Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer.

OBJECTIVES: To evaluate comparative outcomes of transanal total mesorectal excision (TaTME) and laparoscopic TME (LaTME) in patients with rectal cancer. METHODS: We systematically searched multiple databases and bibliographic reference lists. A combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits were applied. Overall intraoperative complications, overall postoperative complications, anastomotic leak, surgical site infections (SSIs), completeness of mesorectal excision, R0 resection, distal (DRM) and circumferential resection margin (CRM), number of harvested lymph nodes, and procedure time were the evaluated outcome parameters. RESULTS: We identified 18 comparative studies reporting a total of 2048 patients evaluating outcomes of TaTME (n = 1000) and LaTME (n = 1048) in patients with rectal cancer. TaTME was associated with significantly higher number of R0 resection (OR 1.67, P = 0.01) and harvested lymph nodes (MD 1.08, P = 0.01), and lower rate of positive CRM (OR 0.67, P = 0.04) and conversion to an open procedure (OR 0.17, P < 0.00001) compared with LaTME. However, there was no significant difference in intraoperative complications (OR 1.18, P = 0.54), postoperative complications (OR 0.89, P = 0.24), anastomotic leak (OR 0.88, P = 0.42), SSIs (OR 0.64, P = 0.26), completeness of mesorectal excision (OR 1.43, P = 0.19), DRM (MD 1.87, P = 0.16), CRM (MD 0.36, P = 0.58), and procedure time (MD - 10.87, P = 0.18) between TaTME and LaTME. Moreover, for low rectal tumours, TaTME was associated with significantly lower rate of anastomotic leak and higher number of lymph nodes (MD 2.06, P = 0.002). CONCLUSIONS: Although the meta-analysis of best available evidence (level 2) demonstrated that TaTME may be associated with better short-term oncological outcomes and similar clinical outcomes compared with LaTME, the differences between the two groups were small questioning their clinical relevance. No solid conclusions can be made due to lack of high quality randomised studies.

Laparoscopic Transcystic Versus Transductal Common Bile Duct Exploration: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate comparative outcomes of laparoscopic transcystic (TC) and transductal (TD) common bile duct (CBD) exploration. METHODS: We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. CBD clearance rate, perioperative complications, and biliary complications were defined as the primary outcome parameters. Procedure time, length of hospital stay, conversion to open procedure were the secondary outcomes. Combined overall effect sizes were calculated using random-effects models. RESULTS: We identified 30 studies reporting a total of 4073 patients comparing outcomes of laparoscopic TC (n = 2176) and TD (N = 1897) CBD exploration. The TC approach was associated with significantly lower overall complications (RD: -0.07, P = 0.001), biliary complications (RD: -0.05, P = 0.0003), and blood loss (MD: -16.20, P = 0.02) compared to TD approach. Moreover, the TC approach significantly reduced the length of hospital stay (MD: -2.62, P < 0.00001) and procedure time (MD: -12.73, P = 0.005). However, there was no significant difference in rate of CBD clearance (RD: 0.00, P = 0.77) and conversion to open procedure (RD: 0.00, P = 0.86) between two groups. CONCLUSIONS: Laparoscopic TC CBD exploration is safe and reduces overall morbidity and biliary complications compared to the TD approach. Moreover, it is associated with significantly shorter length of hospital stay and procedure time. High-quality randomised trials may provide stronger evidence with respect to impact of the cystic duct/CBD diameter, number or size of CBD stones, or cystic duct anatomy on the comparative outcomes of TC and TD approaches.

Impact of cumulative experience on the quality of screening colonoscopy: A 13-year observational study.

OBJECTIVE: To investigate trends in quality of screening colonoscopy (using the Global Rating Score) in the 13 years since introduction of the Bowel Cancer Screening Programme in England. SETTING: An English Bowel Cancer Screening Programme colonoscopy service from 2007 to 2019. METHODS: A retrospective observational study was undertaken using a prospectively collected database in order to analyse trends in screening endoscopies (including patients following positive faecal occult blood test or with high-risk findings on flexible sigmoidoscopy). The Global Rating Score quality indicators for Bowel Cancer Screening Programme colonoscopy were used as outcome measures, and trends over time were analysed. These included caecal intubation rate, adenoma detection rate, colorectal cancer detection rate, proportion of patients with minimal or mild discomfort scores, proportion of patients who required intravenous sedation, and adverse events. RESULTS: There were 5352 colonoscopies included, performed by 3 endoscopists; 73.8% were index procedures (i.e. first Bowel Cancer Screening Programme colonoscopy) and the remainder were follow-up or surveillance colonoscopies. The mean age of patients was 66 (standard deviation 5) years, and 59.8% were male. Mean age increased over time (R2=0.033; p < 0.001). There were significant trends over time towards higher caecal intubation rate (p = 0.015), higher adenoma detection rate (p < 0.001), lower proportion requiring intravenous sedation (p < 0.001). There were no significant trends in comfort scores (p = 0.606), adverse events (p = 0.503) or colorectal cancer detection (p = 0.089). CONCLUSION: There was a consistent improvement in the Global Rating Score for Bowel Cancer Screening Programme colonoscopies since the start of the programme, even when quality was already high at the start. Patients can expect high-quality colonoscopy when participating in the Bowel Cancer Screening Programme.