Intracorporeal Versus Extracorporeal Anastomosis in Robotic Right Colectomy: A Multicenter, Triple-blind, Randomized Clinical Trial.

OBJECTIVE: To determine if minimally invasive right colectomy with intra-corporeal anastomosis improves postoperative recovery compared to extra-corporeal anastomosis. BACKGROUND: Previous trials have shown that intracorporeal anastomosis improves postoperative recovery; however, it has not yet been evaluated in a setting with optimized perioperative care or with patient-related outcome measures. METHODS: This was a multicenter, triple-blind, randomized clinical trial at two high-volume colorectal centers with strict adherence to optimized perioperative care pathways. The patients underwent robotic right colectomy with either intracorporeal or extracorporeal anastomosis. The primary outcome was patient-reported postoperative recovery measured using the "Quality of Recovery-15" questionnaire. ClinicalTrials.gov NCT03130166. RESULTS: A total of 89 patients were randomized and analyzed according to the "Intention-to-treat"-principle. We found no statistically significant differences in patient-reported recovery between the groups. Postoperative pain, nausea, time to ambulation, time to first passage of flatus/stool, length of hospital stay, and pathophysiological tests showed no differences either. The duration of time to create the anastomosis was significantly longer with intracorporeal anastomosis (17 vs 13 min, P = 0.003), while all other intraoperative, postoperative, and pathology variables showed no difference. CONCLUSION: There were no significant differences in postoperative recovery between the two groups.

The effect of intracorporeal versus extracorporeal anastomosis in robotic right colectomy on perianastomotic perfusion: a substudy to a multicenter RCT.

PURPOSE: Previous studies have shown that intracorporeal anastomosis (ICA) in minimally invasive right colectomy may improve postoperative recovery compared with extracorporeal anastomosis (ECA). It has been hypothesized that creating the anastomosis extracorporeally may cause mesenteric traction and compromised intestinal perfusion. The purpose of this study was to investigate the effect of either ICA or ECA on intestinal perfusion. METHOD: This was a substudy to a multicenter, triple-blind randomized clinical trial comparing ICA with ECA in patients undergoing robotic right colectomy for colonic cancer. Videos from intraoperative Indocyanine Green (ICG) fluorescence imaging were analyzed with quantitative ICG perfusion assessment (q-ICG). q-ICG was performed by extracting perfusion metrics from a time-intensity curve generated from an image analysis software: FMAX: maximal fluorescence intensity, TMAX: time until maximal fluorescent signal, T1/2MAX: time until half-maximal fluorescent signal, time ratio (T1/2MAX/TMAX) and slope. RESULTS: A total of 68 patients (33 ICA and 35 ECA) were available for analysis. Demographics were similar between the groups, except for mean arterial blood pressure at the time of ICG infusion, which was significantly lower in the ICA group. We found a significantly steeper slope in the ICA group compared to the ECA group (6.3 vs. 4.7 AU/sec, P = .048). There were no significant differences in FMAX, TMAX, T1/2MAX, and time ratio. CONCLUSION: We found evidence of an improved intestinal perfusion following ICA compared with ECA. This finding may be related to patient outcomes and should be explored further in the future. CLINICALTRIALS: gov NCT03130166.

Safety of early ileostomy closure: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: Patients with a defunctioning ileostomy after rectal resection experience substantial ileostomy-related morbidity and decreased quality of life. Early reversal of the defunctioning ileostomy has been proposed as a method of mitigating these problems. We aimed to evaluate the safety of early ileostomy closure within 6 weeks. METHOD: Randomized controlled trials investigating the safety of early ileostomy closure were identified through a systematic search and review of the current literature. Meta-analysis of the extracted outcome data was performed, and the methodological quality of the individual studies was assessed. RESULTS: The search identified six eligible studies yielding a total of 528 patients, with 269 in the early closure (EC) group and 259 in the standard closure (SC) group. Major complications in the EC group was 5.2% compared with 3.6% in the SC group (RR = 1.12, 95% CI 0.33-3.79). Anastomotic leakage in the EC group was 3.3% compared with 3.5% in the SC group (RR = 0.89, 95% CI 0.29-2.75). The meta-analysis resulted in no statistically significant differences between the groups in any of the primary or secondary outcomes. CONCLUSION: This review was not able to discern a statistically significant difference in postoperative complications when comparing early and standard ileostomy closure. The current literature indicates that early ileostomy closure is not associated with higher complication rates in patients with an uncomplicated postoperative course and radiologically verified intact distal anastomosis after index surgery.