Comparative Study on Therapeutic Efficacy Between Hand-Assisted Laparoscopic Surgery and Conventional Laparotomy for Acute Obstructive Right-Sided Colon Cancer

Laparoscopic versus Open Emergency Surgery for Right Colon Cancers

BACKGROUND

A laparoscopic approach to right colectomies for emergency right colon cancers is under investigation. This study compares perioperative and oncological long-term outcomes of right colon cancers undergoing laparoscopic or open emergency resections and identifies risk factors for survival.

METHODS

Patients were identified from a prospectively maintained institutional database between 2009 and 2019. Demographics, clinicopathological features, recurrence, and survival were investigated. Cox regression analysis was performed for risk factor analysis.

RESULTS

A total of 202 right colectomies (114 open and 88 laparoscopic) were included. ASA III-IV was higher in the open group. The conversion rate was 14.8%. Laparoscopic surgery was significantly longer (156 vs. 203 min, p < 0.001); pTNM staging did not differ. Laparoscopy was associated with higher lymph node yield, and showed better resection clearance (R0, 78.9 vs. 87.5%, p = 0.049) and shorter postoperative stay (12.5 vs. 8.0 days, p < 0.001). Complication rates and grade were similar. The median length of follow-up was significantly higher in the laparoscopic group (20.5 vs. 33.5 months, p < 0.001). Recurrences were similar (34.2 vs. 36.4%). Open surgery had lower five-year overall survival (OS, 27.1 vs. 51.7%, p = 0.001). Five-year disease-free survival was similar (DFS, 55.8 vs. 56.5%). Surgical approach, pN, pM, retrieved LNs, R stage, and complication severity were risk factors for OS upon multivariate analysis. Pathological N stage and R stage were risk factors for DFS upon multivariate analysis.

CONCLUSIONS

A laparoscopic approach to right colon cancers in an emergency setting is safe in terms of perioperative and long-term oncological outcomes. Randomized control trials are required to further investigate these results.

Self-expandable metallic stent as bridge to surgery vs. emergency resection in obstructive right-sided colon cancer: a systematic review and meta-analysis

BACKGROUND

Emergency resection is common for malignant right-sided obstructive colon cancer. As there is evidence showing a potential benefit of self-expandable metal stents as a bridge to surgery, a new debate has been initiated.

OBJECTIVE

The aim of this study was to compare self-expandable metal stents with emergency resection in right-sided obstructive colon cancer.

DATA SOURCE

A systematic search was conducted accessing Medline/PubMed, Scopus, Embase, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

Studies reporting either emergency surgery or stent placement in right-sided obstructive colon cancer were included.

INTERVENTION

Stent or emergency resection in right-sided obstructive colon cancer.

MAIN OUTCOME MEASURES

Morbidity rate, mortality rate, stoma rate, laparoscopic resection rate, anastomotic insufficiency rate, success rate of stent.

RESULTS

A total of 6343 patients from 16 publications were analyzed. The stent success rate was 0.92 (95% CI, 0.87 to 0.95) with perforation of 0.03 (95% CI, 0.01 to 0.06). Emergency resection was performed laparoscopically at a rate of 0.15 (95% CI, 0.09 to 0.24). Primary anastomosis rate in emergency resection was 0.95 (95% CI, 0.91 to 0.97) with an anastomotic insufficiency rate of 0.07 (95% CI, 0.04 to 0.11). The mortality rate after emergency resection was 0.05 (95% CI, 0.02 to 0.09). Primary anastomosis and anastomotic insufficiency rate were similar between the two groups (RR: 1.02; 95% CI, 0.95 to 1.1; p = 0.56 and RR: 0.53; 95% CI, 0.14 to 1.93; p = 0.33). The mortality rate in emergency resection was higher compared to stent (RR: 0.51, 95% CI 0.30 to 10.89, p = 0.016).

LIMITATION

No randomized controlled trials are available.

CONCLUSION

Stent is a safe and successful alternative to emergency resection and may increase the rate of minimally invasive surgery. Emergency resection, however, remains safe and did not result in higher rate of anastomotic insufficiency. Further high-quality comparative studies are warranted to assess long-term outcomes.

Short- and Long-term Outcomes After Laparoscopic Emergency Resection of Left-Sided Obstructive Colon Cancer: A Nationwide Propensity Score-Matched Analysis

BACKGROUND

The role of laparoscopy for emergency resection of left-sided obstructive colon cancer remains unclear, especially regarding impact on survival.

OBJECTIVE

This study aimed to determine short- and long-term outcomes after laparoscopic versus open emergency resection of left-sided obstructive colon cancer.

DESIGN

This observational cohort study compared patients who underwent laparoscopic emergency resection to those who underwent open emergency resection between 2009 and 2016 by using 1:3 propensity-score matching. Matching variables included sex, age, BMI, ASA score, previous abdominal surgery, tumor location, cT4, cM1, multivisceral resection, small-bowel distention on CT, and subtotal colectomy.

SETTING

This was a nationwide, population-based study.

PATIENTS

Of 2002 eligible patients with left-sided obstructive colon cancer, 158 patients who underwent laparoscopic emergency resection were matched with 474 patients who underwent open emergency resection.

INTERVENTIONS

The intervention was laparoscopic versus open emergency resection.

MAIN OUTCOME MEASURES

The main outcome measures were 90-day mortality, 90-day complications, permanent stoma, disease recurrence, overall survival, and disease-free survival.

RESULTS

Intentional laparoscopy resulted in significantly fewer 90-day complications (26.6% vs 38.4%; conditional OR, 0.59; 95% CI, 0.39-0.87) and similar 90-day mortality. Laparoscopy resulted in better 3-year overall survival (81.0% vs 69.4%; HR, 0.54; 95% CI, 0.37-0.79) and disease-free survival (68.3% vs 52.3%; HR, 0.64; 95% CI, 0.47-0.87). Multivariable regression analyses of the unmatched 2002 patients confirmed an independent association of laparoscopy with fewer 90-day complications and better 3-year survival.

LIMITATIONS

Selection bias was the limitation that cannot be completely ruled out because of the retrospective nature of this study.

CONCLUSIONS

This population-based study with propensity score-matched analysis suggests that intentional laparoscopic emergency resection might improve outcomes in patients with left-sided obstructive colon cancer compared to open emergency resection. Management of those patients in the emergency setting requires proper selection for intentional laparoscopic resection if relevant expertise is available, thereby considering other alternatives to avoid open emergency resection (ie, decompressing stoma). See Video Abstract at http://links.lww.com/DCR/B972 .

RESULTADOS A CORTO Y LARGO PLAZO DESPUS DE LA RESECCIN LAPAROSCPICA DE EMERGENCIA EN CNCER DE COLON IZQUIERDO OBSTRUCTIVO UN ANLISIS EMPAREJADO POR PUNTAJE DE PROPENSIN A NIVEL NACIONAL

ANTECEDENTES:El papel de la laparoscopia en la resección de emergencia en cáncer de colon izquierdo obstructivo sigue sin estar claro, especialmente con respecto al impacto en la supervivencia.OBJETIVO:El objetivo de este estudio fue determinar los resultados a corto y largo plazo después de la resección de emergencia laparoscópica versus abierta en cáncer de colon izquierdo obstructivo.DISEÑO:Estudio observacional de cohortes comparó pacientes que se sometieron a resección de laparoscópica de emergencia versus resección abierta de emergencia entre 2009 y 2016, mediante el uso de emparejamineto por puntaje de propensión 1: 3. Las variables emparejadas incluyeron sexo, edad, IMC, puntaje ASA, cirugía abdominal previa, ubicación del tumor, cT4, cM1, resección multivisceral, distensión del intestino delgado en la TAC y colectomía subtotal.ENTORNO CLINICO:A nivel nacional, basado en la población.PACIENTES:De 2002 pacientes elegibles con cáncer de colon izquierdo obstructivo, 158 pacientes con resección laparoscópica s de emergencia e emparejaron con 474 pacientes con resección abierta de emergencia.INTERVENCIONES:Resección laparoscópica de emergencia versus abierta.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas primarias fueron la mortalidad a 90 días, complicaciones a 90 días, estoma permanente, recurrencia de la enfermedad, supervivencia general y supervivencia libre de enfermedad.RESULTADOS:La laparoscopia intencional dió como resultado significativamente menos complicaciones a los 90 días (26,6 % vs 38,4 %, cOR 0,59, IC del 95 %: 0,39-0,87) y una mortalidad similar a los 90 días. La laparoscopia resultó en una mejor supervivencia general a los 3 años (81,0 % vs 69,4 %, HR 0,54, IC del 95 % 0,37-0,79) y supervivencia libre de enfermedad (68,3 % vs 52,3 %, HR 0,64, IC del 95 % 0,47-0,87). Los análisis de regresión multivariable de los 2002 pacientes no emparejados confirmaron una asociación independiente de la laparoscopia con menos complicaciones a los 90 días y una mejor supervivencia a los 3 años.LIMITACIONES:El sesgo de selección no se puede descartar por completo debido a la naturaleza retrospectiva de este estudio.CONCLUSIONES:Estudio poblacional con análisis emparejado por puntaje de propensión sugiere que la resección laparoscópica de emergencia intencional podría mejorar los resultados a corto y largo plazo en pacientes con cáncer de colon izquierdo obstructivo en comparación con resección abierta de emergencia, lo que justifica la confirmación en estudios futuros. El manejo de esos pacientes en el entorno de emergencia requiere una selección adecuada para la resección laparoscópica intencional si se dispone de experiencia relevante, considerando así otras alternativas para evitar la resección abierta de emergencia (es decir, ostomia descompresiva). Consulte Video Resumen en http://links.lww.com/DCR/B972 . (Traducción- Dr. Francisco M. Abarca-Rendon & Dr. Fidel Ruiz Healy).

A Systematic Review Comparing Emergency Resection and Staged Treatment for Curable Obstructing Right-Sided Colon Cancer

BACKGROUND

Treatment for obstructing colon cancer (OCC) is controversial because the outcome of acute resection is less favorable than for patients without obstruction. Few studies have investigated curable right-sided OCC, and patients with OCC usually undergo acute resection. This study aimed to better understand the outcome and best management of potentially curable right-sided OCC.

METHODS

A systematic review of studies was performed with a focus on differences in mortality and morbidity between emergency resection and staged treatment for patients with potentially curable right-sided OCC. In March 2019, the study searched Embase, Medline, Web of Science, Cochrane, and Google scholar databases according to PRISMA guidelines using search terms related to "colon tumour," "stenosis or obstruction and surgery," and "decompression or stents." All English-language studies reporting emergency or staged treatment for potentially curable right-sided OCC were included in the review. Emergency resection and staged resection were compared for mortality, morbidity, complications, and survival.

RESULTS

Nine studies were found to be eligible and comprised 600 patients treated with curative intent for their right-sided OCC by emergency resection or staged resection. The mean overall complication rate was 42% (range 19-54%) after emergency resection, and 30% (range 7-44%) after staged treatment. The average mortality rate was 7.2% (range 0-14.5%) after emergency resection and 1.2% (range 0-6.3%) after staged treatment. The 5-year disease-free and overall survival rates were comparable for the two treatments.

CONCLUSIONS

The patients who received staged treatment for right-sided OCC had lower mortality rates, fewer complications, and fewer anastomotic leaks and stoma creations than the patients who had emergency resection.

Procedural and post-operative complications associated with laparoscopic versus open abdominal surgery for right-sided colonic cancer resection: A systematic review and meta-analysis

BACKGROUND

In this analysis, we aimed to systematically compare the procedural and post-operative complications (POC) associated with laparoscopic versus open abdominal surgery for right-sided colonic cancer resection.

METHODS

We searched MEDLINE, http://www.ClinicalTrials.gov, EMBASE, Web of Science, Cochrane Central, and Google scholar for English studies comparing the POC in patients who underwent laparoscopic versus open surgery (OS) for right colonic cancer. Data were assessed by the Cochrane-based RevMan 5.4 software (The Cochrane Community, London, UK). Mean difference (MD) with 95% confidence intervals (CIs) were used to represent the results for continuous variables, whereas risk ratios (RR) with 95% CIs were used for dichotomous data.

RESULTS

Twenty-six studies involving a total number of 3410 participants with right colonic carcinoma were included in this analysis. One thousand five hundred and fifteen participants were assigned to undergo invasive laparoscopic surgery whereas 1895 participants were assigned to the open abdominal surgery. Our results showed that the open resection was associated with a shorter length of surgery (MD: 48.63, 95% CI: 30.15-67.12; P = .00001) whereas laparoscopic intervention was associated with a shorter hospital stay [MD (-3.09), 95% CI [-5.82 to (-0.37)]; P = .03]. In addition, POC such as anastomotic leak (RR: 0.96, 95% CI: 0.60-1.55; P = .88), abdominal abscess (RR: 1.13, 95% CI: 0.52-2.49; P = .75), pulmonary embolism (RR: 0.40, 95% CI: 0.09-1.69; P = .21) and deep vein thrombosis (RR: 0.94, 95% CI: 0.39-2.28; P = .89) were not significantly different. Paralytic ileus (RR: 0.87, 95% CI: 0.67-1.11; P = .26), intra-abdominal infection (RR: 0.82, 95% CI: 0.15-4.48; P = .82), pulmonary complications (RR: 0.83, 95% CI: 0.57-1.20; P = .32), cardiac complications (RR: 0.73, 95% CI: 0.42-1.27; P = .27) and urological complications (RR: 0.83, 95% CI: 0.52-1.33; P = .44) were also similarly manifested. Our analysis also showed 30-day re-admission and re-operation, and mortality to be similar between laparoscopic versus OS for right colonic carcinoma resection. However, surgical wound infection (RR: 0.65, 95% CI: 0.50-0.86; P = .002) was significantly higher with the OS.

CONCLUSIONS

In conclusion, laparoscopic surgery was almost comparable to OS in terms of post-operative outcomes for right-sided colonic cancer resection and was not associated with higher unwanted outcomes. Therefore, laparoscopic intervention should be considered as safe as the open abdominal surgery for right-sided colonic cancer resection, with a decreased hospital stay.

[Minimally invasive interventions in emergency large bowel surgery]

The current trends in the treatment of various surgical diseases of large bowel using minimally invasive operations are reviewed in the manuscript. It is shown that laparoscopy is currently possible in most cases for urgent large bowel diseases.

A meta-analysis comparing hand-assisted laparoscopic right hemicolectomy and open right hemicolectomy for right-sided colon cancer

Background

Mini-invasive colorectal cancer surgery was adopted widely in recent years. This meta-analysis aimed to compare hand-assisted laparoscopic surgery (HALS) with open right hemicolectomy (OS) for malignant disease.

Methods

PRISMA guidelines with random effects model were adopted using Review Manager Version 5.3 for pooled estimates.

Results

Seven studies that involved 506 patients were included. Compared to OS, HALS improved results in terms of blood loss (MD = 53.67, 95% CI 10.67 to 96.67, p = 0.01), time to first flatus (MD = 21.11, 95% CI 14.99 to 27.23, p < 0.00001), postoperative pain score, and overall hospital stay (MD = 3.47, 95% CI 2.12 to 4.82, p < 0.00001). There was no difference as concerns post-operative mortality, morbidity (OR = 1.55, 95% CI 0.89 to 2.7, p = 0.12), wound infection (OR = 1.69, 95% CI 0.60 to 4.76, p = 0.32), operative time (MD = − 16.10, 95% CI [− 36.57 to 4.36], p = 0.12), harvested lymph nodes (MD = 0.59, 95% CI − 0.18 to 1.36, p = 0.13), and recurrence (OR = 0.97, 95% CI 0.30 to 3.15, p = 0.96).

Conclusions

HALS is an efficient alternative to OS in right colectomy which combines the advantages of OS with the mini-invasive surgery.

Laparoscopic versus open colectomy for obstructing right colon cancer: A systematic review and meta-analysis

BACKGROUND

Hemicolectomy is the treatment of choice for intestinal obstruction from right colon cancer. This review compares the laparoscopic vs open access in hemicolectomy for patients with right colon cancer.

METHODS

A systematic review and meta-analysis of clinical studies published after January 2017 was performed according to the Prisma guidelines. The study has been recorded on the Prospero register (CRD42016044108).

RESULTS

Five studies were included for review. Only one anastomotic leak was reported in conventional open anastomosis group (1.9%) and none of the studies included in the meta-analysis reported re-operations during the first 30 postoperative days. The 30-day postoperative mortality did not differ between the two groups. The length of incision, blood loss, early mobilization after surgery, the 30-day postoperative overall complication rate and hospital length of stay were significantly shorter in the laparoscopic group. The difference in the duration of procedure was statistically significant in favor of the open group. The number of dissected lymph nodes, the overall survival at 5 years and time to flatus were described only in one study, without any significant difference. Finally, none of the trials reported any information concerning differences in the costs between the two techniques.

CONCLUSIONS

The better outcomes described in this study achieved with laparoscopy, must be interpreted with caution because of the small number of patients involved, the selection and publication bias and the low level of evidence of the analysed trials. Indeed, the advantages of a minimally invasive approach, which have been demonstrated by the present meta-analysis, should encourage the use of laparoscopy also in emergency setting.

Hand-assisted laparoscopic surgery versus conventional open surgery in intraoperative and postoperative outcomes for colorectal cancer: An updated systematic review and meta-analysis

AIM

This meta-analysis aims to compare hand-assisted laparoscopic surgery (HALS) and conventional open surgery (OS) for colorectal cancer (CRC) in terms of intraoperative and postoperative outcomes, and to explore the safety, feasibility of HALS for CRC surgery.

METHODS

A systematic literature search with no limits was performed in PubMed, Embase, and Medline. The last search was performed on April 23, 2017. The outcomes of interests included intraoperative outcomes (operative time, blood loss, length of incision, transfusion, and lymph nodes harvested), postoperative outcomes (length of hospital stay, length of postoperative hospital stay, time to first flatus, time to first liquid diet, time to first soft diet, time to first bowel movement, postoperative complications, reoperation, ileus, anastomotic leakage, wound infection, urinary complication, pulmonary infection, and mortality).

RESULTS

Fifteen articles published between 2007 and 2017 with a total of 1962 patients with CRC were included in our meta-analysis. HALS was associated with longer operative time, less blood loss, smaller length of incision, shorter hospital days and postoperative hospital days, less time to first flatus, less wound infection, and less postoperative complications. There was no difference in blood transfusion, lymph node harvested, time to first liquid or soft diet, time to first bowel movement, reoperation, ileus, anastomotic leakage, pulmonary infection, urinary complications, or mortality.

CONCLUSIONS

Our meta-analysis suggests that HALS in CRC surgery improves cosmesis and results in better postoperative recovery outcomes by reducing postoperative complications and hospital days. Furthermore, a large randomized control study is warranted to compare the short-term and long-term outcomes of those 2 techniques for CRC treatment.

Current application and prospects of hand-assisted laparoscopic surgery in gastrointestinal tumors

Hand-assisted laparoscopic surgery (HALS) refers to operations in which the surgeon inserts his/her non-dominant hand through a specific auxiliary device into the peritoneal cavity to assist the laparoscopic instruments. Because there is one hand to assist in the operation, HALS can reduce the difficulty of operation and shorten operative time. Previously, HALS is considered the transitional bridge from the traditional open surgery to laparoscopic surgery, but now, HLAS, together with total laparoscopic surgery and laparoscopic assisted surgery, is considered three forms of routine laparoscopic surgery. Along with the extensive use of laparoscopic surgery in gastrointestinal tumors, HALS, as a new method of laparoscopic surgery, has been gradually used in gastrointestinal tumors in recent years.

Emergent Laparoscopic Colectomy Is an Effective Alternative to Open Resection for Benign and Malignant Diseases: a Meta-Analysis

The aim of this study is to compare the perioperative outcomes between laparoscopic and open resections performed for colonic emergencies. A systematic search of the literature identified previously published comparative studies regarding emergent laparoscopic colectomy (ELC) and emergent open colectomy (EOC). Meta-analysis was performed utilizing a pooled odds ratio (OR) for dichotomous variables and a weighted mean difference (WMD) for continuous variables with 95 % confidence intervals (CIs). Eleven studies involving 752 patients were identified. Although operation time was noted to be significantly shorter for EOC, patients post-ELC had significantly lower overall morbidity (OR 0.44; 95 % CI 0.30, 0.66; P < 0.0001). Meanwhile, recovery time for post-ELC patients was significantly shorter, as was the length of hospital stay (WMD -2.78 days; 95 % CI -3.17, -2.38; P < 0.00001), the time to regular dietary habits (WMD -1.32 days; 95 % CI -2.51, -0.13; P = 0.03), and the time to recover bowel movement (WMD -0.55 days; 95 % CI -0.89, -0.22; P = 0.001). Reoperation rate and mortality were found to be comparable between ELC and EOC. The R0 resection rate and the number of lymph nodes harvested were also comparable between ELC and EOC for malignant diseases. Whether for benign or malignant disease, ELC is a safe and feasible procedure for colonic emergencies compared with EOC, despite being relatively time-consuming.