Right Colon Resection for Colon Cancer: Does Surgical Approach Matter?

Robotic versus laparoscopic right hemicolectomy: a systematic review of the evidence

Robotics may facilitate the realization of fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis and off-midline extraction, when compared to laparoscopy. Our aim was to compare laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. MEDLINE was searched for original studies comparing laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. The systematic review complied with the PRISMA 2020 recommendations. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected and qualitatively assessed. Two-hundred and ninety-three publications were screened, 277 were excluded and 16 were retained for qualitative analysis. The majority of included studies were observational and of limited sample size. When the type of anastomosis was left at surgeon's discretion, intra-corporeal anastomosis was favoured in robotic right hemicolectomy (4/4 studies). When compared to laparoscopy, robotics allowed harvesting more lymph nodes (4/15 studies), a lower conversion rate to open surgery (5/14 studies), a shorter time to faeces (2/3 studies) and a shorter length of stay (5/14 studies), at the cost of a longer operative time (13/14 studies). Systematic review of existing studies, which are mostly non-randomized, suggests that robotic surgery may facilitate fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis, and offer improved post-operative recovery.

Early Discharge after Uncomplicated Elective Colectomy and Risk of Postdischarge Complication

BACKGROUND

This was a retrospective cohort study of adult patients undergoing uncomplicated elective colectomy using the NSQIP database from January 2012 to December 2019. A colectomy is deemed uncomplicated if there are no complications reported during the hospitalization. The objective of this study was to examine the association between discharge timing and postdischarge complications in patients who undergo uncomplicated elective colectomy.

STUDY DESIGN

Patients were stratified into an early discharge group if their length of postoperative hospitalization was ≤3 days for laparoscopic or robotic approaches, or ≤5 days for the open approach, and otherwise into delayed discharge groups. The association between early discharge and any postdischarge complication was examined using unadjusted logistic regression after propensity score matching between early and delayed discharge groups.

RESULTS

Of the 113,940 patients included, 77,979, 15,877, and 20,084 patients underwent uncomplicated laparoscopic, robotic, and open colectomy, respectively. After propensity score matching, the odds of a postdischarge complication were lower for the early discharge group in laparoscopic (odds ratio 0.73, 95% CI 0.68 to 0.79) and robotic (odds ratio 0.63, 95% CI 0.52 to 0.76) approaches, and not different in the open approach (odds ratio 1.02, 95% CI 0.91 to 1.15). There were no clinically meaningful differences in the risk of return to the operating room for all surgical approaches.

CONCLUSIONS

Early discharge after uncomplicated colectomy appears to be safe and is associated with lower odds of postdischarge complications in minimally invasive approaches. Our findings suggest that surgical teams practice sound clinical judgments on selecting patients who benefit from early discharge.

Robotic versus laparoscopic right hemicolectomy with complete mesocolic excision: a retrospective multicenter study with propensity score matching

Objective

During the past decade, the concept of complete mesocolic excision (CME) has been developed in an attempt to minimize recurrence for right-sided colon cancer. This study aims to compare outcomes of robotic versus laparoscopic right hemicolectomy with CME for right-sided colon cancer.

Methods

We performed a retrospective multicenter propensity score matching study. From July 2016 to July 2021, 382 consecutive patients from different Chinese surgical departments were available for inclusion out of an initial cohort of 412, who underwent robotic or laparoscopic right hemicolectomy with CME. Data of all patients were retrospectively collected and reviewed. Of these, 149 cases were performed by a robotic approach, while the other 233 cases were done by laparoscopy. Propensity score matching was applied at a ratio of 1:1 to compare perioperative, pathologic, and oncologic outcomes between the robotic and the laparoscopic groups (n = 142).

Results

Before propensity score matching, there were no statistical differences regarding the sex, history of abdominal surgery, body mass index (BMI), American Joint Committee on Cancer (AJCC) staging system, tumor location, and center between groups (p > 0.05), while a significant difference was observed regarding age (p = 0.029). After matching, two comparable groups of 142 cases were obtained with equivalent patient characteristics (p > 0.05). Blood loss, time to oral intake, return of bowel function, length of stay, and complications were not different between groups (p > 0.05). The robotic group showed a significantly lower conversion rate (0% vs. 4.2%, p = 0.03), but a longer operative time (200.9 min vs. 182.3 min, p < 0.001) and a higher total hospital cost (85,016 RMB vs. 58,266 RMB, p < 0.001) compared with the laparoscopic group. The number of harvested lymph nodes was comparable (20.4 vs. 20.5, p = 0.861). Incidence of complications, mortality, and pathologic outcomes were similar between groups (p > 0.05). The 2-year disease-free survival rates were 84.9% and 87.1% (p = 0.679), and the overall survival rates between groups were 83.8% and 80.7% (p = 0.943).

Conclusion

Despite the limitations of a retrospective analysis, the outcomes of robotic right hemicolectomy with CME were comparable to the laparoscopic procedures with fewer conversions to open surgery. More clinical advantages of the robotic surgery system need to be further confirmed by well-conducted randomized clinical trials with large cohorts of patients.

Comparison of robotic right colectomy and laparoscopic right colectomy: a systematic review and meta-analysis

BACKGROUND

For right colon surgery, there is an increasing body of literature comparing the safety of robotic right colectomy (RRC) with laparoscopic right colectomy (LRC). The aim of the present systematic review and meta-analysis is to assess the safety and efficacy of RRC versus LRC, including homogeneous subgroup analyses for extracorporeal anastomosis (EA) and intracorporeal anastomosis (IA).

METHODS

PubMed, Web of Science, Embase, and Cochrane Library databases were searched for studies published between January 2000 and January 2022. Length of hospital stay, operation time, rate of conversion to laparotomy, time to first flatus, number of harvested lymph nodes, estimated blood loss, rate of overall complication, ileus, anastomotic leakage, wound infection, and total costs were measured.

RESULTS

Forty-two studies (RRC: 2772 patients; LRC: 12,469 patients) were evaluated. Regardless of the type of anastomosis, RRC showed shorter length of hospital stay, lower rate of conversion to laparotomy, shorter time to first flatus, lower rate of overall complications, and a higher number of harvested lymph nodes compared with LRC, but longer operative time and higher total costs. In the IA subgroup, RRC had a shorter length of hospital stay, longer operative time, and lower rate of conversion to laparotomy compared with LRC, with no difference for the remaining outcomes. In the EA subgroup, RRC had a longer operative time, lower estimated blood loss, lower rate of overall complications, and higher total costs compared with LRC, with the other outcomes being similar.

CONCLUSION

The safety and efficacy of RRC is superior to LRC, especially when an intracorporeal anastomosis is performed. Most included articles were retrospective, offering low-quality evidence and limited conclusions.

Short- and Long-Term Outcome of Laparoscopic- versus Robotic-Assisted Right Colectomy: A Systematic Review and Meta-Analysis

Background: There is a rapidly growing literature available on right hemicolectomy comparing the short- and long-term outcomes of robotic right colectomy (RRC) to that of laparoscopic right colectomy (LRC). The aim of this meta-analysis is to revise current comparative literature systematically. Methods: A systematic review of comparative studies published between 2000 to 2021 in PubMed, Scopus and Embase was performed. The primary endpoint was postoperative morbidity, mortality and long-term oncological results. Secondary endpoints consist of blood loss, conversion rates, complications, time to first flatus, hospital stay and incisional hernia rate. Results: 25 of 322 studies were considered for data extraction. A total of 16,099 individual patients who underwent RRC (n = 1842) or LRC (n = 14,257) between 2002 and 2020 were identified. Operative time was significantly shorter in the LRC group (LRC 165.31 min ± 43.08 vs. RRC 207.38 min ± 189.13, MD: −42.01 (95% CI: −51.06−32.96), p < 0.001). Blood loss was significantly lower in the RRC group (LRC 63.57 ± 35.21 vs. RRC 53.62 ± 34.02, MD: 10.03 (95% CI: 1.61−18.45), p = 0.02) as well as conversion rate (LRC 1155/11,629 vs. RRC 94/1534, OR: 1.65 (1.28−2.13), p < 0.001) and hospital stay (LRC 6.15 ± 31.77 vs. RRC 5.31 ± 1.65, MD: 0.84 (95% CI: 0.29−1.38), p = 0.003). Oncological long-term results did not differ between both groups. Conclusion: The advantages of robotic colorectal procedures were clearly demonstrated. RRC can be regarded as safe and feasible. Most of the included studies were retrospective with a limited level of evidence. Further randomized trials would be suitable.

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.

Development and validation of a risk prediction model and nomogram for colon adenocarcinoma based on methylation-driven genes

Evidence suggests that abnormal DNA methylation patterns play a crucial role in the etiology and pathogenesis of colon adenocarcinoma (COAD). In this study, we identified a total of 97 methylation-driven genes (MDGs) through a comprehensive analysis of the Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases. Univariate Cox regression analysis identified four MDGs (CBLN2, RBM47, SLCO4C1, and TMEM220) associated with overall survival (OS) in COAD patients. A risk prediction model was then developed based on these four MDGs to predict the prognosis of COAD patients. We also created a nomogram that incorporated risk scores, age, and TNM stage to promote a personalized prediction of OS in COAD patients. Compared with the traditional TNM staging system, our new nomogram was better at predicting the OS of COAD patients. In cell experiments, we confirmed that the mRNA expression levels of CLBN2 and TMEM220 were regulated by the methylation of their promoter regions. Moreover, immunohistochemistry showed that CBLN2 and TMEM220 were potential prognostic biomarkers for COAD patients. In summary, we have established a risk prediction model and nomogram that might be effectively utilized to promote the prediction of OS in COAD patients.

The art of robotic colonic resection: a review of progress in the past 5 years

Surgery is developing in the direction of minimal invasiveness, and robotic surgery is becoming increasingly adopted in colonic resection procedures. The ergonomic improvements of robot promote surgical performance, reduce workload for surgeons and benefit patients. Compared with laparoscopy-assisted colon surgery, the robotic approach has the advantages of shorter length of hospital stay, lower rate of conversion to open surgery, and lower rate of intraoperative complications for short-term outcomes. Synchronous robotic liver resection with colon cancer is feasible. The introduction of the da Vinci Xi System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) has introduced more flexibility to colonic operations. Optimization of the suprapubic surgical approach may shorten the length of hospital stay for patients who undergo robotic colonic resection. Single-port robotic colectomy reduces the number of robotic ports for better looking and faster recovery. Intestinal anastomosis methods using totally robotic surgery result in shorter time to bowel function recovery and tolerance to a solid diet, although the operative time is longer. Indocyanine green is used as a tracer to assess blood supplementation in the anastomosis and marks lymph nodes during operation. The introduction of new surgical robots from multiple manufacturers is bound to change the landscape of robotic surgery and yield high-quality surgical outcomes. The present article reviews recent advances in robotic colonic resection over the past five years.

C1QTNF6 regulates cell proliferation and apoptosis of NSCLC in vitro and in vivo

OBJECTIVES

Lung cancer has been reported as the leading cause of cancer-associated deaths in humans, and its incidence continues to increase in the world. A growing number of studies have shown that dysregulated genes are associated with the occurrence and poor prognosis of a variety of tumors, including non-small cell lung cancer (NSCLC). C1q/tumor necrosis factor-related protein 6 (C1QTNF6), a member of the C1q/tumor necrosis factor-related protein (CTRP) family, has been revealed to play a role in carcinogenesis and cancer progression. Nevertheless, the effects and mechanisms of C1QTNF6 in NSCLC remain unrevealed.

MATERIALS AND METHODS

MTT (3-(4,5)-dimethylthiahiazo(-z-y1)-3,5-di-phenytetrazoliumromide) and colony formation, flow cytometric and transwell assays were performed to explore the cell function. Real-time PCR (RT-PCR) and Western blot were used to analyze the mRNA and protein expression.

RESULTS

In the present study, we found that C1QTNF6 significantly promoted the proliferation of SPCA1 and A549 cells by MTT and colony formation assays. In addition, down-regulation of C1QTNF6 weakened the tumor growth in vivo. Besides, C1QTNF6 remarkably reduced apoptosis by flow cytometric analysis and TUNEL assay. Furthermore, the capability of migration and invasion was obviously enhanced on C1QTNF6 overexpression.

CONCLUSION

Overall, our results demonstrated that inhibition of C1QTNF6 attenuated cell proliferation, migration, invasion and promoted apoptosis in vitro and in vivo of NSCLC. Based on the above results, our study provided us with a new and key perspective in understanding and treating NSCLC.

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.

Successful patient-oriented surgical outcomes in robotic vs laparoscopic right hemicolectomy for cancer - a systematic review

AIM

Minimally invasive surgical approaches for cancer of the right colon have been well described with significant patient and equivalent oncological benefits. Robotic surgery has advanced in its ability to provide multi-quadrant abdominal access, leading the surgical community to widen its application outside of the pelvis to other abdominal compartments. Globally it is being realized that a patient's surgical episode of care is becoming the epicentre of cancer treatment. In order to establish the role of robotic surgery in a patient's episode of care, 'successful patient-oriented surgical' parameters in right hemicolectomy for malignancy were measured. The objective was to examine the rates of successful patient-oriented surgical outcomes in robotic right hemicolectomy (RRH) compared to laparoscopic right hemicolectomy (LRH) for cancer.

METHODS

A systematic search of MEDLINE (Ovid: 1946-present), PubMed (NCBI), Embase (Ovid: 1966-present) and Cochrane Library was conducted using PRISMA for parameters of successful patient-oriented surgical outcomes in RRH and LRH for malignancy alone. The parameters measured included postoperative ileus, anastomotic complication, surgical wound infection, length of stay (LOS), incisional hernia rate, conversion to open, margin status, lymph node harvest and overall morbidity and mortality.

RESULTS

There were 15 studies which included 831 RRH patients and 3241 LRH patients, with a median age of 62-74 years. No study analysed the concept of successful patient-oriented surgical outcomes. There was no significant difference in the incidence of postoperative ileus, with less time to first flatus in RRH (2.0-2.7 days, compared with 2.5-4.0 days, P < 0.05). Anastomotic leak rate in one study reported a significant increase in LRH compared to RRH (P < 0.05, 0% vs 8.3%). Significantly decreased LOS following RRH was outlined in six studies. One study reported a significantly higher rate of incisional hernias following LRH with extracorporeal anastomoses compared to RRH with intracorporeal anastomoses. Overall rates of conversion to open surgery were less with RRH (0%-3.9% vs 0%-18%, P < 0.001, 0.05). One study outlined significantly higher rates of incomplete resection with an open right hemicolectomy compared with minimally invasive laparoscopic and robotic resections, with positive margin rates of 2.3%, 0.9% and 0% respectively (P < 0.001). Two studies reported significantly higher lymph node harvest in RRH (P < 0.05). Overall morbidity and 30-day mortality were comparable in both approaches.

CONCLUSION

Thirty-day morbidity and mortality were comparable between the two approaches, with patients undergoing RRH having lower anastomotic complications, increased lymph node harvest, and reduced LOS, conversion to open and incisional hernia rates in a number of studies. There are limited data on surgical approach and impact on quality of life and what patients deem successful surgical outcomes. There is a further need for a randomized controlled trial examining successful patient-oriented outcomes in right hemicolectomy for malignancy.