Open compared with laparoscopic complete mesocolic excision with central lymphadenectomy for colon cancer: a systematic review and meta-analysis

AIM

Several studies report improved survival in colon cancer with use of extended lymphadenectomy techniques (ELTs), such as D3 lymphadenectomy or complete mesocolic excision. The noninferiority of laparoscopic versus open techniques has already been established in D2 resections. The aim of this study was to compare the safety and efficacy of open and laparoscopic approaches for ELTs in colon cancer.

METHOD

Major databases, including PubMed, Scopus and the Cochrane library, were searched using defined inclusion and exclusion criteria, and relevant data were extracted. The Cochrane and Newcastle-Ottawa tools were used for critical appraisal and quality assessment. Meta-analysis with various subgroup analyses were undertaken, and clinical and statistical heterogeneity, along with publication bias, were also assessed.

RESULTS

One randomized and seven case-control trials were included. All studies were found to be of low methodological quality with some external validity issues. There was no difference in short-term mortality [OR = 2.16 (95% CI: 0.73-6.41); P = 0.16], anastomotic leakage, ileus or deep-sited infection/abscess. There was a trend for longer operative time [weighted mean difference (WMD) = -30.88 (95% CI: -62.38 to 0.61); P = 0.05] and shorter length of hospital stay [WMD = 2.29 (95% CI: -0.39 to 4.98); P = 0.09] with the laparoscopic approach. Laparoscopic right hemicolectomy had a lower wound-infection rate [OR = 2.87 (95% CI: 1.38-5.98); P = 0.005] compared with the relevant open group. No statistically significant difference was found in overall survival [hazard ratio (HR) = 0.85 (95% CI: 0.69-1.06); P = 0.15], disease-free survival, local recurrence and distant metastases.

CONCLUSION

Based on the current evidence, the laparoscopic technique appears to be at least as safe as the open technique when used in performing ELTs for colonic cancer, with similar morbidity and oncological outcomes.

A new technique of extreme lateral positioning for laparoscopic splenic flexure mobilization

AIM

This aim of this study was to describe a novel positioning technique that assists in the expeditious mobilization of the splenic flexure without the need for redraping or compromise of port placement.

METHOD

A prospective case series was studied to evaluate the technique and its ability to facilitate splenic flexure mobilization.

RESULTS

The technique was used in 12 patients. There were no adverse intra- or postoperative events. The median time (interquartile range) for laparoscopic splenic flexure mobilisation was 10 (9-11.25).

CONCLUSION

This novel positioning technique is safe and feasible. We include a detailed video that describes and demonstrates the requisites for its safe conduct. We also include intra-operative footage demonstrating the benefits of the patient's position.

Composite abdominosacral resection for recurrent rectal cancer

BACKGROUND

En bloc resection of the tumour and adjacent involved organs offers the only realistic curative option for patients with locally recurrent rectal cancer. This study assessed outcomes of composite resection for recurrent tumours involving the sacrum.

METHODS

A consecutive series of patients underwent composite abdominosacral resection (abdominal mobilization and stoma construction followed by sacral division and tumour retrieval) for recurrent rectal cancer between 2001 and 2007. Patients were staged with preoperative computed tomography, magnetic resonance imaging and positron emission tomography. Data were collected prospectively.

RESULTS

Forty patients (28 men; median age 59 (range 31-77) years) underwent surgery with sacral division at the S2/3 interface in 13, S3/4 level in 20 and S4/5 level in seven patients. One patient died and 24 had complications. An R0 resection was achieved in 20 patients and conferred benefit in disease-free interval over an R1 resection. The mean disease-free interval was 55.6 (95 per cent confidence interval (c.i.) 40.0 to 71.3) months for R0 and 32.2 (95 per cent c.i. 19.7 to 44.7) months for R1 resection (P = 0.048).

CONCLUSION

Composite abdominosacral resection of locally recurrent rectal cancer is an effective treatment for a difficult clinical scenario.

Laparoscopic restorative proctocolectomy with and without previous subtotal colectomy

INTRODUCTION

Laparoscopic techniques have been applied to the procedure of restorative proctocolectomy (RPC). The aim of this study was to compare the outcomes of patients after laparoscopic ileal pouch-anal anastomosis (IPAA) with restorative proctocolectomy (RPC) and without previous colectomy [restorative proctectomy (RP)] and to highlight some technical tips.

METHOD

Data were collected prospectively from all patients who underwent laparoscopic IPAA from July 2006 to December 2007.

RESULTS

Thirty-six patients underwent IPAA either with total proctocolectomy (n = 25) or after previous emergency colectomy (n = 11). Postoperative morbidity occurred in 22% of patients. The overall median operative time was 210 (range 120-325), 240 (170-325) and 180 (120-240) min for RPC and RP respectively (P < 0.05). The median length of stay for all patients was 6 (3-26), 6 (4-26) and 4 (3-13) days for RPC and RP respectively (P < 0.05). There was no correlation between BMI, age, use of immunosuppressive agents and length of stay. The operative procedure was facilitated by the use of specific devices at particular stages of the operation.

CONCLUSION

Laparoscopic IPAA is not only safe and feasible for the virgin abdomen but also for patients with a previous emergency colectomy through a midline laparotomy incision.

Laparoscopic abdominosacral composite resection for locally advanced primary rectal cancer

BACKGROUND

En bloc resection of a primary rectal cancer that involves the sacrum is the only curative option for such locally advanced tumours. There is significant morbidity associated with this surgical procedure. A laparoscopic component would potentially provide the patient with the short-term benefits of a minimally invasive approach to the abdominal phase of this challenging operation. The aim of this study was to assess our initial experience with a combined laparoscopic and transsacral approach.

METHODS

A prospective review of patients carefully selected for a laparoscopic abdominosacral composite resection by a single colorectal multidisciplinary team.

RESULTS

Three male patients underwent the procedure. Median duration of surgery was 190 minutes and no blood transfusion was required. Two patients had full intestinal function on the second postoperative day and went home on day 12 and 13. The third patient had a laparotomy for postoperative small-bowel obstruction. All three patients had a R0 (complete) resection with a median lymph node harvest of 15 nodes.

CONCLUSIONS

A laparoscopic proctectomy provides an oncologically sound and minimally invasive option to the abdominal phase of this composite operation. We will continue to gain experience with this combined approach in order to lessen the inevitable morbidity inflicted on the patient in the quest for cure of their locally advanced disease.

Feasibility and functional outcome of laparoscopic sacrocolporectopexy for combined vaginal and rectal prolapse

PURPOSE

Prolapse of multiple pelvic organs causes a variety of symptoms that impair a patient's quality of life. A laparoscopic procedure is described that uses a mesh fixation of the mid-compartment vagina to the sacrum with additional rectopexy to correct both the anatomical deformities and the dysfunction of the posterior compartment.

METHODS

Patients with significant rectal and vaginal prolapse with or without rectocele were recruited. A thorough preoperative physiological assessment of each of the compartments of the pelvic floor was carried out. Patients also completed the Pelvic Floor Distress Inventory before and six months after surgery.

RESULTS

Ten patients underwent the procedure of laparoscopic sacrocolporectopexy (median age 47 years, interquartile range 43-53). No mortality or morbidity occurred. Median global distress inventory scores were significantly lower postoperatively (8.3, interquartile range 0-20.8 vs. 37.5, interquartile range 16.6-60.4) P = 0.012. All three median subscales were also significantly lower postoperatively. The procedure corrected associated rectoceles and descent of the perineum on straining.

CONCLUSION

The described laparoscopic procedure of mesh sacrocolpopexy with rectopexy was safe and feasible and conferred good symptomatic improvement in pelvic floor dysfunction.

Surgical management of pelvic organ prolapse in females: functional outcome of mesh sacrocolpopexy and rectopexy as a combined procedure

PURPOSE

Urogenital prolapse is relatively common compared with rectal prolapse and the combination of urogenital prolapse and rectal prolapse is still more infrequent. This study was designed to evaluate the functional outcome of a series of patients who have undergone open mesh sacrocolporectopexy surgery for combined vaginal and rectal prolapse.

METHODS

Consecutive patients from June 2000 to June 2004 with confirmed vaginal and rectal prolapse subsequently underwent open mesh sacrocolporectopexy. The Cleveland Clinic Short Form-20 Pelvic Floor Distress Inventory questionnaire with Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory, and Colorectal-Anal Distress Inventory subscales was completed by all patients preoperatively and at six months postoperatively.

RESULTS

There were 29 patients with a median age of 66 (interquartile range, 59-73) years. Median period of follow-up was 26 (interquartile range, 15-33) months. Median global pelvic floor distress inventory scores were lower postoperatively compared with preoperatively (96.4 (interquartile range, 50.8-149.7) vs. 182.3 (interquartile range, 140.6-208.6; P = 0.001). All three median subscales scores also were significantly lower postoperatively compared with preoperatively.

CONCLUSIONS

In patients with concurrent vaginal and rectal prolapse, open mesh sacrocolporectopexy confers good symptomatic improvement for urinary-, vaginal-, and rectal-related symptoms.

Broad spectrum antiemetic effects of CP-122,721, a tachykinin NK1 receptor antagonist, in ferrets

The potent, selective, tachykinin NK1 receptor antagonist, CP-122,721 ([(+)-(2S,3S)-3-(2-methoxy-5-trifluoromethoxybenzyl)amino-2- phenylpiperidine]), at 0.01-1 mg/kg, s.c. reduced retching and vomiting elicited by loperamide, copper sulfate, ipecac syrup and cisplatin in a dose-dependent manner. ID50 values after subcutaneous administration ranged from 0.02 mg/kg (loperamide) to 0.08 mg/kg (ipecac). Oral CP-122,721 reduced cisplatin-induced emesis with an ID50 of approximately 0.08 mg/kg. The less active (2R, 3R)-enantiomer, CP-132.687, did not significantly suppress retching or vomiting induced by any of the emetogens. These data support the hypothesis that CP-122,721 blocks emesis by a specific action at tachykinin NK1 receptors. Its broad spectrum of antiemetic activity suggests a central site of action.

Physiological correlates of painful stimulation in preterm infants

OBJECTIVE

The study investigates the physiological responses of preterm infants to procedures that are routinely performed in intensive care nurseries. Changes in heart rate, respiration rate, and oxygen saturation were examined as indicators of the level of discomfort experienced by the infant during the procedures.

DESIGN

Clinical descriptive. Systematic observations of the infants were conducted during periods of rest as well as during routine interventions.

SETTING

All observations were recorded from monitored preterm infants in the intensive care units of two urban hospitals.

PATIENTS

Thirty-five preterm infants 24-30 weeks gestational age and weighing < 2,000 g at birth. Data were collected from all infants in the units who met the weight criterion.

INTERVENTIONS

The researchers observed the infants while the intensive care nursery staff were performing routine care procedures. Observations were made during procedures that adults would consider to be painful, such as injection, heel stick, tape removal, and squeezing of the heel to induce blood flow after heel stick, as well as nonpainful procedures, such as handling, temperature taking, alcohol swabbing, patting, taping a tube, feeding, and placing a pacifier.

MAIN OUTCOME MEASURES

Heart rate, respiration rate, and oxygen saturation were recorded from infant monitors. Mean values of the three measures during procedures were compared with mean values before and after procedures.

RESULTS

Significant differences (p < 0.001) were found among pre-, peri-, and post-procedures for all three outcome measures. Heart rate and respiration rate means were significantly (p < 0.001) higher during procedures that adults consider to be painful than in those regarded as nonpainful. Oxygen saturation was lower (p < 0.001) for painful procedures than for nonpainful procedures. Gender and infant size comparisons yielded inconclusive results.

CONCLUSION

The outcome measures appear to be reliable indices of preterm infant responses to painful stimulation.

Scintigraphic evidence of asymptomatic impaired left ventricular function in type I diabetics

Asymptomatic myocardial disease has been described in relation to longstanding insulin-dependent diabetes mellitus. To detect myocardiopathy in a selected group of 14 patients (aged 21-38 years, duration of diabetes 10-20 years) with insulin-dependent diabetes, we have performed equilibrium gated nuclear angiography with Fourier filtered analysis. These patients had no clinical or echocardiographic signs of cardiac disease. We examined six patients with severe proliferative retinopathy, and eight patients with no signs of retinopathy at fluorescence angiography. The global ejection fraction was within normal limits in all cases. Fourier analysis of scintigraphic data, however, revealed wall motion abnormalities (abnormal amplitude and phase shift) of the left ventricle in all 14 patients, particularly in the anterior and/or septal region. No correlation was found between the degree of wall motion disturbances and prevailing blood glucose or HbA1 concentrations or the presence of retinopathy or autonomic neuropathy. It is concluded that equilibrium gated nuclear angiography in combination with Fourier filtered analysis is a sensitive method of detecting myocardial abnormalities in patients suffering from insulin-dependent diabetes mellitus without cardiac symptoms.