Outcomes for case-matched single-port colectomy are comparable with conventional laparoscopic colectomy

Effects of needlescopic surgery on postoperative pain in intersphincteric or abdominoperineal resection

PURPOSE

Laparoscopic surgery allows minimally invasive treatment of rectal cancer, and needlescopic surgery (NS) offers even more minimally invasive operations beyond the scope of conventional laparoscopic surgery (CS). The aim of this study was to compare short-term outcomes of NS for intersphincteric resection (ISR) or abdominoperineal resection (APR) to treat anal or rectal cancer without an abdominal incision for specimen extraction and to measure abdominal wound pain compared to CS.

METHODS

Between September 2014 and December 2016, a total of 134 patients underwent laparoscopic ISR or APR. Of these, 26 patients underwent NS, and 108 patients underwent CS. Postoperative abdominal wound pain was estimated using the numerical rating scale. Short-term outcomes were compared between NS and CS.

RESULTS

No conversion to CS or open surgery was required. Median operation time was significantly shorter with NS (295 min) than with CS (331.5 min; p = 0.020). Median estimated blood loss was significantly lower with NS (30 ml) than with CS (50 ml; p = 0.011). Postoperative pain score on postoperative day (POD)5 was significantly lower with NS than with CS (p = 0.025), and frequencies of analgesic use were significantly lower with NS than with CS on POD0, POD2, and POD3 (p = 0.032, p = 0.017, p = 0.045, respectively). The postoperative complications occurred at similar frequencies between groups (p = 0.655).

CONCLUSION

NS for ISR or APR offers comparable short-term outcomes to CS, with better pain outcomes.

Quality of life and patient satisfaction after single- and multiport laparoscopic surgery in colon cancer: a multicentre randomised controlled trial (SIMPLE Trial)

BACKGROUND

The clinical benefits of single-port laparoscopic surgery (SPLS) in patients with colon cancer patients are unclear because only a few studies have reported on the quality of life (QoL) of such patients. This study aimed to compare the QoL and patient satisfaction between SPLS and multiport laparoscopic surgery (MPLS) in colon cancer.

METHODS

The multicentre randomised controlled SIngle-port versus MultiPort Laparoscopic surgEry (SIMPLE) trial included patients with colon cancer who underwent radical surgery at seven hospitals in South Korea. We performed a pre-planned secondary analysis of the QoL data of 359 patients from that trial. The QoL was surveyed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 preoperatively and at 1, 3, 6, and 12 months postoperatively. Patient satisfaction was measured with a 5-point questionnaire at these postoperative time points.

RESULTS

Overall, 145 and 147 patients were included in the SPLS and MPLS groups, respectively. Most QoL domains were similar between the groups. In the subgroup analysis of patients without adjuvant chemotherapy, patients in the SPLS group presented with significantly better global health status (p = 0.017), fatigue (p = 0.047), and pain (p = 0.005) scores and tended to have improved physical (p = 0.055), emotional (p = 0.064), and social (p = 0.081) functioning, with marginal significance at 1 month postoperatively, compared to those in the MPLS group. Patient satisfaction regarding surgery (p = 0.002) and appearance of the abdominal scar (p = 0.002) was significantly higher with SPLS than with MPLS at 12 months postoperatively.

CONCLUSION

Patients who underwent SPLS without adjuvant chemotherapy had better global health status, fatigue status, and pain at 1 month postoperatively; however, these improvements were minimal and temporary. In the near future, the effect of SPLS on postoperative QoL should be confirmed through a randomised controlled trial targeting the QoL in colon cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01480128.

The trend of C-Reactive protein allows a safe early discharge after surgery for Crohn's disease

Postoperative C-reactive protein (CRP) level allows to rule out infectious complications ensuring safe hospital discharge in colorectal cancer surgery. Since its clinical significance in Crohn's disease (CD) has not been studied yet, we investigated whether CRP can guide decision-making on hospital discharge in this population. Only consecutive CD patients undergoing resections with primary anastomosis and without covering stoma (2013-2017) were analysed. Pre- and post-operative CRP values, measured daily until discharge, were correlated with postoperative complications including anastomotic leakage (AL), infectious and non-infectious complications. The diagnostic accuracy of CRP in predicting AL was evaluated according to the area under the curve (AUC), using the receiver-operating characteristic (ROC) methodology. Two-hundred and fifty-one consecutive patients undergoing elective surgery for CD were selected. AL was diagnosed in 10 patients (4%). High CRP level was associated with AL on postoperative day (POD) 3-5 (p = 0.002, AUC 0.825) with a positive predictive value of 60%. CRP linear difference of 140 between POD 1 and 3 (AUC 0.800) maximizes sensitivity and specificity with a NPV of 98.6%. CRP trend, measured with the linear difference between POD 1 and 3, is able to rule out anastomotic complications with a high NPV and may allow a safe early hospital discharge after surgery for CD.

Safety and Efficacy of Single-Port Laparoscopic Ileostomy in Palliative Settings

Purpose

Single-port laparoscopic techniques can be optimized with confined incisions. This approach has an intraoperative advantage of excellent visualization of the correct intestinal segment for exteriorization, along with direct visual control of the extraction to avoid twisting. However, only a few studies have verified the efficacy of the technique. Thus, this study assessed the results of single-port laparoscopic stoma creation for fecal diversion, specifically focusing on feasibility, safety, and efficacy.

Methods

Patients who underwent single-incision enterostomy performed by a single surgeon were included. Data on demographics, indications for and chosen procedure, and operation results were retrospectively collected and analyzed.

Results

Between April 2015 and January 2018, a total of 13 patients (8 males, 5 females) with a mean age of 57.7 years (range, 41–83 years) underwent single-port ileostomy creation. The most common reason for diversion was palliative ileostomy for colon obstruction or fistula from peritoneal malignancy (n = 12), followed by colonic fistula with necrotizing pancreatitis (n = 1). There were no cases of conversion to open or multiport laparoscopic surgery. The mean operative time was 54 minutes (range, 37–118 minutes), and the median length of hospital stay was 8 days (range, 2–211 days). A postoperative complication, aspiration pneumonia, was documented in 1 patient and treated conservatively. The mean duration of bowel movement was 0.7 days (range, 0–4 days). All stomas had good function, and there was no 30-day mortality.

Conclusion

Single-port laparoscopic ileostomy in patients with a palliative setting could be a safe and feasible option for fecal diversion.

Short-Term Outcomes of Single-Incision Versus Conventional Laparoscopic Surgery for Colorectal Diseases: Meta-Analysis of Randomized and Prospective Evidence

BACKGROUND

Conventional laparoscopic surgery (CLS) has been established as an alternative to open surgery for colorectal diseases (CRDs); simultaneously, single-incision laparoscopic surgery (SILS) is gaining popularity.

OBJECTIVE

The aim of this study was to compare the short-term efficacy and safety of SILS with CLS for CRDs.

METHODS

MEDLINE, EMBASE, and the Cochrane Library were searched for relevant randomized and prospective studies. Reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases were also screened. Outcome measures included surgical parameters, postsurgical recovery, pain, and adverse events. Meta-analysis was conducted where appropriate, comparing items using weighted mean differences (WMDs) and risk ratios (RRs) according to data type.

RESULTS

A total of nine prospective (three randomized and six non-randomized) researches published from 2011 to 2015 were identified. The overall pooled results showed compared to CLS, SILS was associated with fewer blood transfusions, shorter incision length, and slighter postoperative pain, but more extra ports. All the other parameters were comparable. Randomized evidence supported SILS was associated with less blood loss, and shorter hospital stay, but longer operative time. For only colectomy cases, SILS was associated with more conversions to open surgery. SILS was associated with longer surgical time for Easterners, but not for Westerners. The detected differences were clinically insignificant.

CONCLUSIONS

The results based on randomized and prospective evidence provide convincing support for the clinical similarity that SILS is basically as applicable, effective, and safe as CLS when dealing with colorectal lesions, but not for superiority.

Single-Port Laparoscopic Surgery Can Be Performed Safely and Appropriately for Colon Cancer: Short-Term Results of a Pilot Randomized Controlled Trial

INTRODUCTION

Single-port laparoscopic surgery (SPLS) has gained popularity due to its cosmetic benefit, and therefore, has been applied to several kinds of benign operations, such as appendectomy and cholecystectomy. The safety and suitability of SPLS for colon cancer has not been widely proved. We aimed at validating the safety, efficacy, and short-term quality of life (QOL) of SPLS compared with conventional laparoscopic surgery (CLS) in patients with colon cancer.

MATERIALS AND METHODS

Between June 2010 and April 2011, a total of 62 patients with pathology-proven colon cancer were randomly allocated to two groups: SPLS and CLS. Data were analyzed according to the intention-to-treat principle.

RESULTS

In total, there were 62 patients (35 men and 27 women) with a mean age of 63.0 years (range, 38-82). The baseline characteristics of the patients and tumor factors were well balanced between two groups. The operation time and estimated blood loss were similar, whereas intraoperative complications only occurred in three patients, all of whom were in the SPLS group. Conversion to CLS or open surgery occurred in 6 (19.4%) patients of the SPLS group. The number of harvested lymph nodes and length of proximal and distal resection margins were not statistically different between two groups. Postoperative complications and recovery of bowel function were similar in both groups, but fatal postoperative complication occurred in one case in the SPLS group. The QOL between two groups was identical in all domains until postoperative 12 months.

CONCLUSIONS

SPLS for colon cancer is feasible and can be performed by following oncologic principles. However, surgeons should be aware of the potential for unexpected adjacent organ injury ( ClinicalTrial.gov identifier: NCT01203969).

Two-port laparoscopic anterior resection through a self-made glove device versus conventional laparoscopic anterior resection for rectal cancer: a comparison of short-term surgical results

Background

The laparoscopic approach has become increasingly incorporated into the development of new surgical procedures. An ever-increasing number of surgeons desire methods that minimize surgical trauma and provide improved cosmetic outcomes. Since 2014, we have performed two-port laparoscopic surgery using a transumbilical multichannel glove port and a 12-mm port. The aim of this study was to compare the short-term surgical results of two-port laparoscopic anterior resection (TPLAR) with those of conventional laparoscopic anterior resection (CLAR) for rectal cancer.

Methods

Between January 2014 and May 2014, a total of 27 patients underwent TPLAR and 30 patients underwent CLAR for the treatment of rectal cancer. The short-term surgical results of these two groups of patients were analyzed retrospectively.

Results

The differences in operative time, blood loss, conversion rate, complication rate, distal resection margin, number of harvested lymph nodes, duration until ambulation, duration until first flatus, length of postoperative hospital stay, and overall hospital costs between the two groups were not significant. The median (range) length of the abdominal incisions of the TPLAR patients was shorter than the length of the CLAR patients (5.1 (4.5–16.3) cm vs 8.2 (7.0–10.0) cm, respectively; p < 0.001). The respective median (range) postoperative pain scores were lower in the TPLAR than in the CLAR patients at 24 h (4 (1–6) h vs 5 (2–8) h; p = 0.045), 48 h (3 (1–4) h vs 4 (range 1–8) h; P = 0.004) and 72 h (1 (0–3) h vs 2 (1–5) h; p = 0.010). The median overall score on the satisfaction-with-abdominal-incision questionnaire of the TPLAR patients was significantly higher (better) than the score of the CLAR patients.

Conclusions

TPLAR for rectal cancer is safe and feasible, with short-term perioperative and oncological outcomes similar to those of CLAR. TPLAR provides less postoperative pain and better cosmetic outcomes.

Single-incision versus standard multi-incision laparoscopic colectomy in patients with malignant or benign colonic disease: a systematic review, meta-analysis and assessment of the evidence

BACKGROUND

Single-incision laparoscopic colectomy (SILC) requires only one umbilical port site and (depending on technique) a specimen extraction site. The aim of this study was the assessment of the available evidence for the comparison of SILC to conventional multi-port laparoscopic colectomy (MLC) in adult patients, in whom elective colectomy is indicated because of malignant or benign disease. First, previous meta-analyses on this topic were assessed. Secondly, a systematic review and meta-analysis of randomised controlled trials, was performed.

METHODS

Electronic literature searches (CENTRAL, MEDLINE and EMBASE; up to March 2016) were performed. Additionally, we searched clinical trials registries and abstracts from surgical society meetings. For meta-analysis, risk ratios (RR) or mean differences (MD) with 95 % confidence intervals were calculated and pooled. The quality of previous meta-analyses was evaluated against established criteria (AMSTAR) and their reported results were investigated for consistency.

RESULTS

We identified 6 previous meta-analyses of mostly low methodological quality (AMSTAR total score: 2 - 5 out of 11 items). To fill the evidence gaps, all these meta-analyses had included non-randomised studies, but usually without assessing their risk of bias. In our systematic review and meta-analysis of randomised controlled trials exclusively, we included two randomised controlled trials with a total of 82 colorectal cancer patients. There was insufficient evidence to clarify whether SILC leads to less local complications (RR = 0.52, 95 % CI 0.14 - 1.94) or lower mortality (1 death per treatment group). Length of hospital stay was significantly shorter in the SILC group (MD = -1.20 days, 95 % CI -1.95 to -0.44). One of the two studies found postoperative pain intensity to be lower at the first day. We also identified 7 ongoing trials with a total sample size of over 1000 patients.

CONCLUSION

The currently available study results are too sparse to detect (or rule out) relevant differences between SILC and MLC. The quality of the current evidence is low, and the additional analysis of non-randomised data attempts, but does not solve this problem. SILC should still be considered as an experimental procedure, since the evidence of well-designed randomised controlled trials is too sparse to allow any recommendation.

Reduced port laparoscopic surgery for colon cancer is safe and feasible in terms of short-term outcomes: comparative study with conventional multiport laparoscopic surgery

Purpose

Laparoscopic surgery was previously accepted as an alternative surgical option in treatment for colorectal cancer. Nowadays, single-port laparoscopic surgery (SPLS) is introduced as a method to maximize advantages of minimally invasive surgery. However, SPLS has several limitations compared to conventional multiport laparoscopic surgery (CMLS). To overcome those limitations of SPLS, reduced port laparoscopic surgery (RPLS) was introduced. This study aimed at evaluating the short-term outcomes of RPLS.

Methods

Patients who underwent CMLS and RPLS of colon cancer between August 2011 and December 2013 were included in this study. Short-term clinical and pathological outcome were compared between the 2 groups.

Results

Thirty-two patients underwent RPLS and 217 patients underwent CMLS. Shorter operation time, less blood loss, and faster bowel movement were shown in RPLS group in this study. In terms of postoperative pain, numeric rating scale (NRS) of RPLS was lower than that of CMLS. Significant differences were shown in terms of tumor size, harvested lymph node, perineural invasion, and pathological stage. No significant differences were confirmed in terms of other surgical outcomes.

Conclusion

In this study, RPLS was technically feasible and safe. Especially in terms of postoperative pain, RPLS was comparable to CMLS. RPLS may be a feasible alternative option in selected patients with colon cancer.

Single-incision laparoscopic surgery (SILS) for children with Crohn's disease

PURPOSE

Single-incision laparoscopic surgery (SILS) has been described in adults with Crohn's disease, but its use in pediatric Crohn's patients has been limited. The purpose of this study was to review our experience with SILS in pediatric patients with Crohn's disease.

METHODS

A retrospective review was performed for patients diagnosed with Crohn's disease who underwent small bowel resection or ileocecectomy at a freestanding children's hospital from 2006 to 2014. Data collected included demographic data, interval from diagnosis to surgery, operative time, length of stay, and postoperative outcomes.

RESULTS

Analysis identified 19 patients who underwent open surgery (OS) and 41 patients who underwent SILS. One patient (2.4 %) within the SILS group required conversion to OS. Demographic characteristics were similar between the 2 cohorts. The most common indication for surgery was stricture/obstruction (SILS 70.7 % vs. OS 68.4 %, p = 0.86), and ileocecectomy was the most common primary procedure performed (SILS 90.2 % vs. OS 100 % OS). Operative times were longer for SILS (135 ± 50 vs. 105 ± 37 min, p = 0.02). However, when the last 20 SILS cases were compared to all OS cases, the difference was no longer statistically significant (SILS 123.3 ± 34.2 vs. OS 105 ± 36.5, p = 0.12). No difference was noted in postoperative length of stay (SILS 6.5 ± 2.2 days vs. OS 7.4 ± 2.2 days, p = 0.16) or overall complication rate (SILS 24.4 % vs. OS 26.3 %, p = 0.16).

CONCLUSION

SILS ileocecectomy is feasible in pediatric patients with Crohn's disease, achieving outcomes similar to OS. As experience increased, operative times also became comparable.

SILS sigmoidectomy versus multiport laparoscopic sigmoidectomy for diverticulitis

Background and Objectives:

In this single-institution study, we aimed to compare the safety, feasibility, and outcomes of single-incision laparoscopic sigmoidectomy (SILSS) with multiport laparoscopic sigmoidectomy (MLS) for recurrent diverticulitis.

Methods:

Between October 2011 and February 2013, 60 sigmoidectomies were performed by the same surgeon. Forty patients had a MLS and 20 patients had a SILSS. Outcomes were compared.

Results:

Patient characteristics were similar. There was no difference in morbidity, mortality or readmission rates. The mean operative time was longer in the SILSS group (P = .0012). In a larger proportion of patients from the SILSS group, 2 linear staplers were needed for transection at the rectum (P = .006). The total cost of disposable items was higher in the SILSS group (P < .0001). No additional ports were placed in the SILSS group. Return to bowel function or return to oral intake was faster in the SILSS group (P = .0446 and P = .0137, respectively). Maximum pain scores on postoperative days 1 and 2 were significantly less for the SILSS group (P = .0014 and P = .047, respectively). Hospital stay was borderline statistically shorter in the SILSS group (P = .0053). SILSS was also associated with better cosmesis (P < .0011).

Conclusion:

SILSS is feasible and safe and is associated with earlier recovery of bowel function, a significant reduction in postoperative pain, and better cosmesis.

Transanal Total Mesorectal Excision Versus Laparoscopic Surgery for Rectal Cancer Receiving Neoadjuvant Chemoradiation: A Matched Case-Control Study

BACKGROUND

Neoadjuvant chemoradiation therapy (nCRT) has been indicated for locally advanced rectal cancer. While utilization of laparoscopy in rectal cancer surgery has been popular in recent years, tumors receiving nCRT is still a surgical challenge. Transanal total mesorectal excision (TaTME) has emerged as a focused area of laparoscopic surgery that is becoming an increasingly acceptable approach in the field of rectal surgery.

METHODS

Between December 2013 and April 2015, a total of 50 patients (38 males) with post-nCRT middle or lower rectal cancer who then underwent TaTME at two separate institutions were prospectively documented. Overall, 100 matched control cohorts who received conventional laparoscopic rectal surgery (LapTME) were simultaneously retrieved from a prospectively registered database. Four parameters of sex, age, clinical stage, and American Society of Anesthesiologists (ASA) score were matched for surgical outcomes, and short-term oncological results, including complications and pathological outcomes, were analyzed.

RESULTS

Both the TaTME and LapTME groups received 5-fluorouracil-based chemotherapy and 5 weeks of long-course radiation therapy. Mean operative time for the TaTME group was 182.1 ± 55.4 min (156.6 ± 37.8 min in two-team-approach cases) and 178.7 ± 34.8 min for the LapTME group. The TaTME group yielded longer distal margin lengths. No significant differences were observed in blood loss, intraoperative complication rate, conversion rate, anastomosis type, and free circumferential margin rate.

CONCLUSION

This matched case-control study demonstrated that TaTME is safe and feasible. Compared with LapTME, TaTME not only achieves identical circumferential margin status without compromising other operative and quality parameters but also benefits patients by achieving a longer distal margin. Thus, TaTME has the potential to become an option in managing irradiated rectal cancer.

Genetics, diagnosis and management of colorectal cancer (Review)

Colorectal cancer (CRC) is the third most common type of cancer worldwide and a leading cause of cancer death. Surgery represents the mainstay of treatment in early cases but often patients are primarily diagnosed in an advanced stage of disease and sometimes also distant metastases are present. Neoadjuvant therapy is therefore needed but drug resistance may influence response and concur to recurrent disease. At molecular level, it is a very heterogeneous group of diseases with about 30% of hereditary or familial cases. During colorectal adenocarcinomas development, epithelial cells from gastrointestinal trait acquire sequential genetic and epigenetic mutations in specific oncogenes and/or tumour suppressor genes, causing CRC onset, progression and metastasis. Molecular characterization of cancer associated mutations gives valuable information about disease prognosis and response to the therapy. Very early diagnosis and personalized care, as well as a better knowledge of molecular basis of its onset and progression, are therefore crucial to obtain a cure of CRC. In this review, we describe updated genetics, current diagnosis and management of CRC pointing out the extreme need for a multidisciplinary approach to achieve the best results in patient outcomes.

Comparison of perioperative and short-term oncological outcomes after single- or multiport surgery for colorectal cancer

AIM

The aim of this retrospective study was to compare the short-term surgical results of single-port surgery (SPS) with those of multiport surgery (MPS) for colorectal cancer.

METHOD

We studied 673 consecutive patients who underwent SPS or MPS for colorectal cancer in our department from January 2008 to December 2013. The operative parameters and oncological outcome were analysed and compared between the SPS and the MPS groups retrospectively.

RESULTS

The SPS and MPS groups did not differ significantly in terms of preoperative evaluation. The median operative time was significantly shorter with SPS than with MPS (176 min vs 193 min; P < 0.001). The two groups did not differ significantly in terms of postoperative complications. Length of hospital stay was significantly shorter with SPS than with MPS (8 days vs 10 days; P < 0.001). Oncological resection was similar in the two groups. The disease-free survival rates at 2 years according to the TNM stage did not differ significantly between the two groups (Stage I, 98.5% vs 94.7%; Stage II, 93.4% vs 90.7%; and Stage III, 70.8% vs 68.4%).

CONCLUSION

Our experience demonstrates that SPS is safe and can provide oncological outcomes equal to those of MPS in patients with colorectal cancer.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Single-incision versus conventional multiport laparoscopic colorectal surgery-systematic review and pooled analysis

BACKGROUND

The aim of this pooled analysis is to determine the effect of single-incision laparoscopic colorectal surgery (SILC) on short-term clinical and oncological outcomes compared with conventional multiport laparoscopic colorectal surgery (CLC).

METHODS

An electronic search of Embase, Medline, Web of Science, and Cochrane databases was performed. Weighted mean differences (WMD) were calculated for the effect size of SILC on continuous variables and pooled odds ratios (POR) were calculated for discrete variables.

RESULTS

No significant differences between the groups were noted for mortality or morbidity including anastomotic leak, reoperation, pneumonia, wound infection, port-site hernia, and operative time. The benefits of a SILC approach included reduction in time to return of bowel function (WMD = -1.11 days; 95 % C.I. -2.11 to -0.13; P = 0.03), and length of hospital stay (WMD = -1.9 days; 95 % C.I. -2.73 to -1.07; P < 0.0001). Oncological surgical quality was also shown for SILC for the treatment of colorectal cancer with a similar average lymph node harvest, proximal and distal resection margin length compared to CLC.

CONCLUSIONS

SILC can be performed safely by experienced laparoscopic surgeons with similar short-term clinical and oncological outcomes to CLC. SILC may further enhance some of the benefits of minimally invasive surgery with a reduction in blood loss and length of hospital stay.

Oncologic outcomes of single-incision versus conventional laparoscopic anterior resection for sigmoid colon cancer: a propensity-score matching analysis

BACKGROUND

The aim of this study was to investigate oncologic outcomes, as well as perioperative and pathologic outcomes, of single-incision laparoscopic anterior resection (SILAR) compared with conventional laparoscopic anterior resection (CLAR) for sigmoid colon cancer using propensity-score matching analysis.

METHODS

From July 2009 through April 2012, a total of 407 patients underwent laparoscopic anterior resection for sigmoid colon cancer. Data on short- and long-term outcomes were collected prospectively and reviewed. Propensity-score matching was applied at a ratio of 1:2 comparing the SILAR (n = 60) and CLAR (n = 120) groups.

RESULTS

There was no difference in operation time, estimated blood loss, time to soft diet, and length of hospital stay; however, the SILAR group showed less pain on postoperative day 2 (mean 2.6 vs. 3.6; p = 0.000) and shorter length of incision (3.3 vs. 7.7 cm; p = 0.000) compared with the CLAR group. Morbidity, mortality, and pathologic outcomes were similar in both groups. The 3-year overall survival rates were 94.5 versus 97.1% (p = 0.223), and disease-free survival rates were 89.5 versus 87.4% (p = 0.751) in the SILAR and CLAR groups, respectively.

CONCLUSION

The long-term oncologic outcomes, as well as short-term outcomes, of SILAR are comparable with those of CLAR. Although SILAR might have some technical difficulties, it appears to be a safe and feasible option, with better cosmetic results.

Evaluation of invasiveness in single-site laparoscopic colectomy, using "the PainVision™ system" for quantitative analysis of pain sensation

BACKGROUND

Single-site laparoscopic colectomy (SLC) is increasingly performed for colon cancer. There are few reports on invasiveness in SLC. This study aimed to evaluate the postoperative pain from SLC, as compared to conventional multiport laparoscopic colectomy (MLC).

METHODS

We compared postoperative pain among patients from the SLC group (n = 11) with those from the MLC group (n = 11) who underwent laparoscopic surgery for colon cancer at our institution between May and October 2013. Patients were specifically matched for gender, age, body mass index, tumor size, and performance status. Postoperative pain was evaluated at rest and during mobilization, using a visual analog scale (VAS) on postoperative days (PODs) 1-7, and by postoperative frequency of analgesics; pain intensity was evaluated at rest, using the Pain Vision™ system on PODs 1-7. Other operative outcomes of the two groups were also recorded.

RESULTS

Patient demographics, operative outcomes, time duration before first flatus, and C-reactive protein and WBC count on POD 1 showed no significant differences between groups. Results of sequential VAS during mobilization until POD 7 were significantly less in the SLC group than in the MLC group (p = 0.009). However, sequential VAS at rest did not differ between the two groups (p = 0.11). Measured with the Pain Vision™ system, the difference in pain intensity at rest was statistically significant for the postoperative period (p = 0.003). Total requests for analgesics until POD 7 were reduced in the SLC group compared to that in the MLC group, but lacked statistical significance (three vs. seven, respectively, p = 0.07).

CONCLUSIONS

In both quantitative and objective measurements using the Pain Vision™ system, SLC significantly reduced postoperative pain. SLC is a promising procedure, associated with less invasiveness than MLC.

Current status of laparoscopic surgery for patients with Crohn's disease

PURPOSE

Minimally invasive surgery is increasingly utilized in treatment for refractory or complicated Crohn's disease, and new developments aim at further reducing the abdominal trauma and improving the outcome. This review evaluates current literature about minimally invasive surgery for patients with Crohn's disease, latest advances in single-incision surgery, and methods of specimen extraction.

METHODS

Literature was reviewed with focus on the following topics: indications, surgical procedures, conversions, complications, and short- as well as long-term outcomes of laparoscopic compared to open surgery for refractory, complicated, and recurrent Crohn's disease.

RESULTS

Short-term benefits such as shorter hospital stay and faster postoperative recovery are accompanied by long-term benefits such as better cosmetic results and lower treatment-associated morbidity. Single-incision surgery and minimally invasive methods of specimen extraction help to further reduce the surgical trauma and are gradually implemented in the treatment.

CONCLUSION

In experienced centers, laparoscopic surgery for Crohn's disease is safe and as feasible as open operations, even for selected cases with operations for complicated or recurrent disease. However, accurate analysis of the data is complicated by the heterogeneity of clinical presentations as well as the variety of performed procedures. Additional long-term data are needed for evaluation of true benefits of the new techniques.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of single-incision laparoscopic high anterior resection with standard laparoscopic high anterior resection

AIM

Single-incision laparoscopic surgery (SILS) is gaining momentum. The aim of the present study was to compare the outcome of SILS for high anterior resection with that of standard laparoscopic resection (StdLS).

METHOD

Patients undergoing laparoscopic high anterior resection were prospectively entered into an institutional approved database. Patients treated with SILS were compared with those undergoing StdLS.

RESULTS

Between April 2000 and April 2009, 327 (143 cancer) consecutive unselected patients underwent StdLS; there were three (1%) conversions and 12 (3.6%) covering ileostomies. After April 2009, 55 (29 cancer) consecutive, unselected patients underwent SILS; there were two conversions to a three-port technique (3.6%), no conversions to open resection and two (3.6%) covering ileostomies. There were no significant differences in age, sex, body mass index, hospital of operation or American Society of Anesthesiology (ASA) grade between the two groups. The operating time for SILS was significantly shorter (113 ± 44 min for StdLS vs 79 ± 37 min for SILS; P < 0.0001). SILS patients tolerated a normal diet earlier [10 (2-24) h for SILS vs 18 (2-96) h for StdLS] and were discharged faster [1 (1-8) days for SILS vs 3 (1-24) days for StdLS]. There were no significant differences in return to theatre, readmissions or 30-day mortality.

CONCLUSION

SILS for high anterior resection is feasible, safe and quicker to perform than standard three-port laparoscopic colectomy. It seems to be associated with a faster recovery and earlier discharge.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Single-port laparoscopic colectomy

Single-port laparoscopy (SPL) for colorectal surgery was first described for a right hemicolectomy in 2008. Since then, technology and experience have advanced, and SPL is now reported for a variety of colorectal procedures. Multiple case series and reports have demonstrated the adequate safety of SPL, but there are few reports of a measurable benefit of the technique. SPL is a difficult procedure to learn, it may have relatively high costs, and it is more difficult to perform as well as more physically and mentally taxing on the surgeon. Despite the difficulty and potentially increased cost, SPL suits colorectal patients well as they commonly have a stoma or extraction site adequate in size for a single port. There are cosmetic advantages to this technique, but they apply to a small subset of patients requiring colorectal surgery. There are many tips to incorporate SPL into practice successfully, but the procedure requires patience and experience. As surgeons become more facile with this technique, a group that derives a clear benefit beyond cosmesis will arise, likely a subset of reoperative patients requiring fecal diversion. The accompanying video demonstrates, step by step, the authors' technique of total proctocolectomy and ileo-anal pouch using a single-port device.

Systematic review of single-incision laparoscopic colonic surgery

BACKGROUND

Randomized clinical trials (RCTs) have shown multiport laparoscopic surgery to be safe compared with open surgery in elective colonic disease. Single-incision laparoscopic surgery (SILS) represents the latest advance in laparoscopic surgery. The aim of this systematic review was to establish the safety and complication profile of colonic SILS.

METHODS

The search was performed in October 2011 using PubMed, MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. Search terms were 'colorectal', 'colon', 'colectomy', 'rectal' and single incision/port/trocar/site/scar. Only pure single-incision laparoscopic colonic surgery for benign and malignant colonic disease was included. Primary outcomes were the early postoperative complication profiles of colonic SILS. Secondary outcomes were duration of operation, lymph node yields, conversion rate and duration of hospital stay.

RESULTS

Colonic SILS data were compared with data from a Cochrane review on the short-term outcomes of laparoscopic colonic surgery and four main RCTs on laparoscopic colonic surgery. Median operating times and time to first bowel motion for colonic SILS were comparable with those for laparoscopic colonic surgery. The median lymph node retrieval for malignant disease achieved with SILS was acceptable. Evidence for a reduction in postoperative pain with SILS was conflicting. There was no significant reduction in length of hospital stay with SILS. Most patients selected for colonic SILS had a low body mass index, non-bulky tumours and were operated on by experienced laparoscopic surgeons. There was significant heterogeneity in study group characteristics, indications for surgery, research methodology, operative techniques and follow-up time.

CONCLUSION

Colonic SILS should be restricted to highly selected patients; operations should be performed by experienced laparoscopic surgeons, with critical appraisal of clinical outcomes.

Laparoscopic sigmoid resection with transrectal specimen extraction: a systematic review

AIM

A systematic review was performed to identify differences in surgical technique, postoperative morbidity, length of hospital stay and safety for procedures involving left-sided laparoscopic colectomy with natural orifice specimen extraction.

METHOD

A PubMed search was performed to retrieve studies reporting on left-sided laparoscopic colorectal resection with transrectal specimen extraction. The quality of the different reports was assessed according to the Newcastle-Ottawa Scale. Six studies were included and all but one were cohort studies. Studies on transanal, transvaginal or transcolonic specimen extraction were excluded, as were reports on paediatric surgery.

RESULTS

Six papers (including 94 patients) fulfilled the search criteria. The techniques reported were not standardized and this technical heterogeneity hampered pooled analysis. A meta-analysis could also not be performed because of differences in inter-study methods, study population and results. All studies showed, nevertheless, that the technique is feasible with low morbidity and short postoperative hospital stay. No anal dysfunction was reported.

CONCLUSION

To date, the evidence in favour of left-sided laparoscopic colectomy with transrectal specimen extraction is weak (level IV-V). Future clinical research should focus on standardization of the technique. Randomized controlled trials are necessary to show the superiority of this approach with regard to postoperative pain and morbidity, hospital stay, recovery, function and cosmesis.

Single-incision laparoscopy for colorectal resection: a systematic review and meta-analysis of more than a thousand procedures

AIM

Single-incision laparoscopy for colorectal surgery is of growing importance. The experience of colorectal resection through single-incision laparoscopic surgery was assessed, including the patient outcomes.

METHOD

A meta-analysis was performed of studies comparing single-incision laparoscopic with multiport laparoscopy. Endpoints included conversion to laparotomy, operation time, postoperative morbidity, length of skin incision and length of hospital stay. The MEDLINE database was searched and only comparative studies were included in the meta-analysis. Data were retrieved from full-text manuscripts. Meta-analysis was performed according to the Mantel-Haenszel method for random effects.

RESULTS

From October 2008 to December 2011, 1026 colorectal resections including 921 colonic and 105 rectal procedures using single-incision laparoscopic surgery were reported in 64 studies. Meta-analysis of the 15 comparative studies, including a total of 1075 procedures (494 single-incision and 581 multiport laparoscopies), showed no difference in conversion to open laparotomy [odds ratio (OR) 0.58 (0.24, 1.38); P=0.22], morbidity [OR 0.84 (0.61, 1.15); P=0.27] or operation time [weighted mean difference (WMD) -0.27 (-6.50, 5.95); P=0.93], but a significantly shorter total skin incision [WMD -0.52 (-0.79, -0.25); P<0.001] and a significantly shorter postoperative length of stay [WMD -0.75 (-1.30, -0.20); P=0.008] after single-incision laparoscopic surgery compared with a multiport laparoscopic approach.

CONCLUSION

Although only 15 nonrandomized comparative studies of varying methodology have been reported, this systematic review and meta-analysis of more than 1000 colorectal procedures suggest that single-incision laparoscopic colorectal surgery is feasible and safe.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Single-incision laparoscopic surgeries for colorectal diseases: early experiences of a novel surgical method

Objectives. This paper aims to analyze the feasibility and safety of single-incision laparoscopic colectomy (SILC) and its potential benefits. Methods. Systematic review was performed for the years 1983-August 2011 to retrieve all relevant literature. A total of 21 studies with 477 patients undergoing SILC were selected. Results. Range of operative times and estimated blood losses were 75-229 min and 0-100 mL, respectively. Overall conversion rate was 5.9% (28/477) and an additional laparoscopic port was used in 4.9% (16/329) cases. Range of lymph node number for malignant cases was 12-24.6 and surgical margins were all negative. Overall mortality and morbidity rate was 0.4% (2/477) and 11.7% (43/368), respectively. The length of hospital stay (LOS) varied across reports (2.7-9.2 days). Among 6 case-matched studies, one showed less blood loss in SILC as compared to LAC and 2 showed shorter LOS after SILC versus HALC or LAC/HALC groups. In addition, one study reported maximum pain score on postoperative days 1 and 2 was lower in SILS compared to LAC and HALC. Conclusions. SILC procedure is feasible and safe when performed by surgeons highly skilled in laparoscopy. In spite of technical difficulties, there may be potential benefits associated with SILC over LAC/HALC.

Comparative study of safety and outcomes of single-port access versus conventional laparoscopic colorectal surgery

BACKGROUND

Single-port access (SPA) offers cosmetic advantages in addition to the well-recognised benefits of conventional multi-port laparoscopic (CL) surgery, and can be carried out using standard straight instruments. We report the outcomes of our early experience with SPA colorectal resections in comparison with CL surgery.

METHODS

We compared the following data, patient characteristics, operating time, morbidity, operative mortality, length of hospital stay and tumour variables, of patients who underwent SPA right, left, sigmoid and total colon resections, as well as high anterior resections and panproctocolectomies, with that of patients who underwent equivalent conventional laparoscopic (CL) operations. The 40 SPA and 78 CL patients studied underwent surgery between February 2008 and September 2011.

RESULTS

There was no difference between the SPA and CL operations, as regards the patient's sex (55.0 vs. 62.8% males, p = 0.411), comorbidity (ASA I 10.0 vs. 12.8%; ASA II 57.5 vs. 59.0%; ASA III 32.5 vs. 25.6%; ASA IV 0 vs. 2.6%, p = 0.722) and body mass index (26.2 vs. 28.0 kg/m(2), p = 0.073). However, SPA patients were younger (mean age 54.1 vs. 64.8 years, p = 0.001), and malignancy was a less common indication for surgery (25.0 vs. 71.8%, p < 0.001). There were no conversions to open surgery, and one death occurred in the CL group (1.3%). Mean operating time (162 vs. 170 min, p = 0.547), median post-operative hospital stay (4 vs. 4 days, p = 0.255) and morbidity (7.5 vs. 12.8%, p = 0.538) were comparable.

CONCLUSIONS

SPA laparoscopic surgery appears safe in the hands of experienced laparoscopic surgeons, with no increase in operating time, length of stay, morbidity and mortality. Selection of patients with indications for surgery for benign disease may be of importance to ensure an oncologically safe initial uptake of SPA colorectal practice.

Single-port laparoscopic surgery for inflammatory bowel disease

Background. Single Port Laparoscopic Surgery (SPLS) is being increasingly employed in colorectal surgery for benign and malignant diseases. The particular role for SPLS in inflammatory bowel disease (IBD) has not been determined yet. In this review article we summarize technical aspects and short term results of SPLS resections in patients with Crohn's disease or ulcerative colitis. Methods. A systematic review of the literature until January 2012 was performed. Publications were assessed for operative techniques, equipment, surgical results, hospital stay, and readmissions. Results. 34 articles, published between 2010 and 2012, were identified reporting on 301 patients with IBD that underwent surgical treatment in SPLS technique. Surgical procedures included ileocolic resections, sigmoid resections, colectomies with end ileostomy or ileorectal anastomosis, and restorative proctocolectomies with ileum-pouch reconstruction. There was a wide variety in the surgical technique and the employed equipment. The overall complication profile was similar to reports on standard laparoscopic surgery in IBD. Conclusions. In experienced hands, single port laparoscopic surgery appears to be feasible and safe for the surgical treatment of selected patients with IBD. However, evidence from prospective randomized trials is required in order to clarify whether there is a further benefit apart from the avoidance of additional trocar incisions.

Transanal single port access to facilitate distal rectal mobilization in laparoscopic rectal sleeve resection with hand-sewn coloanal anastomosis

BACKGROUND

Laparoscopic rectal sleeve resection is challenging and technically demanding. Exposure and mobilization of the most distal part of the rectum can be especially hazardous. We propose the use of a single port access device, placed in the anal canal after incision of the sleeve at the appropriate level, to facilitate dissection without sphincter damage. The case of a 51-year-old woman suffering from a recurrent supralevator abscess is presented to illustrate the technique.

METHODS

The procedure consisted of laparoscopic rectal pull-through with rectal sleeve resection and coloanal anastomosis. Incision of the endopelvic fascia and mobilization of the distal mesorectum was performed via the single port device under direct control. Medial-to-lateral mobilization of the colon was performed with a 3-port technique.

RESULTS

Total operating time was 122 min: 50 min for rectal mobilization, 42 min for the laparoscopic part of the procedure and 30 min for the coloanal anastomosis. The patient's recovery was uneventful, and at 1-month follow-up, she was asymptomatic.

CONCLUSIONS

Laparoscopic-assisted transanal single port rectal mobilization seems to be a promising addition to the armamentarium of minimally invasive surgery.