3 months were collected. No recognized difference was found in patient characteristics between these two groups. The ICA group had a significantly shorter operation duration (median (IQR): 120 (110-155) vs. 150 (130-180) min) and less blood loss (median (IQR): 30 (10-30) vs. 30 (30-50) mL) than the ECA group (p < 0.001). No significant differences were found in 30-day readmission (ICA vs. ECA: 1.6% vs. 2.2%, p > 0.999) or recurrence (18.0% vs. 13.4%, p = 0.377) between the two groups. Multivariable analyses revealed no significant differences in OS (adjusted hazard ratio (aHR): 0.65; 95% confidence interval (CI): 0.25-1.44) or CSS (adjusted sub-hazard ratio (aSHR): 0.41, 95% CI: 0.10-1.66) between groups. Conclusions: Both ICA and ECA in LRHC for colon cancer had similar outcomes without statistically significant differences in post-surgical complications, 30-day readmission rates, recurrence rate, and long-term survival outcomes. However, ICA may offer two advantages in terms of a shorter operative duration and reduced blood loss.

Comparison of intracorporeal and extracorporeal anastomosis in laparoscopic right colectomy: an updated meta-analysis and trial sequential analysis

This meta-analysis was conducted to provide updated evidence regarding perioperative safety and efficacy, of IC and EC anastomosis in laparoscopic right colectomies. In this study, the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines were applied. The study protocol received a PROSPERO registration (CRD42020214596). A systematic literature search of the electronic scholar databases (Medline, Web of Science and Scopus) was performed. To reduce type I error, a trial sequential analysis (TSA) algorithm was introduced. The quality of evidence was evaluated based on the GRADE methodology. In total, 46 studies were included in this meta-analysis, Pooled comparisons and TSA confirmed that IC is superior in terms of incisional hernia (0.29; 95%CI: 0.19, 0.44), open conversion (0.45; 95%CI: 0.30, 0.67), reoperation (0.62; 95%CI: 0.46, 0.84]), LOS (- 0.76; 95%CI: - 1.03, - 0.49), blood loss (- 11.50; 95%CI: - 18.42, - 4.58), and cosmesis (- 1.71; 95%CI: - 2.01, - 1.42). Postoperative pain and return of bowel function were, also, shortened when the anastomosis was fashioned intracorporeally. The grading of most evidence ranged from 'low' to 'high'. Due to the discrepancy in the results of RCTs and non-RCTs, and the proportionally smaller sample size of the former, further randomized trials are required to increase the evidence of this comparison.

Effect of Preoperative Oral Antibiotics and Mechanical Bowel Preparations on the Intestinal Flora of Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Single-Center Prospective Pilot Study

INTRODUCTION

 In the last few decades, considerable progress has been made in controlling surgical site infections (SSIs) using a combination of mechanical and oral antibiotic bowel preparation. However, the number of bacteria present after bowel preparation has not been clarified. In this study, we investigated the bacterial cultures of intestinal fluid samples from patients undergoing laparoscopic surgery for colorectal cancer after preoperative bowel preparation.

METHODS

This prospective observational study was designed as a pilot study at a single center. We enrolled 25 consecutive patients who underwent laparoscopic surgery for colorectal cancer between March 2021 and February 2022 at our institution.

RESULTS

The rate of bacterial culture positivity was 56.0%. The most abundant bacterium was Escherichia coli (44.0%). The positivity rates for E. coli on the right and left sides were 54.5% and 35.7%, respectively (P = 0.60). Moreover, there was a significant relationship between a low American Society of Anesthesiologists Physical Status score and E. coli positivity on the right side (P = 0.031). In the left-sided group, female sex and large tumor size were significantly associated with E. coli positivity (P = 0.036 and 0.049, respectively). Superficial SSI occurred in the patient in the left-sided group, but E. coli was negative.

CONCLUSION

This study emphasizes the importance of understanding intestinal fluid contamination and its relationship to infection risk. Future prospective multicenter studies should be conducted to determine the association between intestinal bacteria and different types of preoperative preparation.

Extracorporeal Hand-Sewn vs. Intracorporeal Mechanic Anastomosis During Laparoscopic Right Colectomy

Background and Objectives

To compare the outcomes of extracorporeal hand-sewn side-to-side isoperistaltic ileocolic anastomosis (EHSIA) versus intracorporeal mechanic side-to-side isoperistaltic ileocolic anastomosis (IMSIA) during laparoscopic right hemicolectomy for adenocarcinoma.

Methods

This is a retrospective propensity score-matched analysis of prospectively collected data. Fifty-four patients who underwent surgery with EHSIA (intervention group) were paired with 54 patients who underwent surgery with IMSIA (control group) based on patients' demographics and type of surgery (standard right hemicolectomy or extended right hemicolectomy).

Results

Fifty-four patients were included for each group. Statistically significant differences between groups were not observed in patients' demographics and type of surgery. Conversion occurred in three patients of the intervention group due to intra-abdominal adhesions for previous surgery (5.6%) (p = 0.079). Median operative time was statistically significant shorter in the control group in comparison to the intervention group (85 and 117.5 minutes, respectively, p ≤ 0.0001). In both groups one anastomotic leakage was observed (1.9%) (Clavien-Dindo grade III-a). In the control group one patient (1.9%) underwent reintervention for acute postoperative anemia (Clavien-Dindo grade III-b). Median number of harvested lymph-nodes was 17 and 12 (p ≤ 0.0001), in the intervention and the control group, respectively. Median hospital stay was statistically significant lower in the control group in comparison to the intervention group (5 and 6.5 days, respectively, p ≤ 0.013).

Conclusion

IMSIA showed lower operative time and hospital stay in comparison to EHSIA. Further randomized studies are required to draw definitive conclusions about the best anastomotic technique during laparoscopic right hemicolectomy.