Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis

Laparoscopic versus robotic-assisted, left-sided colectomies: intra- and postoperative outcomes of 683 patients

Background

Robotic-assisted colorectal surgery has gained more and more popularity over the last years. It seems to be advantageous to laparoscopic surgery in selected situations, especially in confined regions like a narrow male pelvis in rectal surgery. Whether robotic-assisted, left-sided colectomies can serve as safe training operations for less frequent, low anterior resections for rectal cancer is still under debate. Therefore, the aim of this study was to evaluate intra- and postoperative results of robotic-assisted laparoscopy (RAL) compared to laparoscopic (LSC) surgery in left-sided colectomies.

Methods

Between June 2015 and December 2019, 683 patients undergoing minimally invasive left-sided colectomies in two Swiss, high-volume colorectal centers were included. Intra- and postoperative outcome parameters were collected and analyzed.

Results

A total of 179 patients undergoing RAL and 504 patients undergoing LSC were analyzed. Baseline characteristics showed similar results. Intraoperative complications occurred in 0.6% of RAL and 2.0% of LSC patients (p = 0.193). Differences in postoperative complications graded Dindo ≥ 3 were not statistically significant (RAL 3.9% vs. LSC 6.3%, p = 0.227). Occurrence of anastomotic leakages showed no statistically significant difference [RAL n = 2 (1.1%), LSC n = 8 (1.6%), p = 0.653]. Length of hospital stay was similar in both groups. Conversions to open surgery were significantly higher in the LSC group (6.2% vs.1.7%, p = 0.018), while stoma formation was similar in both groups [RAL n = 1 (0.6%), LSC n = 5 (1.0%), p = 0.594]. Operative time was longer in the RAL group (300 vs. 210.0 min, p < 0.001).

Conclusion

Robotic-assisted, left-sided colectomies are safe and feasible compared to laparoscopic resections. Intra- and postoperative complications are similar in both groups. Most notably, the rate of anastomotic leakages is similar. Compared to laparoscopic resections, the analyzed robotic-assisted resections have longer operative times but less conversion rates. Further prospective studies are needed to confirm the safety of robotic-assisted, left-sided colectomies as training procedures for low anterior resections.

Robotic versus conventional laparoscopic technique for the treatment of left-sided colonic diverticular disease: a systematic review with meta-analysis

PURPOSE

Minimally invasive surgery has been universally accepted as a valid option for the treatment of diverticular disease, provided specific expertise is available. Over the last decade, there has been a growing interest in the application of robotic approaches for diverticular disease. We aimed at evaluating whether robotic colectomy may offer some advantages over the laparoscopic approach for surgical treatment of diverticular disease by meta-analyzing the available data from the medical literature.

METHODS

The PubMed/Medline, EMBASE, and Web Of Sciences electronic databases were searched for literature up to December 2020. Inclusion criteria considered all comparative studies evaluating robotic versus laparoscopic colectomy for diverticulitis eligible. The conversion rate to the open approach was evaluated as the primary outcome.

RESULTS

The data of 4177 patients from nine studies were included in the analysis. There were no significant differences in the baseline characteristics. Patients undergoing laparoscopic colectomy compared to those who underwent surgery with a robotic approach had a significantly higher risk of conversion into an open procedure (12.5% vs. 7.4%, p < 0.00001) and abbreviated hospital stay (p < 0.0001) at the price of a longer operating time (p < 0.00001).

CONCLUSION

Compared with conventional laparoscopic surgery, the robotic approach offers significant advantages in terms of conversion rate and shortened hospital stay for the treatment of diverticular disease. However, because of the lack of available evidence, it is impossible to draw definitive conclusions.

Surgical Management of Recurrent Uncomplicated Diverticulitis

Sigmoid diverticulitis represents a most common gastroenterological diagnosis in the western world. There has been a significant change in the management of recurrent uncomplicated diverticulitis in the last 10 to 15 years. The absolute number of previous episodes is not used as criteria to recommend surgery anymore. Young age is no longer considered to be an indication for more aggressive surgical treatment. It is accepted that subsequent episodes of diverticulitis are not significantly worse than the first episode. Laparoscopic surgery is now the standard of care for elective surgery for diverticulitis where expertise is available. There is a consensus that decision to perform sigmoid colectomy should be individualized, after careful risk benefit assessment.

Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature

Rectal prolapse is associated with debilitating symptoms including the discomfort of prolapsing tissue, mucus discharge, hemorrhage, and defecation disorders of fecal incontinence, constipation, or both. The aim of treatment is to eliminate the prolapse, correct associated bowel function and prevent new onset of bowel dysfunction. Historically, abdominal procedures have been indicated for young fit patients, whereas perineal approaches have been preferred in older frail patients with significant comorbidity. Recently, the laparoscopic procedures with their advantages of less pain, early recovery, and lower morbidity have emerged as an effective tool for the treatment of rectal prolapse. This article aimed to review the current evidence base for laparoscopic procedures and perineal procedures, and to compare the results of various techniques. As a result, laparoscopic procedures showed a relatively low recurrence rate than the perineal procedures with comparable complication rates. Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy had a small advantage in the improvement of constipation or the prevention of new-onset constipation compared with other laparoscopic procedures. However, the optimal surgical repair has not been clearly demonstrated because of the significant heterogeneity of available studies. An individualized approach is recommended for every patient, considering age, comorbidity, and the underlying anatomical and functional disorders.

Natural Orifice Transluminal Endoscopic Surgery: Long-Term Experience with Hybrid Transvaginal Cholecystectomies

Objective. To assess outcome and safety of 571 hybrid natural orifice transluminal endoscopic surgery (NOTES) cholecystectomies. Methods. We retrospectively analyzed all consecutive NOTES cholecystectomies performed at our center between June 2009 and January 2018. All procedures were performed using a hybrid transvaginal technique, including an umbilical small-size trocar. End points, calculated at discharge, 30 and up to 90 days postoperatively, included intra- and postoperative morbidity assessed by the validated Clavien-Dindo classification and the Comprehensive Complication Index (CCI). Special focus was held on outcome and necessity of pre- and postoperative gynecological examinations. Results. We performed 571 hybrid NOTES cholecystectomies within 9 years. The vast majority were elective, 9.6% were emergency cholecystectomies. 6.7% of patients developed at least one complication until discharge, most of them minor (≤grade II). 30- and 90-day complication rates were 10.7% and 11%, respectively. Mean CCI at discharge and postoperative days 30 and 90 was 1.45 (±6.4), 2.3 (±7.7), and 2.4 (±7.8), respectively. Major complications (≥grade IIIa) occurred in 1.6% of patients, and 4 patients required emergency reoperation. No mortality was observed. In 9.8%, an additional abdominal trocar was placed. All patients underwent routine gynecological examination, whereof only 5 were rejected for transvaginal access preoperatively. In no case transvaginal access was discontinued intraoperatively due to gynecological disease. Conclusion. Hybrid NOTES transvaginal cholecystectomy represents a safe and feasible alternative to standard laparoscopic cholecystectomy. Preoperative gynecological examination is no longer routinely necessary, as intraoperative assessment is adequate.

Preliminary Experience with Laparoscopic Peritoneal Lavage for Complicated Diverticulitis: A New Algorithm for Treatment?

Patients with findings suggestive of a perforated diverticulitis may be subject to colostomy with the attendant morbidity and quality-of-life concerns. Recent literature demonstrates decreased use of laparotomy and colostomy when diagnostic laparoscopy reveals absence of fecal peritonitis. Ten patients presenting with diverticulitis between May 2009 and February 2012 underwent diagnostic laparoscopy. The indication for surgery in nine patients was failure of medical management with or without percutaneous drainage and one had significant pneumoperitoneum at presentation. A comprehensive algorithm was subsequently developed governing medical and surgical management of diverticulitis including the use of diagnostic laparoscopy and laparoscopic peritoneal lavage for patients with Hinchey Stage 3 diverticulitis or abscess formation not amenable to percutaneous drainage. Eight patients underwent diagnostic laparoscopy and laparoscopic peritoneal lavage, whereas two patients underwent diagnostic laparoscopy with conversion to open procedures (low-anterior resection with diverting ileostomy and Hartmann's procedure). Mortality was 0 per cent. Four patients were subsequently readmitted for relapse or recurrence. Two required laparotomy at the time of readmission, ultimately receiving a diagnosis of adenocarcinoma. Two were managed medically and later underwent elective laparoscopic sigmoid colon resection. Diagnostic laparoscopy and laparoscopy peritoneal lavage appear feasible and safe and may be an alternative to more invasive surgery, avoiding laparotomy and colostomy and staging patients for elective laparoscopic resection. Based on our institutional experience, we propose a novel algorithm for the treatment of hospitalized patients with diverticulitis, which incorporates diagnostic laparoscopy and laparoscopic peritoneal lavage while emphasizing patient selection based on clinical examination and imaging.

Acute diverticulitis: old challenge, current trends, open questions

Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.

Comparison of clinical and pathological findings of patients undergoing elective colectomy for uncomplicated diverticulitis

Diverticular disease affects ∼5-10% people worldwide, yet the indications for elective colectomy in uncomplicated diverticulitis are unclear. As there is no strong scientific evidence regarding histology in diverticular disease, the primary outcome of the study was to analyze the degree of inflammation of colonic wall in patients that underwent elective colectomy for uncomplicated diverticulitis and to retrospectively assess the correlation between patient clinical history and pathological features of surgical specimens in order to find some predictive factors that may be strictly correlated with histology. An observational retrospective study was conducted. Patients undergoing elective colectomy for uncomplicated diverticulitis between January 2014 and January 2016 in an academic medical center were collected. The majority of patients (46.2%) had previously encountered one episode of acute diverticulitis prior to colectomy, while 21.5% and 10.8% had experienced two and three or more prior episodes respectively. Most patients had recurrent or chronic abdominal pain in the left iliac fossa (66.2%) for diverticular disease and a large proportion also experienced constipation (40.0%). Diverticulitis was identified pathologically as being "mild" in 44.6% patients and "severe" in 55.4% patients. The mean age was significantly lower in patients with severe diverticulitis (56.7 years) than in patients with mild diverticulitis (67.0 years). 71.9% of males had severe diverticulitis compared to 39.4% of females. Males have a 3.9 times higher risk of histological severe diverticulitis than females (OR = 3.932; 1.390-11.122; p = 0.008). Multivariate logistic regression analysis confirmed that age and gender were independent factors associated with histological diagnosis. Single-institution data and retrospective design were main limitations of this study. Age and gender are independent factors associated with severity inflammation index derived at histological analysis and they could be translated to clinical practice to better categorize patients with uncomplicated diverticulitis at the bedside.

Incidence, associated risk factors, and impact of conversion to laparotomy in elective minimally invasive sigmoidectomy for diverticular disease

BACKGROUND

Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes.

METHODS

The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases.

RESULTS

The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases.

CONCLUSIONS

Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes.

Recurrent Acute Diverticulitis: When to Operate?

Objective

Recurrent acute diverticulitis carries a major burden to any form of health care. Patients present repeatedly to medical centers with a multitude of symptoms and may require different modalities of treatment with significant morbidities and impact on quality of life.

Methods

We therefore wanted to identify factors that would imply the need and time of surgery versus conservative management. The literature was thoroughly searched for major studies tackling this topic. Furthermore, studies reporting on decision making based on quality of life were included. Risks of developing recurrent diverticulitis and the potential need of surgery were identified. Relevant surgical details that would decrease recurrence were also denoted.

Results

Surgery has been the mainstay of treatment for quite some time. However, the paradigms of treatment have changed over the last few years, especially when long-term population studies confirmed that not all patients require surgical treatment with its associated risk of morbidity.

Conclusion

Treatment now has to be patient-tailored with special attention to the subgroup of high-risk patients. These patients must be adequately selected, identifying the impact of the disease on the quality of life and weighing in the risks of the surgical intervention.

Does inferior mesenteric artery ligation affect outcome in elective colonic resection for diverticular disease?

BACKGROUND

The aim of our study was to analyse the role of inferior mesenteric artery (IMA) ligation during elective colonic resection for diverticular disease (DD) with respect to surgical outcome.

METHODS

All patients who underwent elective laparoscopic or open colonic resection for DD from January 2006 to December 2012 were studied. The patients were divided into two groups based on IMA ligation or preservation. The primary end point was to compare anastomotic leakage in the two groups. The secondary end points were operative time, stoma formation, overall post-operative complications, restoration of bowel function and length of post-operative hospital stay.

RESULTS

During the study period, 219 elective colonic resections with primary anastomosis for DD were performed. A laparoscopic technique was employed in 132 (60.3%) cases. IMA ligation was performed in 66 patients (30.1%). Overall anastomotic leakage rate was 4.1%, 4.5% in IMA ligation and 3.9% in IMA preservation group, respectively (P = ns). Mean operative time was 225 ± 43.4 and 191 ± 41.7 min in IMA ligation and preservation group, respectively (P = 0.002). No differences were observed in the rate of overall complications, stoma formation, restoration of bowel function and post-operative length of hospital stay.

CONCLUSIONS

No differences were observed in surgical outcome in IMA ligation and preservation groups, particularly preservation or ligation of the IMA did not affect leakage rate.

Evaluation of Quality of Life and Surgical Outcomes for Treatment of Diverticular Disease

The prevalence of diverticular disease in the Western and industrialized nations has increased over the last century, and our understanding of this disease and its management continues to evolve. In this article, we review the literature regarding the postoperative quality of life (QOL) and functional outcomes following surgical management of diverticulitis, including information regarding bowel function, recurrence of symptoms, and other postoperative sequelae. While objective parameters, such as attacks of diverticulitis, complications, and clinical episodes have been studied, there is a paucity of data on less objective factors, such as overall patient satisfaction after operative management of diverticular disease. The literature shows improvement in QOL following surgical intervention for diverticulitis if preoperative QOL was significantly low, secondary to severe/complicated diverticulitis. However, a subset of patients does continue to have symptoms following surgical intervention for diverticulitis. Often neglected in the literature, there remains a need for prospective data evaluating preoperative function to ascertain the impact of surgery on patients' QOL and postoperative function.

Laparoscopic Management of Colonic Diverticular Disease and its Complications: an Analysis

Dense inflammatory reactions, loss of tissue planes and sepsis make surgical treatment of diverticulitis complex and difficult. Experience with laparoscopic management of this disease is scanty in our country. This study aims to assess the pattern of presentation, the site of involvement and complications of diverticulitis coli. This study also aims to audit the results of laparoscopic approach for complicated colonic diverticulitis. A retrospective analysis of all patients who had laparoscopic management of complicated diverticulitis patients from August 2007 to October 2014 was done from the database. The site of involvement, extent and presence or absence of complications of diverticular disease was noted. The surgical approach, intraoperative parameters and short-term outcome measures were analysed. There were 38 (8.8 %) patients with diverticular disease out of 427 patients who had laparoscopic colorectal surgery in the study period with a median age of 59 years. Out of 38 patients, 50 % had comorbid conditions. Internal fistulae were seen in 9 (23.6 %) patients, 6 with colovesical and 3 with colovaginal fistulae. Elective laparoscopic colectomy with primary anastomosis was done in 34 (89 %) cases of which, and 10 (26 %) patients had abscess on presentation requiring drainage. Four patients required emergency laparoscopic surgery of which primary resection and anastomosis was done in 3 (7.8 %), and Hartmann's operation was done in 1 (2.6 %) patient. Two patients required stoma. The morbidity was seen in 15 % cases, and the mean hospital stay was 9.54 days. Laparoscopic approach for diverticular disease and its complication is feasible and safe. Careful selection of patients, judicious use of diverting stoma and appropriate selection of the procedure help to achieve good results even in those with septic complications and fistulising disease.

Effect of gum chewing on ameliorating ileus following colorectal surgery: A meta-analysis of 18 randomized controlled trials

BACKGROUND AND OBJECTIVE

Chewing gum, as an alternative to sham feeding, had been shown to hasten the recovery of gut function following abdominal surgery. However, conclusions remained contradictory. We sought to conduct an updated meta-analysis to evaluate the efficacy of gum chewing in alleviating ileus following colorectal surgery.

METHODS

We searched PubMed, EMBASE, and Cochrane Library Databases through February 2017 to identify randomized controlled trials (RCTs) evaluating the efficacy of the additional use of chewing gum following colorectal surgery. After screening for inclusion, data extraction, and quality assessment, meta-analysis was conducted by the Review Manager 5.3 software. The outcomes of interest were the time to first flatus, time to first bowel movement, length of hospital stay, and some clinically relevant parameters. We also performed subgroup analyses according to the type of surgical approaches or on trials that adopted enhanced recovery after surgery (ERAS) protocol or sugared gum.

RESULTS

A total of 18 RCTs, involving 1736 patients, were included. Compared with standardized postoperative care, Chewing gum resulted in a shorter passage to first flatus [WMD = -8.81, 95%CI: (-13.45, -4.17), P = 0.0002], earlier recovery of bowel movement [WMD = -16.43, 95%CI: (-22.68, -10.19), P < 0.00001], and a reduction in length of hospital stay [WMD = -0.89, 95%CI: (-1.72, -0.07), P = 0.03]. Chewing gum was also associated with a lower risk of postoperative ileus [OR = 0.41, 95%CI: (0.23, 0.73), P = 0.003]. No evidence of significant advantages in overall postoperative complication, nausea, vomiting, bloating, readmission and reoperation towards the addition of chewing gum was observed. Subgroup analyses all favored gum chewing. However, the findings are hampered by the significant heterogeneity between trials.

CONCLUSIONS

Based on current evidence, chewing gum offers an inexpensive, well-tolerated, safe and effective method to ameliorate ileus following colorectal surgery. However, tightly controlled, randomized and considerably larger multicenter trials are warranted to further validate our findings.

Minimally Invasive Surgery for Complicated Diverticulitis

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann's (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

Enhanced recovery after gastro-intestinal surgery: The scientific background

Enhanced recovery programs (ERP) are without any doubt a major innovation in the care of surgical patients. This multimodal approach encompasses elements of both medical and surgical care. The goal of this in-depth review is to analyze the surgical aspects of ERP, underlining the scientific rationale behind each element of ERP after surgery and in particular, the role of mechanical bowel preparation before colorectal surgery, the place of minimal access surgery, the utility of nasogastric tube, abdominal drainage, bladder catheters and early re-feeding. Publication of factual data has allowed many dogmas to be discarded.

[Risk awareness and training for prevention of complications in minimally invasive surgery]

BACKGROUND

Minimally invasive surgery (MIC) requires surgeons to have a different set of skills and capabilities from that of open surgery. The indirect camera view, lack of a three-dimensional view, restricted haptic feedback with lack of tissue feeling and difficult instrument coordination with fulcrum and pivoting effects result in an additional learning curve compared to open surgery. The prolonged learning curve leads to a higher risk of complications and special awareness of these risks is therefore mandatory. Training of special laparoscopic skills outside the operating room is needed to optimize patient outcome and to minimize the ocurrence of complications related to the learning curve.

RESULTS AND DISCUSSION

Training modalities for laparoscopic surgery include simple box trainers, computer simulation with virtual reality, the use of artificial and cadaver organs, as well as live animal models and cadaver training. These training modalities have been proven in studies to have a beneficial effect on the learning curve for acquisition of laparoscopic skills and for improving operative performance as well as avoidance of complications. Laparoscopic training is currently gaining a more and more important role for official education and accreditation purposes. In some countries the participation in laparoscopic training courses has become mandatory prior to participation in laparoscopic operations. Future research will include the optimization of multimodal training curricula, the development of individualized training approaches that allow both trainee and patient-specific preparation, as well as the use of novel devices to facilitate the collection and transfer of expertise between the generations and schools of surgeons.

Diverticulosis and Diverticulitis

Diverticular disease is a common condition that is associated with variable presentations. For this review article, we performed a review of articles in PubMed through February 1, 2016, by using the following MeSH terms: colon diverticula, colonic diverticulitis, colonic diverticulosis, colonic diverticulum, colonic diverticula, and diverticula. Diverticula are structural alterations within the colonic wall that classically form "pockets" referred to as diverticula. Diverticula form from herniation of the colonic mucosa and submucosa through defects in the circular muscle layers within the colonic wall. Often this is at the sites of penetrating blood vessels in the colon. Diverticular disease is extremely common, which resulted in 2,682,168 outpatient visits and 283,355 hospitalization discharges for diverticulitis or diverticulosis in 2009. Diverticulosis is one of the most common detected conditions found incidentally on colonoscopy. Risk factors for the development of diverticulitis include obesity, smoking, nonsteroidal anti-inflammatory drugs, corticosteroids, and opiates. In contrast, fiber may be protective, but recent studies have questioned the role of fiber in developing diverticular disease. Most patients with diverticulosis will be asymptomatic, but a subset of patients may develop nonspecific abdominal pain (isolated or recurrent), diverticulitis, or segmental colitis associated with diverticulosis. Classically, the treatment of diverticulitis has included antibiotics for all patients. More recent evidence indicates that in mild to even moderate uncomplicated diverticulitis, antibiotics may not be as necessary as initially believed. In more complicated diverticulitis, intravenous antibiotics and surgery may be necessary. Once a patient has had an attack of diverticulitis, increasing fiber may help prevent future attacks. Other modalities such as 5-aminosalicylate products, antibiotics, and probiotics are still of unclear benefit in preventing future episodes of diverticulitis. Similarly, even when patients develop recurrent episodes of diverticulitis, surgery may not be necessary as a prophylactic treatment.

Management of sigmoid diverticulitis: an update

The role, indications and modalities of elective resection for sigmoid diverticulitis remain the cause of fierce debate. During the past two decades clinicians have increasingly recognized that: (1) young patients (<50) are no more at risk to develop more aggressive course of the disease; and (2) patients who present initially with a first uncomplicated attack are no more at risk for developing subsequent complicated diverticulitis requiring emergency surgery. Hence, the previously well-recognized indications (based upon age of the patients or the number of attacks) are no longer valid. Yet, the number of sigmoid resections performed for diverticulitis in industrialized countries is increasing, which seems to indicate that in many cases, uncomplicated sigmoid diverticulitis progressively evolves towards a chronic symptomatic condition, which significantly impacts upon the patients' quality of life. The aims of this review are twofold: (1) to identify which disease presentation still represents good indications for elective laparoscopic sigmoid resection; and (2) to summarize the technical aspects of surgery for a benign condition, such as diverticular disease.

Laparoscopic treatment of complicated colonic diverticular disease: A review

Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann’s procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.

[Major surgery in two days of hospitalization]

A reduction to 2 days the length of stay after a major surgery is possible by enhancing patient empowerment and decreasing morbidity. A rapid patient's empowerment is obtained by the use of means that reduce the impact of the surgical stress and facilitate the recovery. The decrease in postoperative morbidity is obtained by improving the perioperative quality of care. All of these means are gathered in enhanced recovery programs that are clinical pathways designed by a multidisciplinary and multiprofessional team. Regular audits are mandatory for the sustainability of these programs. Organization of a network between hospital and out-of-hospital caregivers is important in order to secure the patient's return home.

Is robot-assisted laparoscopic right colectomy more effective than the conventional laparoscopic procedure? A meta-analysis of short-term outcomes

AIM

The use of robotic technology procedures has proved to be safe and effective, arising as a helpful alternative to standard laparoscopic surgery in a variety of colorectal procedures. However, the role of robotic assistance in laparoscopic right colectomy is still not demonstrated.

METHODS

A systematic review of the literature was carried out performing an unrestricted search in MEDLINE, EMBASE, the Cochrane Library and Google Scholar up to 30th August 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We meta-analyzed the currently available data regarding the incidence of anastomotic leakage, operative time, intra-operative blood loss, conversion rate, retrieved lymphnodes, post-operative hemorrhage, intra-abdominal abscess, time to 1st flatus, post-operative ileus, wound infection, incisional hernia, not-surgical complications, total complications, hospital stay, post-operative mortality, surgery-related costs and total costs, in conventional laparoscopic right colectomy (LRC) compared to robot-assisted laparoscopic right colectomy (RRC).

RESULTS

Overall 8 studies were included, thus resulting in 616 patients. The meta-analysis showed that the RRC decreases the intra-operative blood loss and the time to the 1st flatus, if compared to the LRC. On the other hand, the robotic assistance increases the operative time and the surgery-related costs. No statistically significant differences were found about the other post-operative outcomes.

CONCLUSION

RRC may ensure limited improvements in post-operative outcome, thus increasing procedural costs and without a proved enhanced oncological accuracy to date, if compared to the LRC.

Left colon acute diverticulitis: an update on diagnosis, treatment and prevention

Diverticulosis of the colon is a common disease with an increasing incidence in Western Countries. It represents a significant burden for National Health Systems in terms of costs. Most people with diverticulosis remain asymptomatic, about one quarter of them will develop an episode of symptomatic diverticular disease and up to 5% an episode of acute diverticulitis (AD). AD shows an increasing prevalence. Recently, progresses have been reached about the etiology, pathogenesis, natural course of diverticular disease and its complications; improvements about the diagnosis and treatment of AD have been achieved. However, the treatment options are not well defined because of a lack of solid evidence: there are few systematic reviews and well conducted trials to guide decision-making in the treatment of AD and in the prevention of its recurrences. This review describes the recent evidence about diagnosis, treatment and prevention of AD.

Systematic review of emergent laparoscopic colorectal surgery for benign and malignant disease

Laparoscopic surgery has become well established in the management of both and malignant colorectal disease. The last decade has seen increasing numbers of surgeons trained to a high standard in minimally-invasive surgery. However there has not been the same enthusiasm for the use of laparoscopy in emergency colorectal surgery. There is a perception that emergent surgery is technically more difficult and may lead to worse outcomes. The present review aims to provide a comprehensive and critical appraisal of the available literature on the use of laparoscopic colorectal surgery (LCS) in the emergency setting. The literature is broadly divided by the underlying pathology; that is, inflammatory bowel disease, diverticulitis and malignant obstruction. There were no randomized trials and the majority of the studies were case-matched series or comparative studies. The overall trend was that LCS is associated with shorter hospital stay, par or fewer complications but an increased operating time.Emergency LCS can be safely undertaken for both benign and malignant disease providing there is appropriate patient selection, the surgeon is adequately experienced and there are sufficient resources to allow for a potentially more complex operation.

A prospective clinical study evaluating the development of bowel wall edema during laparoscopic and open visceral surgery

BACKGROUND

To examine bowel wall edema development in laparoscopic and open major visceral surgery.

METHODS

In a prospective study, 47 consecutively operated patients with gastric and pancreatic resections were included. Twenty-seven patients were operated in a conventional open procedure (open group) and 20 in a laparoscopic fashion (lap group). In all procedures, a small jejunal segment was resected during standard preparation, of which we measured the dry-wet ratio. Furthermore, HE staining was performed for measuring of bowel wall thickness and edema assessment.

RESULTS

Mean value (±std) of dry-wet ratio was significantly lower in the open than in the lap group (0.169 ± 0.017 versus 0.179 ± 0.015; p = 0.03) with the same amount of fluid administration in both groups and a longer infusion interval during laparoscopic surgery. Subgroup analyses (only pancreatic resections) still showed similar results. Histologic examination depicted a significantly larger bowel wall thickness in the open group.

CONCLUSIONS

Laparoscopic surgery does not seem to lead to the bowel wall edema observed to occur in open surgery regardless of the degree of intravenous fluid administration, thus supporting its use even in major visceral surgery.

A literature review on the role of totally extraperitoneal repairs for groin pain in athletes

A literature review was made on the role of totally extraperitoneal (TEP) hernia repairs for groin pain in athletes. Electronic databases were searched for literature published from January 1993 to November 2011. There were 10 articles incorporating 196 patients included in this review. Thirty percent of patients were reported to have direct inguinal hernias, 22% had indirect inguinal hernias, and 41% had dilated internal rings. Of note, 30% of cases had no macroscopic abnormality. Four studies reported on an early follow-up ranging between 3 and 6 weeks. Only minimal or mild symptoms were reported. Up to 33% of patients had impaired ability to perform at peak levels. Up to 53% of patients had persistence of symptoms at the early follow-up. Total follow-up time ranged from 3 to 80 months, and most patients were active (90%-100%). At long-term follow-up, 3% to 10% were unable to play, and 5% were reported as being unable to train. Two studies from the same center reported on TEP surgery for osteitis pubis, and most patients returned to sporting activity after 4 to 8 weeks. TEP repair is a good operative intervention in athletes with chronic groin pain not relieved by conservative measures. Athletes recover quickly and return to sport early.

The application of McBurney's single-incision laparoscopic colectomy alleviates the response of patients to postoperative wound pain

BACKGROUND

Single-incision laparoscopic colectomy (SILC) is one of several promising operation choices. Our previous study demonstrated that SILC with a self-made glove-port system both improves the feasibility of SILC and decreases the cost expense of surgery. Because the incision site for SILC could be made at either the umbilicus or McBurney's point, we are interested in whether the incision site affects the outcomes of patients, which is a less explored topic. The purpose of this study is not only to show the results of SILC with a self-made glove-port system for supporting its feasibility, but also to compare the short-term surgical outcomes between SILC with the incision made at the umbilicus and at McBurney's point.

SUBJECTS AND METHODS

We collected and reviewed the medical records of patients who received SILC with a self-made glove-port system for tumors in the left side of the colon from August 2009 to March 2011. All operations were performed by a single surgeon. Comparisons of the demographic characteristics, perioperative data, and clinical outcomes between umbilical and McBurney's SILCs were performed. Postoperative pain was assessed by a visual analog scale and opiate demand.

RESULTS

In total, 61 patients were enrolled in this retrospective study. Five of 48 (10.4%) tumors in the umbilical SILC group and 5 of 13 (38.5%) tumors in the McBurney's SILC group were located below the peritoneal reflection. The tumor location was significantly different between these two groups (P=.015). Patients in the umbilical SILC group had significantly higher frequency of opiate demand than those in the McBurney's SILC group (0.4±0.7 versus 1.4±1.8, respectively; P=.002).

CONCLUSIONS

This study further provides evidence for supporting the safety and feasibility of SILC in treating colorectal diseases. More important is that McBurney's SILC not only alleviates the patient response to wound pain, but also provides the same site for a diverting enterostomy to avoid creating an additional wound.

[Guidelines for enhanced recovery after elective colorectal surgery]

Early recovery after surgery provides patients with all means to counteract or minimize the deleterious effects of surgery. This concept is suitable for a surgical procedure (e.g., colorectal surgery) and comes in the form of a clinical pathway that covers three periods (pre-, intra- and postoperative). The purpose of this Expert panel guideline is firstly to assess the impact of each parameter usually included in the rehabilitation programs on 6 foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, water and energy imbalance, postoperative immobility, sleep alterations and postoperative complications; secondly, to validate the usefulness of each as criteria of efficiency criteria for success of rehabilitation programs. Two main criteria were selected to evaluate the impact of each parameter: the length of stay and frequency of postoperative complications. Lack of information in the literature forced experts to assess some parameters with criteria (duration of postoperative ileus or quality of analgesia) that mainly surrogate a positive impact for the implementation of an early recovery program. After literature analysis, 19 parameters were identified as potentially interfering with at least one of the foreseeable consequences of colorectal surgery. GRADE® methodology was applied to determine a level of evidence and strength of recommendation. After synthesis of the work of experts using GRADE® method on 19 parameters, 35 recommendations were produced by the organizing committee. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. A consensus was reached among anesthesiologists and surgeons on a number of approaches that are likely not sufficiently applied for rehabilitation programs in colorectal surgery such as: preoperative intake of carbohydrates; intraoperative hemodynamic optimization; oral feeding resume before ha24; gum chewing after surgery; patient out of bed and walking at D1. The panel also clarified the value and place of such approaches such as: patient information; preoperative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic prevention of nausea and vomiting; morphine-sparing analgesic techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of approaches such as: bowel preparation for colon surgery; maintain of the nasogastric tube; surgical drainage for colonic surgery.

Laparoscopy in diverticular disease: Controversies

A minimally invasive approach to the management of diverticular disease has gained acceptance over the last number of years. Certainly, in the elective setting, laparoscopic sigmoid resection compares favourably with open surgery. The use of laparoscopy in the context of emergency surgery for complicated diverticular disease remains controversial however recent studies have demonstrated a defined role for laparoscopy in the acute setting.

A systematic review on robotic pancreaticoduodenectomy

BACKGROUND

Robotic surgery might have several advantages in respect of the laparoscopic approach since might make more feasible the execution of a complex procedure such as pancreaticoduodenectomy (PD). The aim of the present systematic review is to evaluate the current state of the literature on robotic PD.

METHODS

A systematic literature search was performed, from January 1st 2003 to July 31st 2012, for studies which reported PDs performed for neoplasm and in which at least one surgical reconstructive or resective step was robotically performed.

RESULTS

Thirteen studies, representing 207 patients, met the inclusion criteria. The definition of the robotic approach was heterogeneous since the technique was defined as robotic, robotic-assisted, robot-assisted laparoscopic and robotic hybrid. Resection and reconstruction steps of robotic PD were also heterogeneous combining sequentially different approaches: totally robotic technique, laparoscopic-robotic resection and robotic reconstruction, laparoscopic resection and robotic reconstruction, hand port-assisted laparoscopic resection and robotic reconstruction, laparoscopic-robotic resection and reconstruction through mini-laparotomy. As regard the type of PD 66% were classic Whipple operations and 34% pylorus-preserving pancreatoduodenectomies. The management of pancreatic stump was a pancreaticogastrostomy in 23%, end-to-side pancreaticojejunostomy in 67%, and fibrin glue occlusion of the main pancreatic duct in 10% of cases. The overall procedure failure (rates of conversion to open surgery) was 14%. The overall morbidity rate was 58% and the reoperation rate was 7.3%.

CONCLUSIONS

There have been an increasing number of recent case series suggesting increased utilization of robotic PD over the past decade. The technical approach is heterogenous. For highly selected patient, robotic PD is feasible with similar morbidity and mortality compared to open or purely laparoscopic approaches. Data on cost analysis are lacking and further studies are needed to evaluate also the cost-effectiveness of the robotic approach for PD in comparison to open or laparoscopic techniques. The current state of the art analysis on robotic DP can be also useful in planning future trials.

Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis

BACKGROUND

The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed.

METHODS

A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities.

RESULTS

The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy.

CONCLUSION

Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeon's personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD.

Transvaginal specimen removal after laparoscopic distal pancreatic resection

PURPOSE

Transvaginal specimen removal has been introduced 20 years ago but then abandoned. With the advent of transvaginal interventions following the introduction of natural orifice transluminal endoscopic surgery, renewed interest was generated for hybrid procedures with minimal access for the intervention and use of transvaginal (TV) specimen removal. We present the first such series after laparoscopic distal pancreatectomy.

METHODS

In seven subsequent women (median age 48 years) with body and tail pancreatic tumors undergoing laparoscopic distal pancreatectomy, the new method of TV specimen removal was applied. The patients' data and the technical successes as well as intra- and postprocedural complications were recorded prospectively. The patients were followed after discharge for gynecological examination.

RESULTS

Specimen removal consisting of the pancreas and spleen in five and the pancreas only in two cases was technically successful; no intraoperative complications were encountered. Postoperative complications consisted of one case of intra-abdominal hemorrhage and one case of pancreatic fistula, attributable to the resection and not to TV specimen removal. Gynecological follow-up was normal in all seven patients.

CONCLUSIONS

The technique of TV specimen removal is feasible and safe also after laparoscopic distal pancreatectomy. It may help to further diminish the access trauma of laparoscopic pancreatic surgery.

Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials

BACKGROUND

The evidence regarding the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) has been mostly based on the data derived from nonrandomized studies. The objective of this study was to evaluate the outcomes of LSG and to present an up-to-date review of the available evidence based on the recent publications of new randomized, controlled trials (RCTs).

METHODS

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched until November 2012 for RCTs on LSG.

RESULTS

Fifteen RCTs, comprising a total of 1191 patients, of whom 795 had undergone LSG, were included. No patient required conversion to open surgery for LSG, laparoscopic gastric bypass (LGB), or laparoscopic adjustable gastric banding (LAGB) procedures. There were no deaths, and the complication rate was 12.1% (range 10%-13.2%) in the LSG group versus 20.9% (range 10%-26.4%) in the LGB group, and 0% in the LAGB group (only 1 RCT). The complications included leakage, bleeding, stricture, and reoperation that occurred with rates of .9%, 3.3%, 0%, and 2.1%, respectively, in the LSG group and rates of 0%, 5%, 0%, and 4%, respectively, in the LGB group. The average operating time in the LSG group was 106.5 minutes versus 132.3 minutes in the LGB group. The percentage of excess weight loss (%EWL) ranged from 49% to 81% in the LSG group, from 62.1% to 94.4% in the LGB group, and from 28.7% to 48% in the LAGB group, with a follow-up ranging from 6 months to 3 years. The type 2 diabetes mellitus (T2DM) remission rate ranged from 26.5% to 75% in the LSG group and from 42% to 93% in the LGB group.

CONCLUSIONS

LSG is a well-tolerated, feasible procedure with a relatively short operating time. Its effectiveness in terms of weight loss is confirmed for short-term follow-up (≤ 3 years). The role of LSG in the treatment of T2DM requires further investigation.

Single-incision laparoscopic versus traditional multiport laparoscopic colorectal surgery--a cumulative meta-analysis and systematic review

PURPOSE

The published data on the evaluation of feasibility and safety of single-incision laparoscopic colorectal surgery (SILC) compared with traditional multiport laparoscopic colorectal surgery (MLC) remained controversial. The present cumulative meta-analysis and systematic review were performed to provide a more objective and precise estimate.

MATERIALS AND METHODS

PubMed, the Cochrane Library, and also, manual searches were employed to identify potentially eligible studies which were published before June 7, 2012. The association was assessed by odds ratio (OR) and means with 95 % confidence intervals (CI).

RESULTS

A total of 20 comparative studies were included, with 670 patients underwent SILC and 838 patients underwent MLC. For overall pooled estimates, no evidence of between trial differences was found in overall conversion rate (OR, 1.7; 95 % CI, 0.97 to 3.01), overall complication rate (OR, 0.82; 95 % CI, 0.63 to 1.08), and operative time (mean, -3.59; 95 % CI, -10.95 to 3.77); significantly between trial differences were found in estimated blood loss (mean, -18.61; 95 % CI, -31.33 to -5.90) and post-operative hospital stay (mean, -0.54; 95 % CI, -0.95 to -0.12). The cumulative meta-analysis identified a potentially increased conversion rate of SILC compared with MLC with the increased percentage of malignancies, but no significant differences could be identified in overall complication rate.

CONCLUSION

This meta-analysis suggested the feasibility and safety of SILC performed by experienced hands, though potentially higher overall conversion rate occurred in malignancies. SILC will benefit the patients much more with its superiority over MLC.

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

OBJECTIVE

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

METHODS

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

RESULTS

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD) = -0.68; 95 % CI = -1.20 to -0.16; p = 0.0099), shorter incision length (pooled WMD = -1.37; 95 % CI = -2.74 to 0.000199; p = 0.05), less estimated blood loss (pooled WMD = -20.25; 95 % CI = -39.25 to -1.24; p = 0.037), and more lymph nodes harvested (pooled WMD = 1.75; 95 % CI = 0.12 to 3.38; p = 0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio = 0.83; 95 % CI = 0.57 to 1.20; p = 0.33) or operative time (pooled WMD = 5.06; 95 % CI = -2.91 to 13.03; p = 0.21).

CONCLUSION

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.

The treatment of anal fistulas with biologically derived products: is innovation better than conventional surgical treatment? An update

New technical approaches involving biologically derived products have been applied in the treatment for anal fistulas in order to avoid the risk of fecal incontinence. The aim of this review was to evaluate the scientific evidence present in the literature regarding these techniques. Trials comparing surgery (fistulotomy, advancement mucosal flap closure and placement of seton) versus fibrin glue, fistula plug or acellular dermal matrix were considered. In fibrin glue versus traditional surgical treatment the healing rate was higher in the surgery group, and the recurrence rate was lower in the traditional surgery group, but these results were not statistically relevant. In acellular dermal matrix (ADM) versus traditional surgical treatment the recurrence rate of fistulas was significantly lower in the ADM group, but non-significant differences were recorded in incontinence and anal deformity. Our review shows that there are no significant advantages of the new techniques involving biologically derived products. Further randomized controlled trials are needed.

Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) may offer advantages over conventional laparoscopic cholecystectomy (LC).

METHODS

MEDLINE, Embase, PubMed, CINAHL, Cochrane Central Register of Controlled Trials and the Cochrane Library were searched for randomized clinical trials on SILC versus LC until May 2012. Odds ratio (OR) and weight mean difference (WMD) were calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis.

RESULTS

Thirteen randomized clinical trials included a total of 923 procedures. SILC had a higher procedure failure rate than LC (OR 8·16, 95 per cent c.i. 3·42 to 19·45; P < 0·001), required a longer operating time (WMD 16·55, 95 per cent c.i. 9·95 to 23·15 min; P < 0·001) and was associated with greater intraoperative blood loss (WMD 1·58, 95% of c.i. 0·44 to 2·71 ml; P = 0·007). There were no differences between the two approaches in rate of conversion to open surgery, length of hospital stay, postoperative pain, adverse events, wound infections or port-site hernias. Better cosmetic outcomes were demonstrated in favour of SILC as measured by Body Image Scale questionnaire (WMD -0·97, 95% of c.i. -1·51 to -0·43; P < 0·001) and Cosmesis score (WMD -2·46, 95% of c.i. -2·95 to -1·97; P < 0·001), but this was based on comparison with procedures in which multiple and often large ports (10 mm) were used.

CONCLUSION

SILC has a higher procedure failure rate with more blood loss and takes longer than LC. No trial was adequately powered to assess safety.

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.

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

OBJECTIVE

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

METHODS

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

RESULTS

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD) = -0.68; 95 % CI = -1.20 to -0.16; p = 0.0099), shorter incision length (pooled WMD = -1.37; 95 % CI = -2.74 to 0.000199; p = 0.05), less estimated blood loss (pooled WMD = -20.25; 95 % CI = -39.25 to -1.24; p = 0.037), and more lymph nodes harvested (pooled WMD = 1.75; 95 % CI = 0.12 to 3.38; p = 0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio = 0.83; 95 % CI = 0.57 to 1.20; p = 0.33) or operative time (pooled WMD = 5.06; 95 % CI = -2.91 to 13.03; p = 0.21).

CONCLUSION

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.