ABSTRACT
BACKGROUND: Several non-randomized and retrospective studies have suggested that intracorporeal anastomosis (IA) has advantages over extracorporeal anastomosis (EA) in laparoscopic right colectomy, but scientific evidence is lacking. The aim was to compare short-term outcomes and to define the possible benefits of IA compared with EA in elective laparoscopic right colectomy. METHODS: An RCT was conducted from May 2015 to June 2018. The primary endpoint was duration of hospital stay. Secondary endpoints were intraoperative technical events and postoperative clinical outcomes. RESULTS: A total of 140 patients were randomized. Duration of surgery was longer for procedures with an IA than in those with an EA (median 149 (range 95-215) versus 123 (60-240) min; P < 0·001). Wound length was shorter in the IA group (median 6·7 (4-9·5) versus 8·7 (5-13) cm; P < 0·001). Digestive function recovered earlier in patients with an IA (median 2·3 versus 3·3 days; P = 0·003) and the incidence of paralytic ileus was lower (13 versus 30 per cent; P = 0·022). Less postoperative analgesia was needed in the IA group (mean(s.d.) weighted analgesia requirement 39(24) versus 53(26); P = 0·001) and the pain score was also lower (P = 0·035). The postoperative decrease in haemoglobin level was smaller (mean(s.d.) 8·8(1·7) versus 17·1(1·7) mg/dl; P = 0·001) and there was less lower gastrointestinal bleeding (3 versus 14 per cent; P = 0·031) in the IA group. IA was associated with a significantly better rate of grade I and II complications (P = 0·016 and P = 0·037 respectively). The duration of hospital stay was slightly shorter in the IA group (median 5·7 (range 2-19) versus 6·6 (2-23) days; P = 0·194). CONCLUSION: Duration of hospital stay was similar, but IA was associated with less pain and fewer complications. Registration number: NCT02667860 ( http://www.clinicaltrials.gov).
ANTECEDENTES: Varios estudios no aleatorizados y retrospectivos sugieren que la anastomosis intracorpórea (intracorporeal anastomosis, IA) tiene ventajas sobre la anastomosis extracorpórea (extracorporeal anastomosis, EA) en la colectomía laparoscópica derecha, pero no hay suficientes evidencias científicas. El objetivo del estudio fue comparar los resultados a corto plazo y definir los posibles beneficios de la anastomosis intracorpórea versus extracorpórea en la colectomía derecha laparoscópica electiva. MÉTODOS: Se realizó un ensayo clínico prospectivo y aleatorizado de mayo de 2015 a junio de 2018. El criterio de valoración principal fue la duración de la estancia hospitalaria. Los criterios de valoración secundarios fueron los eventos técnicos intraoperatorios y los resultados clínicos postoperatorios. RESULTADOS: Se aleatorizaron 140 pacientes. El tiempo quirúrgico fue más largo para la IA que para la EA (149,49 ± 27,24 versus 123,35 ± 36,56 min; P = 0,001). La longitud de la herida fue más corta en la IA (6,65 ± 1,21 versus 8,72 ± 1,44 cm; P < 0,001). La función digestiva se recuperó antes en la IA que en la EA (2,3 versus 3,3 días, P = 0,003) y la incidencia de íleo paralítico fue menor (13% versus 30%, P = 0,022). Los requisitos de analgesia postoperatoria fueron menores con la IA (39 ± 24,3 versus 53 ± 26; P < 0,001) y la puntuación de dolor (EVA) también fue menor (P < 0,035). El descenso de la hemoglobina en el postoperatorio y la hemorragia gastrointestinal baja fueron menores en la IA que en la EA (-8,83 ± 1,7 versus -17,07 ± 1,7 mg/dl; P = 0,001) y (2,8% versus 14%; P = 0,031), respectivamente. La clasificación de Clavien-Dindo mostró que la IA se asoció con resultados significativamente mejores que la EA: grado I (10% versus 27% P = 0,016); grado II (18% versus 35%, P = 0,0369). La puntuación del índice de complicación integral (comprehensive complication index, CCI) fue menor en el grupo IA (5,33 ± 9,2 versus 11,15 ± 14,34; P = 0,006). La estancia hospitalaria fue más corta en el grupo de IA pero sin diferencia significativa (5,65 ± 3,75 versus 6,58 ± 4,63 días; P = 0,194). CONCLUSIÓN: La IA presenta ventajas clínicas sobre la EA en la colectomía derecha laparoscópica.
Subject(s)
Anastomosis, Surgical/methods , Colectomy/methods , Laparoscopy/methods , Adult , Aged , Aged, 80 and over , Colon/surgery , Female , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Operative Time , Pain, Postoperative/epidemiology , Perioperative Care , Single-Blind Method , Treatment OutcomeABSTRACT
BACKGROUND: Colorectal cancer (CRC) is the third most frequent cancer diagnosed in men and the second in women. Laparoscopic surgery has been a technical revolution in colorectal surgery, facilitating a better recovery of patients with lower morbidity and better esthetic results, compared to traditional surgery via laparotomy, without compromising safety and long-term oncological results. PURPOSE: The trial is a randomized controlled trial indented to evaluate the two interventions with thorough measurements of the postoperative variables and complications to improve the evaluation of the surgical technique. The primary endpoint is to compare the hospital stay, which will be measured in days between both groups. The purpose of the study at secondary endpoints is to compare intraoperative and postoperative events between both groups in terms of operating time, anastomotic performance time, intraoperative complications, number of harvested lymph nodes, need for blood transfusion, length of the surgical wound, start and tolerance of oral intake, beginning of digestive functionality, postoperative pain, need for analgesic administration, surgical wound infection, paralytic ileus, anastomosis leakage or dehiscence, need for surgical reintervention, and hospital readmission within the first 30 days after surgery. METHODS: This trial is a prospective, randomized, single-blind, and single-center clinical trial comparing intracorporeal anastomosis versus extracorporeal anastomosis for right laparoscopic hemicolectomy. CONCLUSIONS: Nowadays, there are several retrospective trials comparing the benefits for extracorporeal anastomosis versus intracorporeal anastomosis in right colon cancer patients. Considering the impact for laparoscopic surgery, we think it is necessary to do a randomized trial comparing extracorporeal versus intracorporeal anastomosis modalities. TRIAL REGISTRATION: www.clinicaltrials.gov No. NCT02667860 and Hospital de la Santa Creu i Sant Pau Research Institute No. IIBSP-AIE-2015-01.
Subject(s)
Colectomy , Laparoscopy , Anastomosis, Surgical/adverse effects , Clinical Audit , Colectomy/adverse effects , Endpoint Determination , Humans , Laparoscopy/adverse effects , Reproducibility of Results , Sample SizeABSTRACT
BACKGROUND AND AIMS: Intra-abdominal local recurrences of colorectal cancer can be difficult to localize and excise because they are not easily visible or palpable. MATERIALS AND METHODS: We report on our experience using the computed tomography-guided harpoon technique to locate and resect these nodules in seven patients. RESULTS: No complications were recorded during the procedures. Six nodes were malignant and all margins were tumor free. CONCLUSIONS: Harpoon placement for intra-abdominal local recurrences of colorectal cancer is a feasible and useful technique that provides direct localization and complete excision of lesions.
Subject(s)
Abdominal Neoplasms/diagnostic imaging , Abdominal Neoplasms/surgery , Colorectal Neoplasms/pathology , Neoplasm Recurrence, Local/diagnostic imaging , Neoplasm Recurrence, Local/surgery , Surgery, Computer-Assisted , Abdominal Neoplasms/secondary , Aged , Aged, 80 and over , Colorectal Neoplasms/diagnostic imaging , Female , Humans , Male , Middle Aged , Positron-Emission Tomography , Retrospective Studies , Tomography, X-Ray ComputedABSTRACT
BACKGROUND: The incidence of perineal hernia after abdominoperineal excision and extralevator abdominoperineal excision ranges from 1 to 26%. In this systematic review, we compared surgical options and postoperative outcomes of perineal hernia repair in this setting from 2012 to 2016 with findings in a review of publications 1944-2011. METHODS: We searched the PubMed database using the keywords "hernia" AND "perineum" identified 392 papers published from 1946 to 2016. Two hundred and ninety-six papers published before 2012 were excluded and 96 were found to be potentially relevant. RESULTS: Twenty-one studies with a total of 108 patients were included in the final analysis. Perineal hernia repair was performed using the perineal approach in 75 patients (69.44%), the laparoscopic approach in 25 patients (23.14%), the open abdominal approach in three patients (2.77%) and the laparoscopic perineal approach in three patients (2.77%) and the open abdominoperineal approach in two patients (1.8%). Non-absorbable mesh was used in 41 (37.96%) of cases, composite mesh in 20 (18.51%) and biological mesh in 19 (17.59%). Flap reconstruction was used in 25 patients (23.14%). First and second recurrences were observed in 26 (24.07%) and 7 (26.92%) cases, respectively. CONCLUSIONS: Comparison of perineal hernia repair from 1944 to 2011 and from 2012 to 2016 showed that perineal and laparoscopic approaches are currently the most commonly used techniques. Primary defect closure was abandoned in favor of synthetic or composite mesh placement. Use of flap reconstruction spread rapidly and the recurrence rate was low. Randomized control trials and a larger sample size are needed to confirm these data and to develop a gold standard treatment for secondary hernia repair after abdominoperineal excision or extralevator abdominoperineal excision.
