1
|
Megafu OM. Statistical Fragility in Minimally Invasive Colorectal Surgery Studies: A Review of Randomized Trials. J Laparoendosc Adv Surg Tech A 2024; 34:614-621. [PMID: 38900698 DOI: 10.1089/lap.2024.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
Purpose: The P value has been used as a statistical tool in randomized controlled trials (RCTs) to establish significance but does not provide information on the robustness of a study when used alone. The fragility index (FI) provides a supplemental approach for demonstrating robustness in RCTs that report dichotomous outcomes. This study aims to determine the statistical fragility of RCTs that compare minimally invasive techniques with open techniques in managing benign and malignant colorectal diseases. Methods: Dichotomous outcomes of minimally invasive surgery versus open surgery in RCTs from 2000 to 2023 were assessed. The overall FI and fragility quotient (FQ) of each study were calculated. Results: Of the 1377 screened studies, 50 met the inclusion criteria. In total, 820 outcomes were recorded with 747 outcomes reported as not significant (P ≥ .05) and 73 as significant (P < .05). The overall FI for all studies including all outcomes was 5 (interquartile range [IQR] 4-7) with a FQ of 0.031 (IQR 0.014-0.062). Of the 50 RCTs, 6 (12%) reported a loss to follow-up that was greater than the overall FI of 5. Conclusions: As RCTs are judged increasingly beyond just the P value, practicing colorectal surgeons will benefit from using and interpreting the FI, FQ, and the P value of studies both in analyzing future RCTs and in determining whether or not to make a change in their clinical practice if there is an efficiently true discovery.
Collapse
Affiliation(s)
- Olajumoke M Megafu
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| |
Collapse
|
2
|
Hartwig MFS, Bulut M, Ravn-Eriksen J, Hansen LB, Bojesen RD, Klein MF, Jakobsen HL, Rasmussen M, Rud B, Eriksen JO, Eiholm S, Fiehn AMK, Quirke P, Gögenur I. Combined endoscopic and laparoscopic surgery (CELS) for early colon cancer in high-risk patients. Surg Endosc 2023; 37:8511-8521. [PMID: 37770605 PMCID: PMC10615913 DOI: 10.1007/s00464-023-10385-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/06/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Local excision of early colon cancers could be an option in selected patients with high risk of complications and no sign of lymph node metastasis (LNM). The primary aim was to assess feasibility in high-risk patients with early colon cancer treated with Combined Endoscopic and Laparoscopic Surgery (CELS). METHODS A non-randomized prospective feasibility study including 25 patients with Performance Status score ≥ 1 and/or American Society of Anesthesiologists score ≥ 3, and clinical Union of International Cancer Control stage-1 colon cancer suitable for CELS resection. The primary outcome was failure of CELS resection, defined as either: Incomplete resection (R1/R2), local recurrence within 3 months, complication related to CELS within 30 days (Clavien-Dindo grade ≥ 3), death within 30 days or death within 90 days due to complications to surgery. RESULTS Fifteen patients with clinical T1 (cT1) and ten with clinical T2 (cT2) colon cancer and without suspicion of metastases were included. Failure occurred in two patients due to incomplete resections. Histopathological examination classified seven patients as having pT1, nine as pT2, six as pT3 adenocarcinomas, and three as non-invasive tumors. In three patients, the surgical strategy was changed intraoperatively to conventional colectomy due to tumor location or size. Median length of stay was 1 day. Seven patients had completion colectomy performed due to histological high-risk factors. None had LNM. CONCLUSIONS In selected patients, CELS resection was feasible, and could spare some patients large bowel resection.
Collapse
Affiliation(s)
- Morten F S Hartwig
- Department of Surgery, Center for Surgical Science, Zealand University Hospital Koege, Lykkebaekvej 1, 4600, Koege, Denmark.
- Department of Surgery, Zealand University Hospital, Koege, Denmark.
| | - Mustafa Bulut
- Department of Surgery, Center for Surgical Science, Zealand University Hospital Koege, Lykkebaekvej 1, 4600, Koege, Denmark
- Department of Surgery, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens Ravn-Eriksen
- Department of Surgery, Center for Surgical Science, Zealand University Hospital Koege, Lykkebaekvej 1, 4600, Koege, Denmark
- Department of Surgery, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lasse B Hansen
- Department of Surgery, Center for Surgical Science, Zealand University Hospital Koege, Lykkebaekvej 1, 4600, Koege, Denmark
- Department of Surgery, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rasmus D Bojesen
- Department of Surgery, Center for Surgical Science, Zealand University Hospital Koege, Lykkebaekvej 1, 4600, Koege, Denmark
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - Mads Falk Klein
- Department of Surgery, Copenhagen University Hospital - Herlev & Gentofte Hospital, Herlev, Denmark
| | - Henrik L Jakobsen
- Department of Surgery, Copenhagen University Hospital - Herlev & Gentofte Hospital, Herlev, Denmark
| | - Morten Rasmussen
- Department of Surgery, Copenhagen University Hospital - Bispebjerg Hospital, Copenhagen, Denmark
| | - Bo Rud
- Department of Surgery, Copenhagen University Hospital - Hvidovre Hospital, Hvidovre, Denmark
| | - Jens-Ole Eriksen
- Department of Pathology, Zealand University Hospital, Roskilde, Denmark
| | - Susanne Eiholm
- Department of Pathology, Zealand University Hospital, Roskilde, Denmark
| | - Anne-Marie K Fiehn
- Department of Surgery, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Pathology, Zealand University Hospital, Roskilde, Denmark
| | - Phil Quirke
- Pathology & Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Ismail Gögenur
- Department of Surgery, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
3
|
Symer M, Connolly J, Yeo H. Management of the Malignant Colorectal Polyp. Curr Probl Surg 2022; 59:101124. [DOI: 10.1016/j.cpsurg.2022.101124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
4
|
Cirocchi R, Randolph J, Cheruiyot I, Davies RJ, Wheeler J, Gioia S, Reznitskii P, Lancia M, Carlini L, Fedeli P, di Saverio S, Henry BM. Surgical anatomy of sigmoid arteries: A systematic review and meta-analysis. Surgeon 2021; 19:e485-e496. [PMID: 33414045 DOI: 10.1016/j.surge.2020.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/07/2020] [Accepted: 11/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis was to determine the prevalence of the number of sigmoid arteries (SA) and variations in their origins. METHODS A thorough systematic search of literature through February 2020 was conducted on major electronic databases to identify eligible studies. Data were extracted and pooled into a meta-analysis using Metafor package in R. The primary outcome was the variations in the SA origin (according to modified Zebrowski classification), and the secondary outcome was the prevalence of the number of SA. RESULTS A total of 22 studies (n = 2653 patients) were included. Type 1 modified Zebrowski (separated origins or common trunk of the SA originating from descending recto-sigmoid trunk (DRST)) was the most common origin type of the SA (pooled prevalence estimate (PPE) = 49.67% (95% CI 32. 67- 66.71)), while type 3 (separated origins or common trunk of 1 or 2 SA originating from DRST or superior rectal artery (SRA) and 1 or 2 SA originating from DRST or SRA) was the least common (PPE = 0.18%; 95% CI 0.00-2.82)). Of the Type 1 variants, the not specified (N.S) variant was by far the most prevalent. The number of SA ranged from one to five, with three being the mode (PPE = 42.3%). CONCLUSION This is the most comprehensive analysis of arterial vascular anatomy of the sigmoid colon. In light of the highly variable anatomical pattern displayed by the SA, thorough pre-operative knowledge of their anatomy can be crucial in minimizing incidences of iatrogenic injury.
Collapse
Affiliation(s)
- Roberto Cirocchi
- Department of Surgical Science, University of Perugia, Piazza Dell'Universitá, 06123, Perugia, PG, Italy
| | - Jutsus Randolph
- Georgia Baptist College of Nursing. Mercer University, Atlanta, USA
| | - Isaac Cheruiyot
- Department of Human Anatomy, University of Nairobi, P.O. Box 30197, Nairobi, 00100, Kenya; International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31-034, Krakow, Poland.
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - James Wheeler
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Sara Gioia
- Department of Surgical Science, University of Perugia, Piazza Dell'Universitá, 06123, Perugia, PG, Italy
| | - Pavel Reznitskii
- N.V. Sklifosovsky Research Institute for Emergency Medicine, B. Sucharevskaya Pl. 3/1, 129090, Moscow, Russian Federation
| | - Massimo Lancia
- Department of Surgical Science, University of Perugia, Piazza Dell'Universitá, 06123, Perugia, PG, Italy
| | - Luigi Carlini
- Department of Surgical Science, University of Perugia, Piazza Dell'Universitá, 06123, Perugia, PG, Italy
| | | | - Salomone di Saverio
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Brandon Michael Henry
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| |
Collapse
|
5
|
Abdalla S, Meillat H, Fillol C, Zuber K, Manceau G, Dubray V, Beyer-Berjot L, Lefevre JH, Selvy M, Benoist S, Micelli Lupinacci R. Ileocecal Valve Sparing Resection for the Treatment of Benign Cecal Polyps Unsuitable for Polypectomy. JSLS 2021; 25:JSLS.2021.00023. [PMID: 34316245 PMCID: PMC8280722 DOI: 10.4293/jsls.2021.00023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Not all benign-appearance polyps are amenable to endoscopic removal and colectomy is required in some cases. This study aims to compare the early outcomes of cecal wedge resection with ileocecal valve sparring versus standard right colectomy in patients with endoscopically unresectable cecal polyps referred for surgery. Methods: From Apr 2010 to Aug 2019, all consecutive patients who underwent cecal wedge resection or right colectomy in ten European centers for a presumed endoscopically benign polyp unsuitable for endoscopic resection were retrospectively analyzed. The primary endpoint was morbidity. Secondary endpoints were operative time and length of hospital stay. Results: One hundred and ten patients were included: 25 patients underwent cecal wedge resection and 85 a right colectomy. There were 56 men (51%) and 90% of the procedures were performed laparoscopically. 29 lesions were located at the appendix orifice (26.4%). Mortality was nil. There were no significant differences between both procedures for morbidity rate (20% versus 24.7%) or reoperation (4% versus 4.7%). Cecal wedge was related to shorter operative time (63 min versus 150 min, P = .008) and shorter hospital stay (5 days versus 6 days, P = .049). Only 1 patient had a salvage right colectomy after cecal wedge for a pTis adenoma. Conclusions: For benign-appearance cecal polyps unsuitable for endoscopic ablation, cecal wedge resection is safe and should be considered as an attractive alternative to right colectomy.
Collapse
Affiliation(s)
| | | | | | - Kevin Zuber
- Fondation Ophtalmologique Rothschild, Paris, France
| | | | - Vincent Dubray
- Université de Lille, Service de Chirurgie Digestive et Générale, Hôpital Claude Huriez, CHU de Lille, 59037 Lille, France
| | | | - Jérémie H Lefevre
- Sorbonne Université, Department of Digestive Surgery, AP-HP, Hôpital St Antoine, 75012 Paris, France
| | - Marie Selvy
- Service de Chirurgie Digestive, CHU Estaing, 63100 Clermont-Ferrand, France
| | - Stéphane Benoist
- Service de Chirurgie Digestive et Oncologique, CHU Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - Renato Micelli Lupinacci
- Service de Chirurgie Digestive et Oncologique, Hôpital Ambroise Paré, 92104 Boulogne-Billancourt, France
| |
Collapse
|
6
|
Evaluation of a progressive algorithmic approach for the treatment of unresectable colon polyps using colon conservation techniques. Surg Endosc 2020; 35:6633-6642. [PMID: 33237464 DOI: 10.1007/s00464-020-08163-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The majority of endoscopically unresectable colon polyps (EUCP) are treated by segmental colectomy. However, up to 90% of EUCP do not harbor malignancy, making colectomy an unnecessary procedure. To minimize unnecessary segmental colectomy, we established a progressive treatment algorithm utilizing colon conservation techniques (CCT). In our progressive CCT algorithm, patients with EUCP first underwent endoscopic submucosal dissection (ESD). If unsuccessful, they progressed to combined endo-laparoscopic surgery (CELS) and ultimately to segmental colectomy, if necessary. METHODS We performed a retrospective analysis of all patients treated by our progressive CCT algorithm from August 2015 to April 2019. Demographic information, polyp characteristics, and clinical outcomes were analyzed. We also compared the outcomes of our CCT algorithm group to 156 patients undergoing segmental colectomy for EUCP at related institutions from August 2015 to August 2018. RESULTS A total of 102 EUCP in 97 patients were treated with our progressive CCT algorithm. Of these, 76 of 102 (75.5%) EUCP were removed without requiring segmental colectomy, with 42 EUCP removed via ESD and 34 via CELS. Interval surveillance colonoscopy confirmed that 72 of 97 (74.2%) patients with EUCP treated by CCT completely avoided segmental colectomy. Polyps > 5 cm in size was a significant predictor of CCT failure (OR 3.83, P = 0.03). When compared to an external cohort of patients undergoing segmental colectomy for EUCP, the CCT algorithm was associated with longer operative time, but shorter length of stay, with no difference in postoperative complications. The estimated total healthcare cost of the CCT algorithm was lower than segmental colectomy ($10,956.77 versus $16,692.94), with more dramatic cost savings seen in ESD ($4,492.70) and CELS ($8,507.06). CONCLUSIONS An established progressive CCT algorithm can result in high colon conservation rate and decrease associated health care costs compared to segmental colectomy. It is a reasonable treatment strategy for patients with EUCP.
Collapse
|
7
|
Liu ZH, Jiang L, Chan FSY, Li MKW, Fan JKM. Combined endo-laparoscopic surgery for difficult benign colorectal polyps. J Gastrointest Oncol 2020; 11:475-485. [PMID: 32655925 DOI: 10.21037/jgo.2019.12.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Prevention of colorectal cancer (CRC) depends largely on the detection and removal of colorectal polyps. Despite the advances in endoscopic techniques, there are still a subgroup of polyps that cannot be treated purely by endoscopic approach, which comprise of about 10-15% of all the polyps. These so-called "difficult colorectal polyps" are polyps with large size, morphology, at difficult location, scarring or due to recurrence, which have historically been managed by surgical segmental resection. In treating benign difficult colorectal polyps, we have to balance the operative risks and morbidities associated with surgical segmental resection. Therefore, combined endoscopic and laparoscopic surgery (CELS) has been developed to remove this subgroup of difficult benign polyps. We review the currently use of CELS for difficult benign colorectal polyps which includes laparoscopy-assisted endoscopic polypectomy (LACP), full-thickness laparo-endoscopic excision (FLEX) and colonoscopy-assisted laparoscopic wedge resection (CAL-WR).
Collapse
Affiliation(s)
- Zhong-Hui Liu
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Li Jiang
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Fion Siu-Yin Chan
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China.,Department of Surgery, The University of Hong Kong, Hong Kong, China
| | | | - Joe King-Man Fan
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China.,Department of Surgery, The University of Hong Kong, Hong Kong, China.,Asia-Pacific Endo-Lap Surgery Group (APELS), Hong Kong, China
| |
Collapse
|
8
|
Currie AC, Blazeby JM, Suzuki N, Thomas-Gibson S, Reeves B, Morton D, Kennedy RH. Evaluation of an early-stage innovation for full-thickness excision of benign colonic polyps using the IDEAL framework. Colorectal Dis 2019; 21:1004-1016. [PMID: 30993857 DOI: 10.1111/codi.14650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 04/02/2019] [Indexed: 01/27/2023]
Abstract
AIMS Colectomy is the current approach for patients with endoscopically unresectable benign polyps but risks considerable morbidity. Full-thickness laparoendoscopic excision (FLEX) is a novel procedure, specifically developed to treat endoscopically unresectable benign colonic polyps, which could reduce the treatment burden of the current approach and improve outcomes. However, traditional evaluations of surgical innovations lack methodological rigour. This study reports the development and feasibility of the FLEX procedure in selected patients. METHOD A prospective development study using the Idea, Development, Evaluation, Assessment, Long-term study (IDEAL) framework was undertaken, by one surgeon, of the FLEX procedure in selected patients with endoscopically unresectable benign colonic polyps. Three-dimensional (3D)-CT colonography reconstructions were used preoperatively to rehearse patient-specific, critical manoeuvres. Targetted, full-thickness excision was performed: after marking the margin of the caecal polyp using circumferential endoscopic argon plasma coagulation, transmural endoscopic sutures were used to evert the bowel and resection was undertaken by laparoscopic linear stapling. Feasibility outcomes (establishing 'local success') included evidence of complete polyp resection without adverse events (especially safe closure of the excision site). RESULTS Ten patients [median (interquartile range) age: 74 (59-78) years] with polyp median diameters of 35 (30-41) mm, were referred for and consented to receive the FLEX procedure. During the same time frame, no patient underwent colectomy for benign polyps. One further patient received FLEX for local excision of a presumed malignant polyp because severe comorbidity prohibited standard procedures. The FLEX procedure was successfully performed locally, with complete resection of the polyp and safe closure of the excision site, in eight patients. Three noncompleted procedures were converted to laparoscopic segmental colectomy under the same anaesthetic because of endoscopic inaccessibility (two patients) and transcolonic suture failure (one patient). CONCLUSIONS The FLEX procedure is still under development. Early data demonstrate that it is safe for excision of selected benign polyps. Modifications to transcolonic suture delivery are now required and there is a need for wider adoption before more definitive evaluation can be performed.
Collapse
Affiliation(s)
- A C Currie
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK
| | - J M Blazeby
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK.,Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - N Suzuki
- Wolfson Department of Endoscopy, St Mark's Hospital, Harrow, Middlesex, UK
| | - S Thomas-Gibson
- Wolfson Department of Endoscopy, St Mark's Hospital, Harrow, Middlesex, UK
| | - B Reeves
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
| | - D Morton
- Department of Surgery, University of Birmingham, Birmingham, West Midlands, UK
| | - R H Kennedy
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
9
|
Shi Y, Song Z, Gu Y, Zhang Y, Zhang T, Zhao R. Short-Term Outcomes of Three-Port Laparoscopic Right Hemicolectomy Versus Five-Port Laparoscopic Right Hemicolectomy: With a Propensity Score Matching Analysis. J INVEST SURG 2019; 33:822-827. [PMID: 30947574 DOI: 10.1080/08941939.2019.1579276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Purpose: The aim of this study is to compare the short-term and pathological outcomes of TPLRC (Three-port laparoscopic right hemicolectomy) and FPLRC (Five-port laparoscopic right hemicolectomy), using propensity score matching analysis. Methods: One hundred and sixty-eight patients who accepted laparoscopic right hemicolectomy with either three ports or five ports from January 2013 to October 2017 were non-randomly selected and analyzed retrospectively. Propensity score matching model was used to eliminate the patients' selection bias between two groups. Results: A total of 168 patients were involved. After propensity score matching, 39 for each group were compared. The number of harvested lymph nodes was significantly larger in the TPLRC group than in the FPLRC group (18.36 ± 8.58 vs. 14.90 ± 6.63, p = 0.048). A lower mean operative time was observed in the TPLRC group (136.24 ± 26.78 vs. 168.64 ± 43.68 min, p < 0.001). A less blood loss in the TPLRC group (62.44 ± 55.17, 135.54 ± 139.11 ml, p = 0.003). No significant differences in the other short-term outcomes between the two groups. Conclusions: TPLRC is a safe and feasible surgical procedure with similar results of FPLRC in short-term clinical outcomes. TPLRC has the advantages of shorter operative time, less blood loss and larger number of harvested lymph nodes. A randomized prospective clinical trial of long-term outcomes of TPLRC is required to further prove the present results.
Collapse
Affiliation(s)
- Yi Shi
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zijia Song
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yifei Gu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yaqi Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ren Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of General Surgery, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
10
|
Abstract
BACKGROUND Endoscopic mucosal resection comprises the first-line treatment for large cecal polyps. With up to 14% of unresectable colonic polyps harboring malignancy, the management of endoscopically unresectable cecal polyps remains an oncologic right hemicolectomy, which can be associated with substantial postoperative morbidity. OBJECTIVE This study compares the outcomes of patients with cecal polyps who underwent either endoscopic mucosal resection, a cecectomy, or a right hemicolectomy. DATA SOURCES Patients undergoing either endoscopic mucosal resection, partial cecectomy, or right hemicolectomy from 2008 to 2017 at a single tertiary care institution were selected. STUDY SELECTION This was a retrospective cohort study. MAIN OUTCOME MEASURES The primary outcomes measured were the rate of malignancy, complication rate, estimated blood loss, and hospital length of stay between surgical cohorts. RESULTS One hundred twenty-nine patients with cecal polyps were identified, of which 52 were referred for surgery. Nineteen underwent partial cecectomy and 33 (27.3%) underwent right hemicolectomy. Two patients undergoing cecectomy required conversion to hemicolectomy because the resected specimen did not contain the polyp. The 2 surgical cohorts did not differ significantly regarding age, sex, or ASA classification. Procedural complication rates were higher among those undergoing hemicolectomy compared with those undergoing cecectomy (37.1% versus 5.9%, p = 0.02). Estimated blood loss (50 vs 10 mL, p = 0.02), operative duration (98 vs 76 minutes, p = 0.009), and length of stay (4 vs 2 days, p < 0.001) were higher in patients undergoing hemicolectomy than in those undergoing cecectomy. No invasive malignancies were identified on final pathology within the cecectomy cohort. LIMITATIONS Single-institution data and retrospective design were limitations of this study. CONCLUSIONS In tertiary centers, the majority of large cecal polyps are benign and can be addressed by using endoscopic mucosal resection. When involvement of the appendiceal orifice or ileocecal valve precludes endoscopic treatment, surgical resection is the standard of care. In the subset of cases not involving the ileocecal valve and without preoperative evidence of malignancy, partial cecectomy spares the ileocecal valve and can offer reduced postoperative morbidity compared with a formal right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/A674.
Collapse
|
11
|
Mlynarsky L, Zelber-Sagi S, Miller E, Kariv R. Endoscopic resection of large colorectal adenomas - clinical experience of a tertiary referral centre. Colorectal Dis 2018; 20:391-398. [PMID: 29105290 DOI: 10.1111/codi.13954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/03/2017] [Indexed: 12/17/2022]
Abstract
AIM Colorectal cancer is a leading cause of cancer-related mortality. Adenomatous polyps are typically resected endoscopically to prevent cancer while giant and complex polyps are managed surgically. No criteria clearly define the indications for surgical vs endoscopic resection. Our aim was to evaluate factors associated with the short-term efficacy and safety of endoscopic resection of large (≥ 20 mm) and giant (≥ 40 mm) adenomas. METHOD Consecutive cases with colonic adenomas larger than 20 mm resected endoscopically were included. Endoscopic, clinical and histological details of polyps were recorded as well as the need for surgical resection. RESULT A total of 351 resections were included. The average adenoma diameter was 30.34 ± 10.66 mm. Surgery was recommended in 21 (5.98%) cases. In a multivariate analysis for efficacy, two variables were independent risk factors for surgery: adenoma size [OR 1.08 (95% CI: 1.04-1.12)] and caecal location [5.97(1.60-22.33)]. Postpolypectomy complications were documented in 85 (24.2%) cases: bleeding 69 (19.7%), perforations 8(2.3%) and significant discomfort 15(4.3%). Twenty-one patients (6.0%) developed serious complications requiring further hospitalization. In multivariate analysis for safety, independent risk factors for postpolypectomy complications included adenoma size [1.04 (1.06-1.01)], polyp morphology [sessile 2.55 (1.45-4.51), flat 2.40 (1.04-5.52)] and submucosal adrenaline injection [1.87 (1.11-3.20)]. Increments of 1 mm in adenoma diameter beyond 20 mm increased the need for surgery by 8% and the risk of complications by 4%. CONCLUSION Resection of large or giant adenomas is generally a safe procedure. Although adenoma size and morphology are significant predictors of efficacy and safety, each case should be individually evaluated in a specialist unit for feasibility of endoscopic resection.
Collapse
Affiliation(s)
- L Mlynarsky
- The Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Zelber-Sagi
- The Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - E Miller
- The Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Kariv
- The Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
12
|
Malmstrøm ML, Brisling S, Klausen TW, Săftoiu A, Perner T, Vilmann P, Gögenur I. Staging with computed tomography of patients with colon cancer. Int J Colorectal Dis 2018; 33:9-17. [PMID: 29116438 DOI: 10.1007/s00384-017-2932-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Accurate staging of colonic cancer is important for patient stratification. We aimed to correlate the diagnostic accuracy of preoperative computed tomography (CT) with final histopathology as reference standard. METHODS Data was collected retrospectively on 615 consecutive patients operated for colonic cancer. Evaluation was based upon T-stage. Patients were stratified into high-risk and low-risk groups, based on the extent of tumor invasion beyond the proper muscle layer of more or less than 5 mm. The Kendall tau correlation coefficient was used to calculate concordance between radiological (r)T-stage obtained at CT imaging and pathological (p)T-stage from the final pathology. RESULTS In total, 501 patients were included. We found no significant differences in the Kendall tau values for diagnostic measures between the groups at the 95% confidence interval (CI) level: 49% (95% CI, 43-55) for all individuals, 48% (95% CI, 40-56) for screened individuals, and 47% (95% CI, 37-56) for non-screened individuals. The overall sensitivity and specificity for all individuals in identifying high-risk tumors on CT was 65% (95% CI, 56-73) and 89% (95% CI, 85-92). The risk of ending up in the high-risk group due to overstaging among all individuals was calculated as the number needed to harm 11.7 (95% CI, 9-16). CONCLUSIONS There is basis for improvement of CT-based preoperative staging of patients with colorectal cancer. Supplementary modalities may be needed for correct staging of patients preoperatively, especially in relation to stratification of patients into neoadjuvant treatments or tailored therapy in patients with early cancers.
Collapse
Affiliation(s)
- M L Malmstrøm
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Køge, Denmark.
| | - S Brisling
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Roskilde, Denmark
| | - T W Klausen
- Department of Hematology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - A Săftoiu
- Research Centre of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
| | - T Perner
- Department of Radiology, Zealand University Hospital, University of Copenhagen, Roskilde, Denmark
| | - P Vilmann
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - I Gögenur
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Køge, Denmark
| |
Collapse
|
13
|
Zhou HT, Wang P, Liang JW, Su H, Zhou ZX. Short-term outcomes of overlapped delta-shaped anastomosis, an innovative intracorporeal anastomosis technique, in totally laparoscopic colectomy for colon cancer. World J Gastroenterol 2017; 23:6726-6732. [PMID: 29085217 PMCID: PMC5643293 DOI: 10.3748/wjg.v23.i36.6726] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/29/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To introduce an innovative intracorporeal anastomosis technique named overlapped delta-shaped anastomosis (ODA) for colon cancer cases undergoing totally laparoscopic colectomy (TLC) and to assess its feasibility and safety.
METHODS From January 2016 to March 2017, a total of 20 consecutive patients with colon cancer accepted TLC and the ODA technique at our medical center. Patient demographics, operative outcomes, perioperative complications, and pathological results were collected and analyzed.
RESULTS We successfully completed TLC and the ODA procedure in all 20 cases, including 6 (30%) males and 14 (70%) females. In total, 11 (55%), 2 (10%), and 7 (35%) cases accepted right hemicolectomy, transverse hemicolectomy, and left hemicolectomy, respectively. None of the surgeries were converted to an open operation. Mean operative time was 178.5 min, and mean estimated blood loss was 58.5 mL. Mean time to first flatus was 2.5 d, and mean postoperative hospitalization duration was 6.8 d. No severe complications occurred, such as anastomotic leakage, snastomotic stenosis, anastomotic bleeding, and wound infection, except for one case who suffered from an abdominal infection and another case who suffered from gastric paralysis syndrome. Tumor recurrence was not observed in any patient during the follow-up period.
CONCLUSION The ODA technique for colon cancer cases undergoing TLC appears to be safe and feasible, although our current results need to be verified in further studies.
Collapse
Affiliation(s)
- Hai-Tao Zhou
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Peng Wang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jian-Wei Liang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hao Su
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zhi-Xiang Zhou
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| |
Collapse
|
14
|
Abstract
Difficult colorectal polyps represent lesions that pose a challenge to traditional endoscopic snare polypectomy. These polyps have historically been managed by surgical resection. Currently, several less invasive options are available to avoid colectomy. Repeat colonoscopy and snare polypectomy by an expert endoscopist, endoscopic mucosal resection, endoscopic submucosal dissection, and combined endoscopic and laparoscopic surgery have been developed to remove difficult polyps without the need for formal surgical resection. Patients with rectal polyps have the advantage of additional transanal minimally invasive techniques to enhance their resectability. Today, most colorectal polyps can be managed without the need for formal surgical resection.
Collapse
Affiliation(s)
- Mark J Pidala
- Colon & Rectal Surgery, University of Texas/McGovern Medical School, 800 Peakwood Drive, Suite 2C, Houston, TX 77090, USA.
| | - Marianne V Cusick
- Colon & Rectal Surgery, University of Texas/McGovern Medical School, Smith Tower, Suite 2307, 6550 Fannin Street, Houston, TX 77030, USA
| |
Collapse
|
15
|
Laparoscopically assisted colonoscopic polypectomy - viable option for curative surgery in elderly patients. Wideochir Inne Tech Maloinwazyjne 2017; 12:120-124. [PMID: 28694896 PMCID: PMC5502343 DOI: 10.5114/wiitm.2017.68138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/14/2017] [Indexed: 11/19/2022] Open
Abstract
Introduction Colorectal cancer (CRC) is the third most common cancer worldwide and the fourth most frequent cause of cancer-related death in the world. CRC screening programs have been widely introduced worldwide, allowing for early detection and removal of precancerous lesions and avoiding major surgical intervention. However, not all polyps are suitable for conventional and advanced colonoscopic polypectomy. Thus, laparoscopically assisted colonoscopic polypectomy (LACP) was introduced to clinical practice as a method of choice for these polyps and adenomas. Aim To overlook our experience in laparoscopically assisted colonoscopic polypectomies and evaluate effectiveness and quality of the procedure. Material and methods A retrospective analysis of a prospectively maintained database was performed. using the Vilnius University Hospital Santariskiu Klinikos patient database for the period from 2010 to 2016, resulting in 21 cases in which LACP was performed. All procedures were performed using combined laparoscopy and videocolonoscopy techniques. Morphology of adenomas was classified according to the Paris classification during the procedure. Creation of the database was approved by the Lithuanian Bioethics committee. Results Twenty-two adenomas were removed from 21 patients, aged 65.33 ±8.9. There was no difference between male and female age, but occurrence of adenomas in females was 2-fold higher. The majority of removed lesions were localized in the cecum and mean size was 27.2 ±11.1 mm. The morphology of adenomas was distributed equally between 0–Is, 0–Ip, and 0–IIa, except one, which belonged to 0–III. Histological analysis revealed that tubulovillous adenoma occurrence was 1.4 times higher than tubulous adenoma. There was only one postoperative complication – bleeding from the adenoma resection site, which was managed by conservative means. One patient developed G2 adenocarcinoma at the polyp resection site and was referred for radical surgery. Conclusions The LACP is a safe procedure with minimal risk to the elderly patient. Patient follow-up is essential for detection of recurrence.
Collapse
|
16
|
Yelika SB, Abbas SK, Lee KP, Tou S, Bergamaschi R. A detachable laparoscopic bulldog clamp in laparoscopic-assisted colonoscopic polypectomy - a video vignette. Colorectal Dis 2017; 19:596-597. [PMID: 28419742 DOI: 10.1111/codi.13684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 01/23/2017] [Indexed: 02/08/2023]
Affiliation(s)
- S B Yelika
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, Stony Brook, New York, USA
| | - S K Abbas
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, Stony Brook, New York, USA
| | - K P Lee
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, Stony Brook, New York, USA
| | - S Tou
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, Stony Brook, New York, USA
| | - R Bergamaschi
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, Stony Brook, New York, USA
| |
Collapse
|
17
|
Endoscopic ultrasonography and computed tomography scanning for preoperative staging of colonic cancer. Int J Colorectal Dis 2017; 32:813-820. [PMID: 28432444 DOI: 10.1007/s00384-017-2820-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE With an increasing demand for more accurate preoperative staging methods for colon cancer, we aimed to compare preoperative tumour (T)- and nodal (N)-stage in patients with left-sided colon cancer by endoscopic ultrasonography (EUS) and computed tomography (CT) with post-operative histology as gold standard. METHODS A total of 44 patients were prospectively recruited at Herlev and Roskilde University Hospitals during November 2014-January 2016. Thirty-five patients were included in the final analysis and underwent EUS, CT and surgery within 2 weeks. Diagnostic values were evaluated for "low risk" (T1+T2+T3 with ≤5 mm extramural invasion) and "high risk" (T3 with >5 mm of extramural spread + T4) colonic cancer. RESULTS Sensitivity and specificity in "low risk" colonic cancer evaluated with EUS was 0.90 [0.74;0.98] and 0.75 [0.19;0.99] and with CT 0.96 [0.80;0.99] and 0.25 [<0.01;0.81]. EUS and CT were poor in predicting N0 or N+ disease. CONCLUSIONS The sensitivity of EUS and CT were good and comparable regarding T-stage evaluation, while EUS had a significantly higher specificity in the evaluation of "low risk" tumours. The results obtained for "high risk" colonic cancer were difficult to evaluate due to small patient numbers. EUS could be considered as a supplement to CT scans in selecting patients for neoadjuvant therapies, or local transmural treatment, in the future. TRIAL REGISTRATION NCT02324023.
Collapse
|
18
|
Kin C. Management of malignant polyps. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2016.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
19
|
Engel A. Laparascopic assisted colonscopic polypectomy: a truly multidisciplinary treatment and research platform. Colorectal Dis 2016; 18:1029-1030. [PMID: 27807944 DOI: 10.1111/codi.13533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander Engel
- Royal North Shore Hospital, Colorectal Surgery, University of Sydney, Sydney, New South Wales, Australia.
| |
Collapse
|