A standardized use of intraoperative anastomotic testing in colorectal surgery in the new millennium: is technology taking over? A systematic review and network meta-analysis.

BACKGROUND: Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) and intraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL. METHODS: A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology. RESULTS: Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14-0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21-1.30) and IOC (RR 0.49; Crl 0.10-1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14-0.87) and IOC (RR 0.44; Crl 0.14-0.87). CONCLUSIONS: This study suggests that intraoperative testing for a good blood supply using ICG may reduce the AL rate following colorectal surgery.

Long-term outcomes in ypT0 rectal cancers: An international multi-centric investigation on behalf of Italian Society of Surgical Oncology Young Board (YSICO).

AIM: To investigate the outcome and pattern of survivals of rectal cancer patients presenting a complete or nearly complete tumor response after neo-adjuvant treatment. METHODS: Young surgeons <40 years old affiliated to the Italian Society of Surgical Oncology (YSICO) from 13 referral centers for colorectal cancer treatment, were invited to participate a retrospective study. Records from patients treated from 2005 to 2015 with a pathological diagnosis of ypT0/ypTis were retrieved and pooled in a common data-base for statistical purposes. All clinical and pathological variables were reviewed. Univariate and multivariate analyses were conducted with the end-point of survivals. RESULTS: Two hundreds and sixty-one patients were analyzed including 237 ypT0 and 24 ypTis. Nodal positive patients were 8.7%. More than sixty-six percent of the patients did not perform adjuvant chemotherapy, with a statistical difference comparing N0 versus N+ patients (66.8% vs 40.9%, p 0.02). Mean follow-up was of 47.6 months. Twenty-two relapses were observed, 91.6% at a distant site. The mean time to recurrence was of 35.3 months. On univariate analysis, the use of adjuvant chemotherapy correlated with better OS exclusively in ypT0N + patients and not in ypT0N0. Univariate and multivariate analyses documented nodal positivity as the only prognostic factor correlated with a worse OS. CONCLUSION: Recurrences were mostly diagnosed at a distant site and within the third year of follow-up. Nodal positivity was the only variable independently correlated with a worse OS. Univariate analysis documented a benefit for the use of adjuvant chemotherapy treatment exclusively in ypT0N + rectal cancers.

Tumor regression grade and survival after neoadjuvant treatment in gastro-esophageal cancer: A meta-analysis of 17 published studies.

INTRODUCTION: Major pathologic regression after neoadjuvant therapy is a strong and favorable prognostic factor in several types of cancer (breast, rectal and bladder). This information is less clear and has yet to be systematically evaluated in upper gastrointestinal tumors. We performed a meta-analysis to evaluate the prognostic impact of tumor regression after preoperative therapy on disease-free survival (DFS) and overall survival (OS) in gastro-esophageal cancer patients. METHODS: we searched for relevant articles in PubMed, SCOPUS, Web of Science, CINAHL, LILACS, Ovid, Cochrane Library, Google Scholar and Embase up to June 2, 2016. Data of tumor regression (complete or near-complete pathologic response) that independently correlated with OS and DFS in multivariate analysis were extracted, and the proper hazard ratios (HRs) with corresponding 95% confidence intervals (95% CIs) were pooled according to the random effect model. RESULTS: a total of 17 studies-which included 3145 patients-were considered in the final analysis. Major pathologic response was significantly related with better OS (HR 0.46, 95% CI 0.32-0.66, P < 0.001) and DFS (HR = 0.40, 95% CI 0.26-0.62, P < 0.001). Pathologic complete response (pCR) or major tumor regression were associated with the same degree of benefit in outcome compared to no or minimal pathologic regression, regardless of histology. CONCLUSION: major pathologic response is associated with a significant improvement in OS compared to no response or minor pathologic changes after neoadjuvant therapy in gastro-esophageal cancers. This should be considered a robust prognostic factor to guide postoperative treatment and follow-up.