Comparison of clinical outcomes between laparoscopic and open surgery for left-sided colon cancer: a nationwide population-based study

Does surgeon or hospital volume influence outcome in dedicated colorectal units?-A Viennese perspective

OBJECTIVE

A clear relationship between higher surgeon volume and improved outcomes has not been convincingly established in rectal cancer surgery. The aim of this study was to evaluate the impact of individual surgeon's caseload and hospital volume on perioperative outcome.

METHODS

We retrospectively analyzed 336 consecutive patients undergoing oncological resection for rectal cancer at two Viennese hospitals between 1 January 2015 and 31 December 2020. The effect of baseline characteristics as well as surgeons' caseloads (low volume: 0-5 cases per year, high volume > 5 cases per year) on postoperative complication rates (Clavien-Dindo Classification groups of < 3 and ≥ 3) were evaluated.

RESULTS

No differences in baseline characteristics were found between centers in terms of sex, smoking status, or comorbidities of patients. Interestingly, only 14.7% of surgeons met the criteria to be classified as high-volume surgeons, while accounting for 66.3% of all operations. There was a significant difference in outcomes depending on the treating center in univariate and multivariate binary logistic regression analysis (odds ratio (OR) = 2.403, p = 0.008). Open surgery was associated with lower complication rates than minimally invasive approaches in univariate analysis (OR = 0.417, p = 0.003, 95%CI = 0.232-0.739) but not multivariate analysis. This indicated that the center's policy rather than surgeon volume or mode of surgery impact on postoperative outcomes.

CONCLUSION

Treating center standards impacted on outcome, while individual caseload of surgeons or mode of surgery did not independently affect complication rates in this analysis. The majority of rectal cancer resections are performed by a small number of surgeons in Viennese hospitals.

Appendiceal Neuroendocrine Neoplasms: A Comprehensive Review

ABSTRACT

Appendiceal neuroendocrine neoplasm (NEN) is the most common adult appendiceal malignant tumor, constituting 16% of gastrointestinal NENs. They are versatile tumors with varying morphology, immunohistochemistry, secretory properties, and cancer genomics. They are slow growing and clinically silent, to begin with, or present with features of nonspecific vague abdominal pain. Most acute presentations are attributed clinically to appendicitis, with most cases detected incidentally on pathology after an appendectomy. Approximately 40% of them present clinically with features of hormonal excess, which is likened to the functional secretory nature of their parent cell of origin. The symptoms of carcinoid syndrome render their presence clinically evident. However, slow growing and symptomatically silent in its initial stages, high-grade neuroendocrine tumors and neuroendocrine carcinomas of the appendix are aggressive and usually have hepatic and lymph node metastasis at presentation. This review article focuses on imaging characteristics, World Health Organization histopathological classification and grading, American Joint Committee on Cancer/Union or International Cancer Control, European Neuroendocrine Tumor Society staging, European Neuroendocrine Tumor Society standardized guidelines for reporting, data interpretation, early-stage management protocols, and advanced-stage appendiceal NENs. Guidelines are also set for the follow-up and reassessment. The role of targeted radiotherapy, chemotherapy, and high-dose somatostatin analogs in treating advanced disease are discussed, along with types of ablative therapies and liver transplantation for tumor recurrence. The search for newer location-specific biomarkers in NEN is also summarized. Regarding the varying aggressiveness of the tumor, there is a scope for research in the field, with plenty of data yet to be discovered.

The impact of surgical volume on outcomes in newly diagnosed colorectal cancer patients receiving definitive surgeries

Colorectal cancer (CRC) patients who receive cancer surgeries from higher-volume providers may have better outcomes. However, the definitions of surgical volume may affect the results. We aim to analyze the effects of different definitions of surgical volume on patient outcomes. We conducted a nationwide population-based study in Taiwan that enrolled all patients who underwent definitive surgery for newly diagnosed CRC. We used three common definitions of surgical volume: total volume means the total surgical number conducted by the same provider during the study period; cumulative volume was calculated as the number of operations the surgeon performed before the index procedure; annual volume was calculated as the number of times the surgeon had been responsible for surgery during the index year. In this study, we included 100,009 newly diagnosed CRC patients, including 55.8% males, of median age 66 years at diagnosis (range 20-105 years). After adjustment for the patient and provider characteristics, we found that CRC patients receiving definitive surgery by higher-volume providers had better outcomes, especially where surgeon volume may play a more important role than hospital volume. The cumulative volume could predict the 5-year mortality of the study cohort better than the total and annual volume.

Short- and long-term results of open vs laparoscopic multisegmental resection and anastomosis for synchronous colorectal cancer located in separate segments

BACKGROUND

It remains unclear whether laparoscopic multisegmental resection and anastomosis (LMRA) is safe and advantageous over traditional open multisegmental resection and anastomosis (OMRA) for treating synchronous colorectal cancer (SCRC) located in separate segments.

AIM

To compare the short-term efficacy and long-term prognosis of OMRA as well as LMRA for SCRC located in separate segments.

METHODS

Patients with SCRC who underwent surgery between January 2010 and December 2021 at the Cancer Hospital, Chinese Academy of Medical Sciences and the Peking University First Hospital were retrospectively recruited. In accordance with the inclusion and exclusion criteria, 109 patients who received right hemicolectomy together with anterior resection of the rectum or right hemicolectomy and sigmoid colectomy were finally included in the study. Patients were divided into the LMRA and OMRA groups (n = 68 and 41, respectively) according to the surgical method used. The groups were compared regarding the surgical procedure's short-term efficacy and its effect on long-term patient survival.

RESULTS

LMRA patients showed markedly less intraoperative blood loss than OMRA patients (100 vs 200 mL, P = 0.006). Compared to OMRA patients, LMRA patients exhibited markedly shorter postoperative first exhaust time (2 vs 3 d, P = 0.001), postoperative first fluid intake time (3 vs 4 d, P = 0.012), and postoperative hospital stay (9 vs 12 d, P = 0.002). The incidence of total postoperative complications (Clavien-Dindo grade: ≥ II) was 2.9% and 17.1% (P = 0.025) in the LMRA and OMRA groups, respectively, while the incidence of anastomotic leakage was 2.9% and 7.3% (P = 0.558) in the LMRA and OMRA groups, respectively. Furthermore, the LMRA group had a higher mean number of lymph nodes dissected than the OMRA group (45.2 vs 37.3, P = 0.020). The 5-year overall survival (OS) and disease-free survival (DFS) rates in OMRA patients were 82.9% and 78.3%, respectively, while these rates in LMRA patients were 78.2% and 72.8%, respectively. Multivariate prognostic analysis revealed that N stage [OS: HR hazard ratio (HR) = 10.161, P = 0.026; DFS: HR = 13.017, P = 0.013], but not the surgical method (LMRA/OMRA) (OS: HR = 0.834, P = 0.749; DFS: HR = 0.812, P = 0.712), was the independent influencing factor in the OS and DFS of patients with SCRC.

CONCLUSION

LMRA is safe and feasible for patients with SCRC located in separate segments. Compared to OMRA, the LMRA approach has more advantages related to short-term efficacy.

Postoperative inflammatory response in colorectal cancer surgery: a meta-analysis

PURPOSE

Surgical removal of the cancerous tissue remains the cornerstone of curative treatment for colorectal cancer and results in an inflammatory response. An exaggerated inflammatory response has been implicated in the promotion of tumor proliferation and has shown associations with postoperative complications. Literature on the preferred surgical technique to minimize inflammatory response is inconclusive. Therefore, the aim of this study was to assess the inflammatory response and postoperative incidence of infectious complications following surgery for colorectal cancer.

METHODS

Embase, PubMed, and Cochrane databases were searched for RCTs that reported inflammatory parameters as a function of surgical modality only. Data related to CRP or IL-6 levels on postoperative days 1 and 3 and data related to postoperative infections were subject to a pairwise meta-analysis to compare open versus laparoscopic techniques.

RESULTS

The literature search and screening process yielded 4151 studies. Ten studies met criteria, including 568 patients. Only studies on laparoscopic and open surgery were found. Pooled analyses found lower Il-6 and CRP levels on postoperative day 1 and lower CRP levels on postoperative day 3 for laparoscopic surgery compared to open surgery. However, there was no difference in incidence of postoperative infectious complications.

CONCLUSION

The findings of this study indicate a superior inflammatory profile for laparoscopic surgery compared to an open approach for colorectal cancer surgery. For future research, it would be worthwhile to conduct a randomized controlled trial to compare the postoperative inflammatory response and related clinical outcomes between minimally invasive surgical approaches, including laparoscopic and robot-assisted surgery.

Perioperative outcomes of robotic and laparoscopic surgery for colorectal cancer: a propensity score-matched analysis

BACKGROUND

Robotic colorectal surgery is becoming the preferred surgical approach for colorectal cancer (CRC). It offers several technical advantages over conventional laparoscopy that could improve patient outcomes. In this retrospective cohort study, we compared robotic and laparoscopic surgery for CRC using a national cohort of patients.

METHODS

Using the colectomy-targeted ACS-NSQIP database (2015-2020), colorectal procedures for malignant etiologies were identified by CPT codes for right colectomy (RC), left colectomy (LC), and low anterior resection (LAR). Optimal pair matching was performed. "Textbook outcome" was defined as the absence of 30-day complications, readmission, or mortality and a length of stay < 5 days.

RESULTS

We included 53,209 out of 139,759 patients screened for eligibility. Laparoscopic-to-robotic matching of 2:1 was performed for RC and LC, and 1:1 for LAR. The largest standardized mean difference was 0.048 after matching. Robotic surgery was associated with an increased rate of textbook outcomes compared to laparoscopy in RC and LC, but not in LAR (71% vs. 64% in RC, 75% vs. 68% in LC; p < 0.001). Robotic LAR was associated with increased major morbidity (7.1% vs. 5.8%; p = 0.012). For all three procedures, the mean conversion rate of robotic surgery was lower than laparoscopy (4.3% vs. 9.2%; p < 0.001), while the mean operative time was higher for robotic (225 min vs. 177 min; p < 0.001).

CONCLUSIONS

Robotic surgery for CRC offers an advantage over conventional laparoscopy by improving textbook outcomes in RC and LC. This advantage was not found in robotic LAR, which also showed an increased risk of serious complications. The associations highlighted in our study should be considered in the discussion of the surgical management of patients with colorectal cancer.

Possible Advantages of Minimal-Invasive Approaches in Rectal Cancer Surgery: A Nationwide Analysis

(1) Background: Laparoscopic resection for colon and rectal cancer was introduced in the early 1990s; the aim of this analysis was to show possible advantages of minimal-invasive approaches in rectal cancer surgery. (2) Methods: From 2016 to 2020, all patients undergoing open, laparoscopic or robotic-assisted rectal cancer surgery in Germany were retrospectively analyzed regarding sex distribution, conversion rates and in-hospital mortality rates according to nationwide hospital billing data based on diagnosis-related groups (DRGs). (3) Results: In total, 68,112 patients were analyzed, and most commonly, low anterior rectal resections with primary anastomosis (n = 25,824) were performed with an increase of minimal-invasive procedures over the years (open: 51% to 27%; laparoscopic: 47% to 63% and robotic: 2% to 10%). In-hospital mortality rate was 2.95% (n = 2012). In total, 4.61%, 1.77%, 1.14% and 3.95% of patients with open, laparoscopic, robotic and converted-to-open surgery died during hospital stay, respectively (open vs. laparoscopic p < 0.0001; open vs. robotic p < 0.00001; laparoscopic vs. robotic p = 0.001). Conversion rates were significantly more favorable in the robotic compared to the laparoscopic group. (11.94% vs. 2.53%; p < 0.0001). (4) Conclusion: Minimal-invasive rectal cancer surgery might have some advantages in terms of a reduced in-hospital mortality, and an improved conversion rate for the robotic approach.

Mid-term outcomes of laparoscopic vs open colectomy for pathological T4 and/or N2 colon cancer patients: Multicenter study using propensity score matched analysis

OBJECTIVES

We aimed to assess mid-term outcomes after laparoscopic surgery (LAP) vs open surgery (OP) for pathological T4 (pT4) and/or N2 (pN2) colon cancer.

METHODS

We retrospectively reviewed 255 primary tumor resections for pT4 and/or pN2 colon cancer performed from 2015 to 2020 at six hospitals, divided into LAP (n = 204) and OP groups (n = 51). After propensity score matching to minimize selection bias, 47 matched patients per group were assessed.

RESULTS

Before matching, the rate of males (53.9% vs. 37.3%, P = .042), left sided colon cancer (53.9% vs 37.3%, P = .042), D3 lymph node dissection (90.7% vs 68.6%, P < .001) and body mass index (kg/m2 ) (22.3 vs 21.8, P = .039) were significantly greater in the LAP group. The rate of pT4b (7.8% vs 40.4%, P < .001) was lower and pN2 was higher (57.4% vs 37.3%, P = .012) in the LAP group. After matching, preoperative characteristics and pathologic status were equivalent between the groups. The LAP and OP groups showed comparable overall survival (OS) (2-year OS, 84.5% vs 76.8%, P = .055) and recurrence-free survival (RFS) (2-year RFS, 73.9% vs 52.8%, P = .359). In the patients with pT4, OS (2-year OS, 79.4% vs 75.7%, P = .359) and RFS (2-year RFS, 71.3% vs 58.7%) were comparable. In the patients with pN2, OS (2-year OS, 83.4% vs 76.3%) and RFS (2-year RFS, 69.6% vs 36.2%) were also comparable.

CONCLUSIONS

LAP for pT4 and/or pN2 colon cancer showed comparable mid-term outcomes compared with OP. LAP was an acceptable surgical approach in this cohort.

Robotic versus laparoscopic left colectomy with complete mesocolic excision for left-sided colon cancer: a multicentre study with propensity score matching analysis

PURPOSE

Robotic surgery for right-sided colon and rectal cancer has rapidly increased; however, there is limited evidence in the literature of advantages of robotic left colectomy (RLC) for left-sided colon cancer. The purpose of this study was to compare the outcomes of RLC versus laparoscopic left colectomy (LLC) with complete mesocolic excision (CME) for left-sided colon cancer.

METHODS

Patients who had RLC or LLC with CME for left-sided colon cancer at five hospitals in China between January 2014 and April 2022 were included. A one-to-one propensity score matched analysis was performed to decrease confounding. The primary outcome was postoperative complications occurring within 30 days of surgery. Secondary outcomes were disease-free survival, overall survival and the number of harvested lymph nodes.

RESULTS

A total of 292 patients (187 male; median age 61.0 [20.0-85.0] years) were eligible for this study, and propensity score matching yielded 102 patients in each group. The clinicopathological characteristics were well-matched between groups. The two groups did not differ in estimated blood loss, conversion to open rate, time to first flatus, reoperation rate, or postoperative length of hospital stay (p > 0.05). RLC was associated with a longer operation time (192.9 ± 53.2 vs. 168.9 ± 52.8 min, p = 0.001). The incidence of postoperative complications did not differ between the RLC and LLC groups (18.6% vs. 17.6%, p = 0.856). The total number of lymph nodes harvested in the RLC group was higher than that in the LLC group (15.7 ± 8.3 vs. 12.1 ± 5.9, p < 0.001). There were no significant differences in 3-year and 5-year overall survival or 3-year and 5-year disease-free survival.

CONCLUSION

Compared to laparoscopic surgery, RLC with CME for left-sided colon cancer was found to be associated with higher numbers of lymph nodes harvested and similar postoperative complications and long-term survival outcomes.

Robotic versus laparoscopic left colectomy with complete mesocolic excision for left-sided colon cancer: a multicentre study with propensity score matching analysis

BACKGROUND

Robotic surgery for right-sided colon and rectal cancer has rapidly increased; however, there is limited evidence in the literature of advantages of robotic left colectomy (RLC) for left-sided colon cancer. The purpose of this study was to compare the outcomes of RLC versus laparoscopic left colectomy (LLC) with complete mesocolic excision (CME) for left-sided colon cancer.

METHODS

Patients who had RLC or LLC with CME for left-sided colon cancer at 5 hospitals in China between January 2014 and April 2022 were included. A one-to-one propensity score matched analysis was performed to decrease confounding. The primary outcome was postoperative complications occurring within 30 days of surgery. Secondary outcomes were disease-free survival, overall survival and the number of harvested lymph nodes.

RESULTS

A total of 292 patients (187 males; median age 61.0 [20.0-85.0] years) were eligible for this study, and propensity score matching yielded 102 patients in each group. The clinical-pathological characteristics were well-matched between groups. The two groups did not differ in estimated blood loss, conversion to open rate, time to first flatus, reoperation rate, or postoperative length of hospital stay (p > 0.05). RLC was associated with a longer operation time (192.9 ± 53.2 vs. 168.9 ± 52.8 minutes, p=0.001). The incidence of postoperative complications did not differ between the RLC and LLC groups (18.6% vs. 17.6%, p = 0.856). The total number of lymph nodes harvested in the RLC group was higher than that in the LLC group (15.7 ± 8.3 vs. 12.1 ± 5.9, p< 0.001). There were no significant differences in 3-year and 5-year overall survival or 3-year and 5-year disease-free survival.

CONCLUSIONS

Compared to laparoscopic surgery, RLC with CME for left-sided colon cancer was found to be associated with higher numbers of lymph nodes harvested and similar postoperative complications and long-term survival outcomes.

Association between the proportion of laparoscopic approaches for digestive surgeries and the incidence of consequent surgical site infections, 2009-2019: A retrospective observational study based on national surveillance data in Japan

BACKGROUND

Surgical site infections (SSIs) are among the most common healthcare-associated infections. Laparoscopy is increasingly being used in various surgical procedures. However, no study has examined the association between the proportion of laparoscopic procedures and the incidence of SSIs in digestive surgery using nationwide surveillance data.

METHODS

We retrospectively investigated national SSI surveillance data from the Japan Nosocomial Infections Surveillance between 2009 and 2019. The annual trend of the SSI rate and the proportion of laparoscopic procedures were assessed, focusing on five major digestive surgeries. This was based on data from 109,544 (appendix surgery), 206,459 (gallbladder surgery), 60,225 (small bowel surgery), 363,677 (colon surgery), and 134,695 (rectal surgery) procedures. The effect of a 10% increase in the proportion of laparoscopic procedures on the reduction of the SSI rate was estimated using mixed-effect logistic regression.

FINDINGS

The average SSI rate of the five digestive surgeries decreased from 11.8% in 2009 to 8.1% in 2019. The proportion of laparoscopic procedures in each of the five digestive surgeries increased continuously (p<0.001). The SSI rate for laparoscopic procedures was always lower than that for open procedures. The results were consistent between all and core hospitals participating in the surveillance. The odds ratios of the 10% increase in the proportion of laparoscopic procedures for five digestive surgeries were always <0.950 (p<0.001).

CONCLUSION

An increase in the proportion of laparoscopic procedures was associated with a reduction in the SSI rate in digestive surgeries.

Laparoscopic versus open surgery for elderly patients with colorectal cancer: a systematic review and meta-analysis of matched studies

BACKGROUND

To compare clinical and survival outcomes between laparoscopic versus open surgery in elderly colorectal cancer patients.

METHODS

PubMed, Embase and Scopus databases were systematically searched. The review included studies that were either randomized controlled trials (RCTs) or observational in design. STATA was used for statistical analysis.

RESULTS

The meta-analysis was conducted with 24 studies. Compared with elderly subjects with open surgery, those undergoing laparoscopic surgery had a lower risk of mortality (within 3 months postoperatively) (RR 0.70, 95% CI: 0.53, 0.94). The long-term overall survival (HR 0.96, 95% CI: 0.89, 1.04), disease-free survival (HR 1.02, 95% CI: 0.93, 1.13), risk of recurrence (RR 1.44, 95% CI: 0.90, 2.30) and readmission (RR 1.11, 95% CI: 0.88, 1.40) rates were statistically similar in both the groups. The operative time (in minutes) was higher (WMD 30.37, 95% CI: 17.75, 43.0) and the blood loss (in ml) was lower (WMD -78.85, 95% CI: -101.96, -55.75) in those undergoing laparoscopic surgery. The length of hospital stay (in days) (WMD -2.53, 95% CI: -3.11, -1.95) and the time of return of bowel movements (in days) (WMD -1.06, 95% CI: -1.20, -0.93) was lower in those with laparoscopic surgery. The pooled risk of complications was lower in those with laparoscopic surgery (RR 0.66, 95% CI: 0.60, 0.74), compared with open surgery.

CONCLUSIONS

Findings suggest that in elderly subjects with colorectal cancer, laparoscopic surgery appears to be more beneficial than open surgery and should be prioritized, subject to the availability of required technical skills and facilities.

Initial Retrocolic Endoscopic Tunnel Approach As an Ergonomic and Oncologically Apt Laparoscopic Technique for Resection of Malignant Right Colonic Lesions: An Experience from a University Hospital

Introduction: Radical minimal access cancer surgery has demonstrated similar outcomes as open surgery of late, but with less morbidity, improving the quality of life especially in patients with colorectal cancer. Initial retrocolic endoscopic tunnel approach (IRETA) has been described in the literature by Palanivelu et al. as a laparoscopic technique for radical resection of malignant right colonic lesions (MRCL) following the modified concept of medial to lateral dissection. In this work, the authors present their experience of this ergonomic surgical technique. Materials and Methods: To begin with, retrocolic dissection was carried out to free and dissect the ascending colon up to hepatic flexure with the reflection of the peritoneum over the right colon along the white line of Toldt with abdominal wall kept intact initially to sustain intracorporeal specimen steadiness. Subsequently, the specimen is lifted medially in a distinct lymphovascular sheath, leading to high ligation of ileocolic, right colic, and the right branch of the middle colic vein with a consequent definite en bloc thorough removal of the lesion. The specimen was delivered through a transumbilical incision. Results: Ten patients (age 45.4 ± 5.6 years) underwent resection by the IRETA technique with a mean operating time of 185 ± 30 minutes and blood loss of 90 ± 20 mL. Mean hospital stay was 6 days. R0 surgical resection was achieved in all patients with proper marginal clearance. Ninety percent had adequate lymph nodal resection. One patient had an intraoperative complication and n = 3 patients developed postoperative ileus. Adjuvant chemotherapy was given and there is no recurrence on 28 months of average follow-up. Conclusion: With the increasing use of laparoscopic surgery for the management of colorectal cancers, the IRETA technique appears to be an ergonomic and oncologically robust procedure for the removal of MRCL. The presented data set needs to be increased with at least 5 years of follow-up to establish long-term surgical outcomes.

International survey on opinions and use of minimally invasive surgery in small bowel neuroendocrine neoplasms

INTRODUCTION

Although minimally invasive surgery is becoming the standard technique in gastrointestinal surgery, implementation for small bowel neuroendocrine neoplasms (SB-NEN) is lagging behind. The aim of this international survey was to gain insights into attitudes towards minimally invasive surgery for resection of SB-NEN and current practices.

METHODS

An anonymous survey was sent to surgeons between February and May 2021 via (neuro)endocrine and colorectal societies worldwide. The survey consisted of questions regarding experience of the surgeon with minimally invasive SB-NEN resection and training.

RESULTS

A total of 58 responses from five societies across 20 countries were included. Forty-one (71%) respondents worked at academic centers. Thirty-seven (64%) practiced colorectal surgery, 24 (41%) endocrine surgery and 45 (78%) had experience in advanced minimally invasive surgery. An open, laparoscopic or robotic approach was preferred by 23 (42%), 24 (44%), and 8 (15%) respondents, respectively. Reasons to opt for a minimally invasive approach were mainly related to peri-operative benefits, while an open approach was preferred for optimal mesenteric lymphadenectomy and tactile feedback. Additional training in minimally invasive SB-NEN resection was welcomed by 29 (52%) respondents. Forty-three (74%) respondents were interested in collaborating in future studies, with a cumulative median (IQR) annual case load of 172 (86-258).

CONCLUSIONS

Among respondents, 69% applies minimally invasive surgery for resection of SB-NEN. Arguments for specific operative approaches differ, and insufficient training in advanced laparoscopic techniques seems to be a barrier. Future collaborative studies can provide better insight in selection criteria and optimal technique.

Short-term outcomes in robot-assisted compared to laparoscopic colon cancer resections: a systematic review and meta-analysis

Background

Robot-assisted surgery is increasingly adopted in colorectal surgery. However, evidence for the implementation of robot-assisted surgery for colon cancer is sparse. This study aims to evaluate the short-term outcomes of robot-assisted colon surgery (RCS) for cancer compared to laparoscopic colon surgery (LCS).

Methods

Embase, MEDLINE, and Cochrane Library were searched between January 1, 2005 and October 2, 2020. Randomized clinical trials and observational studies were included. Non-original literature was excluded. Primary endpoints were anastomotic leakage rate, conversion to open surgery, operative time, and length of hospital stay. Secondary endpoints were surgical efficacy and postoperative morbidity. We evaluated risk of bias using RoB2 and ROBINS-I quality assessment tools. We performed a pooled analysis of primary and secondary endpoints. Heterogeneity was assessed by I², and possible causes were explored by sensitivity- and meta-regression analyses. Publication bias was evaluated by Funnel plots and Eggers linear regression test. The level of evidence was assessed by GRADE.

Results

Twenty studies enrolling 13,799 patients (RCS 1740 (12.6%) and LCS 12,059 (87.4%) were included in the meta-analysis that demonstrated RCS was superior regarding: anastomotic leakage (odds ratio (OR) = 0.54, 95% CI [0.32, 0.94]), conversion (OR = 0.31, 95% CI [0.23, 0.41]), overall complication rate (OR = 0.85, 95% CI [0.73, 1.00]) and time to regular diet (MD =  − 0.29, 95% CI [− 0.56, 0.02]). LCS proved to have a shortened operative time compared to RCS (MD = 42.99, 95% CI [28.37, 57.60]). Level of evidence was very low according to GRADE.

Conclusion

RCS showed advantages in colonic cancer surgery regarding surgical efficacy and morbidity compared to LCS despite a predominant inclusion of non-RCT with serious risk of bias assessment and a very low level of evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08782-7.

The additional analgesic effects of transverse abdominis plane block in patients receiving low-dose intrathecal morphine for minimally invasive colorectal surgery: a randomized, single-blinded study

Purpose

Intrathecal analgesia (ITA) and transverse abdominis plane block (TAPB) are effective pain control methods in abdominal surgery. However, there is still no gold standard for postoperative pain control in minimally invasive colorectal surgery. This study aimed to investigate whether the analgesic effect could be increased when TAPB, which can further reduce wound somatic pain, was administered in low-dose morphine ITA patients.

Methods

Patients undergoing elective colorectal surgery were randomized into an ITA with TAPB group or an ITA group. Patients were evaluated for pain 0, 8, 16, 24, and 48 hours after surgery. The primary outcome was the total morphine milligram equivalents administered 24 hours after surgery. The secondary outcomes were pain scores, ambulatory variables, inflammation markers, hospital stay duration, and complications within 48 hours after surgery.

Results

A total of 64 patients were recruited, and 55 were compared. There was no significant difference in morphine use over the 24 hours after surgery in the 2 groups (ITA with TAPB, 15.3 mg vs. ITA, 10.2 mg; P = 0.270). Also, there was no significant difference in pain scores. In both groups, the average pain score at 24 and 48 hours was 2 points or less, showing effective pain control.

Conclusion

ITA for pain control in patients with colorectal surgery is an effective pain method, and additional TAPB was not effective.

Colorectal cancer surgery in Asia during the COVID-19 pandemic: A tale of 3 cities

Purpose

The COVID-19 pandemic has put tremendous strain on healthcare systems. Surgical societies worldwide have advised minimizing non-essential surgeries in order to preserve hospital resources. Given the medical resources and COVID-19 incidence between countries across the world differ, so should colorectal practices. No formal guidelines have emerged from Asia. We wanted to find out what the current practice was in Asian colorectal centres outside China.

Introduction

The COVID-19 pandemic has significantly impacted surgical practice worldwide. At the time of the writing of this paper, there are over 4.2 million cases reported with deaths exceeding 290 000 patients.¹ With an abrupt disruption to worldwide supply chains, societal lockdowns and surge of cases into many hospitals, resource allocation was diverted and prioritised for all COVID-19 related services.

Methods

A questionnaire survey of current colorectal practice was carried out involving 3 major colorectal cancer centres, one each from 3 major cities: Singapore, Taichung and Daegu. Components of the survey include infrastructure and manpower, case selection, surgical approach, operating room management and endoscopy practice.

Results

All 3 centres continued to provide standard-of-care colorectal cancer surgery despite the COVID-19 pandemic. Two centres deferred surgery for benign colorectal conditions. Minimally Invasive Surgery (MIS) was still the preferred approach when indicated but with protocolized precautions undertaken. Other services such as pelvic exenteration, TATME and pelvic lymph node dissection were still offered if oncologically indicated. Elective diagnostic endoscopy services have also continued in two centres.

Conclusion

Elective colorectal services continue to take place in the 3 surveyed Asian hospitals with heightened precautions. Provided there is adequate resource, colorectal cancer services should still continue to prevent consequences of neglecting or delaying cancer treatment. Practice should hence be tailored to the local resource of individual centres accordingly.

[Evidence in minimally invasive oncological surgery of the colon and rectum]

An essential component of the treatment of colorectal cancer is a resection of the tumor-bearing segment of the bowels. After the development of minimally invasive procedures the feasibility and safety in oncological, colorectal surgery was questioned. The broad study situation for colon cancer over the last years showed predominantly consistent benefits during the perioperative phase and non-inferiority concerning long-term oncological outcomes. The implementation of laparoscopic rectal resection was more hesitant due to the complexity of the procedure and insufficient study data; however, overall the short-term benefits seem to be maintained and laparoscopic rectal resection is thought to be noninferior to open resection in the long run even though findings on the quality of the resected specimen are heterogeneous. Accordingly, most guidelines now include a recommendation of laparoscopic resection for colorectal cancer. The limitation with respect to an achievable oncological equivalency of resection takes account of the complexity and the requirements of the intervention only in the setting of rational selection of patients and sufficient experience of the surgeon.

Surgery for Colorectal Cancer: A Trigger for Liver Metastases Development? New Insights into the Underlying Mechanisms

Surgery is a crucial intervention and provides the best chance of cure for patients with colorectal cancer. Experimental and clinical evidence, however, suggests that paradoxically surgery itself may precipitate or accelerate tumor recurrence and/or liver metastasis development. This review addresses the various aspects of surgery-induced metastasis formation and sheds light on the role of inflammation as potential trigger for metastasis development. Understanding these mechanisms may provide potential new perioperative interventions to improve treatment outcomes, and as such could transform the perioperative timeframe from a facilitator of metastatic progression to a window of opportunity to reduce the risk of liver metastasis development. Ultimately, this can potentially improve long-term survival rates and quality of life in patients with colorectal cancer.

Laparoscopic versus robotic right colectomy with extra-corporeal or intra-corporeal anastomosis: a systematic review and meta-analysis

PURPOSE

The aim of the present systematic review and meta-analysis is to compare laparoscopic right colectomy (LRC) versus robotic right colectomy (RRC) using homogeneous subgroup analyses for extra-corporeal anastomosis (EA) and intra-corporeal anastomosis (IA).

METHODS

MEDLINE, Scopus, and Web of Science databases were searched up to April 2020 for prospective or retrospective studies comparing LRC versus RRC on at least one short- or long-term outcome. The primary outcome was the length of hospital stay (LOS). The secondary outcomes included operative and pathological results, survival, and total costs. LRC and RRC were compared using three homogeneous subgroups: without distinction by the type of anastomosis, EA only, and IA only. Pooled data analyses were performed using mean difference (MD) and random effects model.

RESULTS

Thirty-seven of 448 studies were selected. The included patients were 21,397 for the LRC group and 2796 for the RRC group. Regardless for the type of anastomosis, RRC showed shorter LOS, lower blood loss, lower conversion rate, shorter time to flatus, and lower overall complication rate compared with LRC, but longer operative time and higher total costs. In the EA subgroup, RRC showed similar LOS, longer operative time, and higher costs compared with LRC, the other outcomes being similar. In the IA subgroup, RRC showed shorter LOS and longer operative time compared with LRC, with no difference for the remaining outcomes.

CONCLUSIONS

Most included articles are retrospective, providing low-quality evidence and limiting conclusions. The more frequent use of the IA seems to explain the advantages of RRC over LRC.