Multicenter Controlled Study of Intracorporeal Mechanical Side-to-Side Isoperistaltic Anastomosis versus Extracorporeal Anastomosis in Laparoscopic Right Hemicolectomy: HEMI-D-TREND-Study

Laparoscopic and robotic intracorporeal resection and end-to-end anastomosis in left colectomy: a prospective cohort study - stage 2a IDEAL framework for evaluating surgical innovation

PURPOSE

To analyze the safety and feasibility of intracorporeal resection and anastomosis in upper rectum, sigmoid, and left colon surgery, via both laparoscopic and robotic approaches. The secondary aim was to assess possible short-term differences between laparoscopic versus robotic surgery.

METHODS

A prospective observational cohort study according to IDEAL framework exploration and assessment stage (Development, stage 2a), evaluating and comparing the laparoscopic approach and the robotic approach in left colon, sigmoid, and upper rectum surgery with intracorporeal resection and end-to-end anastomosis. Demographic, preoperative, surgical, and postoperative variables of patients undergoing laparoscopic and robotic surgery are described and compared according to the surgical technique used.

RESULTS

Between May 2020 and March 2022, seventy-nine patients were consecutively included in the study, 41 operated via laparoscopy (laparoscopic left colectomy: LLC) and 38 by robotic surgery (robotic left colectomy: RLC). There were no statistically significant differences between the two groups in terms of demographic variables. In surgical variables, the median surgical times differed significantly: 198 min (SD 48 min) for LLC vs. 246 min (SD 72 min) for RLC (p = 0.01, 95% CI: - 75.2 to - 20.5)). The only significant difference regarding postoperative complications was a higher degree of relevant morbidity in the LLC (Clavien-Dindo > II (14.6% vs. 0%, p = 0.03) and Comprehensive Complication Index (IQR 22 vs. IQR 0, p = 0.03). The pathological results were similar in both approaches.

CONCLUSION

Laparoscopic and robotic intracorporeal resection and anastomosis are feasible and safe, and obtain similar surgical, postoperative, and pathological results than described in literature. However, morbidity seems to be higher in LLC group with fewer relevant postoperative complications. The results of this study enable us to proceed to stage 2b of the IDEAL framework.

CLINICAL TRIAL REGISTRATIONS

The study is registered in Clinical trials with the registration code NCT0445693.

Medium-term oncological outcomes of totally laparoscopic colectomy with intracorporeal anastomosis for right-sided and left-sided colon cancer: propensity score matching analysis

Background

This retrospective study aimed to compare long-term oncological outcomes between laparoscopic-assisted colectomy (LAC) with extracorporeal anastomosis (EA) and totally laparoscopic colectomy (TLC) with intracorporeal anastomosis (IA) for colon cancers, including right- and left-sided colon cancers.

Methods

Patients with stage I–III colon cancers who underwent elective laparoscopic colectomy between January 2013 and December 2017 were analyzed retrospectively. Patients converted from laparoscopic to open surgery and R1/R2 resection were excluded. Propensity score matching (PSM) analysis (1:1) was performed to overcome patient selection bias.

Results

A total of 388 patients were reviewed. After PSM, 83 patients in the EA group and 83 patients in the IA group were compared. Median follow-up was 56.5 months in the EA group and 55.5 months in the IA group. Estimated 3-year overall survival (OS) did not differ significantly between the EA group (86.6%; 95% confidence interval (CI), 77.4–92.4%) and IA group (84.8%; 95%CI, 75.0–91.1%; P = 0.68). Estimated 3-year disease-free survival (DFS) likewise did not differ significantly between the EA group (76.4%; 95%CI, 65.9–84.4%) and IA group (81.0%; 95%CI, 70.1–88.2%; P = 0.12).

Conclusion

TLC with IA was comparable to LAC with EA in terms of 3-year OS and DFS. TLC with IA thus appears to offer an oncologically feasible procedure.

How to start and develop a multicenter, prospective, randomized, controlled trial

Our main goal is to describe how to start and develop a multicenter, prospective, randomized, controlled trial. The first step is to have an idea that will become the hypothesis and a main objective. A bibliographic search should be done to check for clinical interest and originality. Moreover, the study must be feasible and should be finished within 4 years. In order to start the multicenter study, a protocol should be written (in accordance with the SPIRIT guidelines Standard Protocol items: Recommendations for Interventional Trials), including the design type, sample size and participating hospitals. Randomization is key to the design and, therefore, the CONSORT (Consolidated Standards of Reporting Trials) guidelines must be followed. However, if the study cannot be randomized, the TREND (Transparent Reporting of Evaluations with Non-Randomized Designs) guidelines are recommended. When the protocol is approved by the Ethics Committee for Clinical Investigation of the hospital, we ought to create visibility. It is suggested to register the trial on ClincalTrials.gov and submit its publication to indexed magazines. Financial resources are necessary to execute the study and maintain an online database. This allows the registry to be updated and accessible to all the participants in the study. What is more, randomization can be done immediately. And last, but not least, is motivation. Multicentricity equals to participation of all the chosen medical centers. Updating and motivating them by sending a newsletter every 1-3 months keeps participants engaged in the study.