Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review

Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the Cochrane Consumers and Communication Review Group's template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches.

Is inferior mesenteric artery ligation during sigmoid colectomy for diverticular disease associated with increased anastomotic leakage? A meta-analysis of randomized and non-randomized clinical trials

AIM

A meta-analysis was conducted to compare preservation with ligation of the inferior mesenteric artery (IMA) during sigmoidectomy for diverticular disease.

METHOD

Randomized and non-randomized clinical trials were identified using the following electronic databases: Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, Science Citation Index, Greynet, SIGLE, National Technological Information Service, British Library Integrated Catalogue. The analysed end-points were the anastomotic leakage rate, overall morbidity and 30-day postoperative mortality.

RESULTS

Four studies were included involving 400 patients. The anastomotic leakage rate was 7.3% in the preservation group and 11.3% in the ligation group. There was no statistically significant difference between the groups (OR 0.72, 95% CI 0.11-4.76; P=0.73). Overall morbidity and 30-day postoperative mortality were not compared since these data were reported in only one study.

CONCLUSION

The meta-analysis did not show any advantage for preservation of the IMA during sigmoid colectomy for diverticular disease in terms of anastomotic leakage.

Laparoscopic vs open resection for rectal cancer: a meta-analysis of randomized clinical trials

AIM

Laparoscopic and open rectal resection for cancer were compared by analysing a total of 26 end points which included intraoperative and postoperative recovery, short-term morbidity and mortality, late morbidity and long-term oncological outcomes.

METHOD

We searched for published randomized clinical trials, presenting a comparison between laparoscopic and open rectal resection for cancer using the following electronic databases: PubMed, OVID, Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE.

RESULTS

Nine randomized clinical trials (RCTs) were included in the meta-analysis incorporating a total of 1544 patients, having laparoscopic (N = 841) and open rectal resection (N = 703) for cancer. Laparoscopic surgery for rectal cancer was associated with a statistically significant reduction in intraoperative blood loss and in the number of blood transfusions, earlier resuming solid diet, return of bowel function and a shorter duration of hospital stay. We also found a significant advantage for laparoscopy in the reduction of post-operative abdominal bleeding, late intestinal adhesion obstruction and late morbidity. No differences were found in terms of intra-operative and late oncological outcomes.

CONCLUSION

The meta-analysis indicates that laparoscopy benefits patients with shorter hospital stay, earlier return of bowel function, reduced blood loss and number of blood transfusions and lower rates of abdominal postoperative bleeding, late intestinal adhesion obstruction and other late morbidities.

Sentinel lymph node biopsy under local anaesthesia versus general anaesthesia: reliability and cost-effectiveness analysis in 153 patients with malignant melanoma

AIM

The aim of our study was to evaluate feasibility, reliability and cost-benefit balance of sentinel node (SN) biopsies conducted under local anaesthesia (LA) in patients affected by stage I-B or II cutaneous melanoma.

PATIENTS AND METHODS

A retrospective analysis was carried out in 153 patients, evaluating the number of harvested lymph nodes, perioperative and postoperative complications, operating time and operating room costs, comparing interventions under LA and general anaesthesia (GA). Operations were carried out under LA in 112 cases (73%) and under GA in the remaining 41(27%).

RESULTS

The mean number of removed SN was overall higher in the GA group but was not significantly different under LA with respect to the subgroups of axillary biopsies. No difference was noted in the number of complications. Operating time was significantly shorter under LA, with significantly lower costs.

CONCLUSION

LA for groin and axillary SN biopsies can be a reliable and effective alternative to GA in melanoma patients, with shorter operating time, lower costs and without the side-effects and risks associated with GA.