Pancreatic stump closure after distal pancreatectomy: Systematic review and meta-analysis of randomized clinical trials comparing non-autologous versus no reinforcement: Value of prediction intervals.

BACKGROUND: This meta-analysis of randomized trials aimed to assess the benefits and harms of non-autologous versus no reinforcement of the pancreatic stump following distal pancreatectomy (DP). METHODS: It was performed in accordance with PRISMA 2020 and AMSTAR 2 Guidelines. (registered in PROSPERO ID: EROCRD42021286863). RESULTS: Nine relevant articles (between 2009 and 2021) were retrieved, comparing non-autologous reinforcement (757 patients) with non-reinforcement (740 patients) after PD. Pooled analysis showed a statistically significant lower rate of postoperative pancreatic fistula (POPF) in the reinforcement group (RR â€‹= â€‹0.677; 95 â€‹% CI [0.479, 0.956], p â€‹= â€‹0.027). The 95 â€‹% predictive interval (0.267-1.718) showed heterogeneity. Non-autologous reinforcement other than with "Tachosil®" was effective (subgroup analysis). No statistically significant differences were found between the two groups with regard to secondary outcomes. CONCLUSIONS: This meta-analysis showed that covering the stump with non-autologous reinforcement other than Tachosil® had a preventive effect on the onset of POPF.

Revolutionizing sphincter preservation in ultra-low rectal cancer: exploring the potential of transanal endoscopic intersphincteric resection (taE-ISR): a propensity score-matched cohort study.

BACKGROUND: With the optimization of neoadjuvant treatment regimens, the indications for intersphincteric resection (ISR) have expanded. However, limitations such as unclear surgical field, impaired anal function, and failure of anal preservation still exist. Transanal total mesorectal excision can complement the drawbacks of ISR. Therefore, this study combined these two techniques and proposed transanal endoscopic intersphincteric resection (taE-ISR), aiming to explore the value of this novel technique in anal preservation for ultra-low rectal cancer. MATERIAL AND METHODS: Four high-volume centres were involved. After 1:1 propensity score-matching, patients with ultra-low rectal cancer underwent taE-ISR ( n =90) or ISR ( n =90) were included. Baseline characteristics, perioperative outcomes, pathological results, and follow-up were compared between the two groups. A nomogram model was established to assess the potential risks of anal preservation. RESULTS: The incidence of adjacent organ injury (0.0% vs. 5.6%, P =0.059), positive distal resection margin (1.1% vs. 8.9%, P =0.034), and incomplete specimen (2.2% vs. 13.3%, P =0.012) were lower in taE-ISR group. Moreover, the anal preservation rate was significantly higher in taE-ISR group (97.8% vs. 82.2%, P =0.001). Patients in the taE-ISR group showed a better disease-free survival ( P =0.044) and lower cumulative recurrence ( P =0.022) compared to the ISR group. Surgery procedure, tumour distance, and adjacent organ injury were factors influencing anal preservation in patients with ultra-low rectal cancer. CONCLUSION: taE-ISR technique was safe, feasible, and improved surgical quality, anal preservation rate and survival outcomes in ultra-low rectal cancer patients. It held significant clinical value and showed promising application prospects for anal preservation.

Inferior mesenteric artery ligation level in rectal cancer surgery: still no answer-a systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis is to summarize the current scientific evidence regarding the impact of the level of inferior mesenteric artery (IMA) ligation on post-operative and oncological outcomes in rectal cancer surgery. METHODS: We conducted a systematic review of the literature up to 06 September 2022. Included were RCTs that compared patients who underwent high (HL) vs. anterior (LL) IMA ligation for resection of rectal cancer. The literature search was performed on Medline/PubMed, Scopus, and the Web of Science without any language restrictions. The primary endpoint was overall anastomotic leakage (AL). Secondary endpoints were oncological outcomes, intraoperative complications, urogenital functional outcomes, and length of hospital stay. RESULTS: Eleven RCTs (1331 patients) were included. The overall rate of AL was lower in the LL group, but the difference was not statistically significant (RR 1.43, 95% CI 0.95 to 2.96). The overall number of harvested lymph nodes was higher in the LL group, but the difference was not statistically significant (MD 0.93, 95% CI - 2.21 to 0.34). The number of lymph nodes harvested was assessed in 256 patients, and all had a laparoscopic procedure. The number of lymph nodes was higher when LL was associated with lymphadenectomy of the vascular root than when IMA was ligated at its origin, but there the difference was not statistically significant (MD - 0.37, 95% CI - 1.00 to 0.26). Overall survival at 5 years was slightly better in the LL group, but the difference was not statistically significant (RR 0.98, 95% CI 0.93 to 1.05). Disease-free survival at 5 years was higher in the LL group, but the difference was not statistically significant (RR 0.97, 95% CI 0.89 to 1.04). CONCLUSIONS: There is no evidence to support HL or LL according to results in terms of AL or oncologic outcome. Moreover, there is not enough evidence to determine the impact of the level of IMA ligation on functional outcomes. The level of IMA ligation should be chosen case by case based on expected functional and oncological outcomes.

5 year oncological outcomes of the HIGHLOW randomized clinical trial.

INTRODUCTION: The oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA MATERIALS AND METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled. RESULTS: Five-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years. CONCLUSION: We confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.

Use of fluorescence imaging and indocyanine green during colorectal surgery: Results of an intercontinental Delphi survey.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

A novel knotless hand-sewn end-to-end anastomosis using V-loc barbed suture vs. stapled anastomosis in laparoscopic left colonic surgery: A propensity scoring match analysis.

Background: Laparoscopic colectomy is widely practiced for colon cancer, but many variations exist for anastomosis after laparoscopic colon cancer radical resection. Method: We retrospectively analyzed 226 patients who underwent laparoscopic-assisted radical resection for left colon cancer with knotless hand-sewn end-to-end anastomosis (KHEA) technique with barbed V-loc™ suture material and compared perioperative outcomes, safety, and efficacy to those undergoing stapled anastomosis from 2010 to 2021. Results: After the 1:2 propensity score matching, 123 participants with similar preoperative characteristics (age, body mass index, TNM stage, and tumor location) were enrolled in the study: 41 in the KHEA and 82 in the stapler group. Statistically significant differences were found in time to accomplish the anastomosis (mean 7.9 vs. 11.9 min, p < 0.001) and hospital costs (mean 46,569.71 vs. 50,915.35 CNY, p < 0.05) that differed between the KHEA and stapler group, respectively. No statistically significant difference was found in the mean delay to bowel function recovery (2.6 vs. 2.7 days, p = 0.466), duration of hospital stay (8.6 vs. 7.9 days, p = 0.407), or rate of postoperative complications (14.6% vs. 11.0%, p = 0.563). Anastomotic leakage occurred in 11 patients: 5 (12.2%) vs. 6 (7.3%) (p > 0.05) in the KHEA and stapler group, respectively. Conclusion: KHEA is feasible and safe for anastomosis after laparoscopic left hemicolectomy. The KHEA technique could reduce operation time and hospital costs with complication rates comparable to stapling.

Laparoscopic versus open emergent colectomy for ischemic colitis: a propensity score-matched comparison.

INTRODUCTION: Laparoscopic colectomy is rarely performed for ischemic colitis. The aim of this propensity score-matched study was to compare preoperative characteristics, intraoperative details and short-term outcomes for emergent laparoscopic colectomy versus the traditional open approach for patients with ischemic colitis. METHODS: Retrospective review of 96 patients who underwent emergent colectomy for ischemic colitis between January 2011 and December 2020 (39 via laparoscopy, 57 via laparotomy) was performed. We compared short-term outcomes after using a one-to-one ratio and nearest-neighbor propensity score matching to obtain similar preoperative and intraoperative parameters in each group. RESULTS: Patients in the open group experienced more surgical site complications (52.6% vs. 23.0%, p = 0.004), more intra-abdominal abscesses (47.3% vs. 17.9%, p = 0.003), longer need for ventilator support (20 days vs. 0 days, p < 0.001), more major complications (77.2% vs. 43.5%, p = 0.001), higher mortality (49.1% vs. 20.5%, p = 0.004), and longer hospital stay (32 days vs. 19 days, p = 0.001). After propensity score matching (31 patients in each group), patients undergoing open (vs. laparoscopy) had more surgical site complications (45.1% vs. 19.4%, p = 0.030) and required longer ventilator support (14 vs. 3 days, p = 0.039). After multivariate analysis, Charlson Comorbidity Index (p = 0.024), APACHE II score (p = 0.001), and Favier's classification (p = 0.023) were independent predictors of mortality. CONCLUSIONS: Laparoscopic emergent colectomy for ischemic colitis is feasible and is associated with fewer surgical site complications and better respiratory function, compared to the open approach.

Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience.

The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2 weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O2 therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15 days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94-5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal peritonitis.

Anatomic patterns and clinical significance of gastrocolic trunk of Henlé in laparoscopic right colectomy for colon cancer: Results of the HeLaRC trial.

BACKGROUND: Recent interest in laparoscopic right colectomy with D3 lymphadenectomy for right colon cancer, has raised renewed attention to the anatomic variations of the gastrocolic trunk of Henlé (GTH). Understanding the vascular structure of the GTH region for individual patients should improve surgical outcomes. The goal of this nationwide multicenter study (Anatomical Classification of Henlé's Trunk in Laparoscopic Right Hemi-colectomy (HeLaRC) trial) was to study the anatomic patterns of the GTH region, to clarify the implications of GTH in laparoscopic right colectomy with D3 lymphadenectomy (D3-RC) and analyze their clinical significance. METHODS: We enrolled 583 patients from 26 centers across China who underwent D3-RC. The number of tributaries, length and types of GTH constitutions and their influence on intra-operative data were investigated. A nomogram score (based on the length of GTH, body mass index (BMI), tumor location, T stage and type of GTH (type I vs. non-type I) was established to assess the potential hazard of bleeding. RESULTS: The GTH was found in 567 patients (97.3%). The distribution of GTH types was 0 (14.1%, n = 80), I (53.3%, n = 302), II (27.0%, n = 153), III (5.6%, n = 32). Of note, the type I GTH, T1 stage and tumor location at ileocecal or ascending colon were correlated with shorter exposure time of the GTH region (P < 0.0001). Short length of GTH (P = 0.002) and tumor location (transverse colon vs. non transverse colon) (P = 0.003) were correlated with the amount of GTH bleeding during the surgery. Nomogram discrimination was good (C-index: 0.72 (95% CI: 0.64, 0.80)). The dissection plane was better in patients with type I GTH than with other types (P = 0.023). CONCLUSION: GTH pattern variations may affect surgical outcomes in patients undergoing D3-RC. Better recognition of GTH anatomy might lead to a safer operation with better oncologic quality.

Structured training curriculums for transanal total mesorectal excision in China: refinement is needed.

Background: Transanal total mesorectal excision (TaTME) is an alternative for mid-low rectal cancer. In China, this procedure has been performed in high-volume centers with structured training curriculums. The efficacy of the TaTME structured training curriculums in China is still unclear. This multicenter study aimed to explore the effectiveness of the structured training curriculums in China. Methods: Seven high-volume centers in China participated in this study. The first 25 patients who underwent TaTME in each center were enrolled. In the cohort, patients were divided into 3 groups. The first 5 procedures (group 1) were performed under proctoring according to the requirement of structured training curriculums. The latter 20 cases without proctoring were split into 2 groups (10 cases in each group, groups 2 and 3) according to the order of operation date. The baseline characteristics, perioperative complications, and pathological outcomes were compared between groups 1 and 2, as well as between groups 2 and 3. Results: Symptomatic anastomotic leakage (AL) occurred in 18.6% of the patients in group 2 compared with 5.7% in group 1 (P1=0.08) and 5.0% in group 3 (P2=0.04). Seven (11.3%) patients in group 2 developed defecation disorders whereas no patients had this complication in group 3 (P2=0.02). Compared with group 2, the operative time was shorter (235 vs. 223 min, P2=0.40), while the rates of intraoperative complications (15.7% vs. 5.7%, P2=0.10), postoperative complications (31.3% vs. 25.7%, P2=0.06), AL (20.0% vs. 8.6%, P2=0.04), and positive distal resection margin (DRM) (7.5% vs. 2.9%, P2=0.27) were lower in group 3. Conclusions: The effect of the structured training curriculums was acceptable but needed further improvement. The prevalence of anastomosis-related complications and the quality control of specimens are still not optimal, and measures for refinement (for example, more cases under proctoring) are needed in the curriculums.

Peritoneal contamination and associated post-operative infectious complications after natural orifice specimen extraction for laparoscopic colorectal surgery.

BACKGROUND: Peritoneal contamination is a major concern during natural orifice specimen extraction after laparoscopic colorectal resection (LCR-NOSE), but few data are available. We explored the prevalence, risk factors, and association between clinical outcomes and infectious complications in patients with positive peritoneal drain fluid culture (PDFC) after LCR-NOSE. METHOD: We retrospectively analyzed patient records in our prospectively maintained registry database who underwent LCR-NOSE between 2011and 2020. Peritoneal drain fluid was collected within 12 h post-operative and cultures for microorganisms were obtained. The relationships between PDFC, clinical variables, and infectious complications were examined by univariate and multivariable analysis. RESULTS: Of 241 consecutive patients who underwent LCR-NOSE and drainage fluid culture, 59 (24.5%) had PDFC. Anterior resection (Odds ratio OR 2.40) was identified as an independent predictor for PDFC. Twenty-eight patients (11.6%) developed infectious complications. Multivariable analysis identified low anterior resection (OR 2.74), prolonged operative time (OR 3.20), and PDFC (OR 5.14) as independent risk factors. Pseudomonas aeruginosa was the most frequently found microorganism (OR 5.19) responsible for infectious complications. CONCLUSIONS: Microorganisms are commonly present in the peritoneum after LCR-NOSE and play a critical role in the development of infectious complications and related morbidity. Specific caution is warranted in patients contaminated with specific types of microorganisms.

Short and long-term outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for colorectal and appendiceal cancer peritoneal metastasis: Propensity score-matched comparison between laparoscopy vs. open approaches.

BACKGROUND: In light of today's role of minimally access surgery in colorectal oncologic treatment, we analyzed the impact of laparoscopic cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in selected patients with peritoneal metastases (PM) originating from colorectal and appendiceal cancer (CRAC). METHODS: Postoperative and oncologic outcomes were compared between patients with CRAC-PM treated by CRS/HIPEC undergoing laparoscopic (L-CRS/HIPEC) or open (O-CRS/HIPEC) procedures according to data collected from our tertiary referral hospital prospective database from April 2016 to April 2021. We excluded patients who did not undergo operation with curative intent. L-CRS was performed in patients who had no multifocal mesenteric lesions, no large abdominal mass, nor massive adhesions. Patients were matched by propensity scores 1:1 for peritoneal cancer index, completeness of cytoreduction score, concomitant resectable distal metastasis, primary tumor location, RAS mutation status and American Society of Anesthesiologists (ASA) classification. RESULTS: Of 106 eligible patients, 68 were matched (34 L-CRS/HIPEC; 34 O-CRS/HIPEC) by propensity scores. Compared with the open approach, L-CRS/HIPEC was associated with less overall surgical morbidities (14.7% vs. 38.2%; p = 0.028), shorter median hospital stay (10 [5-15] vs. 12 [8-33] days; p < 0.001) and reduced median waiting time before adjuvant chemotherapy (4.7 [3.0-13.2] vs. 5.7 [4.1-24.1] weeks; p = 0.047). No statistically significant difference was found in operative time or major morbidity rates between the two groups. After a median follow-up of 33.2 months, the rate of early peritoneal loco-regional recurrence, location of initial recurrence or 3-year survival outcomes were not statistically significantly related to the type of access (L-CRS/HIPEC vs. O-CRS/HIPEC). CONCLUSIONS: Laparoscopy for CRS/HIPEC is technically feasible and oncologically safe to treat selected patients with CRAC-PM. Further randomized control trials are required to confirm the benefits of minimal access surgery for the management of PM.

Laparoscopic redo anastomosis for management of intraperitoneal anastomotic leakage after colonic surgery.

BACKGROUND: There is still no consensus on the management of intraperitoneal anastomotic leakage after colonic surgery. Among of various treatment strategies, laparoscopic redo anastomosis for intraperitoneal leakage has rarely been reported in the literature and is condemned by some. The aim of this study is to demonstrate the feasibility and safety of laparoscopic redo anastomosis for intraperitoneal anastomotic leakage. METHODS: Retrospective chart review of laparoscopic redo anastomosis for intraperitoneal anastomotic leakage after colonic surgery from January 2013 to May 2020. An accompanying video demonstrates the technique. RESULTS: Fifteen consecutive patients underwent laparoscopic redo anastomosis for management of leakage after colonic surgery; two patients required conversion to open repair. A protective stoma was created in three patients during the second operation. There was no re-leakage nor mortality in this series. CONCLUSIONS: Laparoscopic redo anastomosis was feasible and safe for the management of intraperitoneal anastomotic leakage after colonic surgery. Considering the advantages of re-do laparoscopy, this procedure should be part of every surgeon's armamentarium to deal with anastomotic leakage and represents a logical alternative to the "Diversion and Drainage" technique.

Laparoscopic Reintervention for Intraperitoneal Leaks After Colonic Surgery: Do We Need a Routine Stoma?

INTRODUCTION: No universal consensus exists on the management of intraperitoneal anastomosis leakage after colonic surgery. The aim of the study was to evaluate the outcomes of laparoscopic reintervention without stoma creation for intraperitoneal leaks after colonic surgery. MATERIAL AND METHODS: Single tertiary center study conducted from January 2010 to December 2020. 54 patients with intraperitoneal leakage were divided into 2 groups according to whether they received a stoma (n = 37) or not (n = 17) during laparoscopic reintervention. Short term outcome was analyzed. RESULTS: Patients in the no stoma group had lower American Society of Anesthesiologists (ASA) score (P = .009), lower Acute Physiology And Chronic Health Evaluation II (APACHE II) score (5 vs. 10; P < .001) compared with the stoma group. Intensive care unit admission (43.2% vs. 5.8%; P = .006) and major complications (35.1% vs. 5.8%; P = .015) occurred more in the stoma group compared to the no stoma group. After multivariate logistic regression analysis, initial surgical procedure (P = .001) and APACHE II score (P = .039) were significant predictors of no stoma. The APACHE II score(P = .035) was an independent predictor of major complications. Finally, Receiver Operating Characteristic curve analysis showed that the cutoff value of APACHE II score for no stoma was 7.5. CONCLUSIONS: In our study, APACHE II score was an independent predictor of stoma formation and the cutoff value of APACHE II score for no stoma was 7.5. Our results need to be confirmed by larger and randomized studies. In particular, a specific APACHE II threshold to omit a stoma in this setting remains to be determined.

Transanal endoluminal repair for anastomotic leakage after low anterior resection.

BACKGROUND: There is still no consensus on the management of colorectal anastomotic leakage after low anterior resection. The goal was to evaluate the outcomes of patients who underwent transanal endoluminal repair + laparoscopic drainage ± stoma vs. drainage only ± stoma. METHODS: Retrospective chart review of patients sustaining anastomotic leakage after laparoscopic low anterior resection between January 2013 and September 2020 who required laparoscopic reoperation. RESULTS: Forty-nine patients were included, 22 patients underwent combined laparoscopy and transanal endoluminal repair and 27 patients had drainage with a stoma (n = 16) or drainage alone (n = 11), without direct anastomotic repair. The overall morbidity rate was 30.6% and the mortality rate was 2%. Combined laparoscopic lavage/drainage and transanal endoluminal repair of anastomotic leakage was associated with a lower complication rate (13.6% vs. 44.4%, p = 0.03) and fewer intraabdominal infections (4.5% vs. 29.6%, p = 0.03) compared with no repair. CONCLUSIONS: Combined laparoscopic lavage/drainage and transanal endoluminal repair is effective in the management of colorectal anastomosis leakage and was associated with lower morbidity-in particular intraabdominal infection-compared with no repair. However, our results need to be confirmed in larger, and ideally randomized, studies.