Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus

Background

There are different open healing and primary closure approaches for chronic pilonidal sinus (CPD) that differ in principles and extension.

Aims

To compare the results of different closure surgical techniques, we performed a meta-analysis of randomized controlled trials (RCT) comparing: (1) open wide excision versus open limited excision (sinusectomy) or unroofing (sinotomy); (2) midline closure (conventional and tension-free) versus off-midline; (3) advancing versus rotation flaps; and (4) sinusectomy/sinotomy versus primary closure.

Methods

Data extraction and risk of bias assessment were conducted independently by the authors using the Cochrane Collaboration’s tool. Data were pooled using fixed and random-effects models. Primary outcomes were rate of healing, recurrence, wound infection and dehiscence. Twenty-five trials (2,949 patients) were included.

Results

Four trials compared limited versus radical open healing. Although recurrence rate did not differ, all other outcomes favored the limited approach. Ten studies compared midline versus off-midline primary closure; wound infection and dehiscence were significantly higher after midline closure. Six RCT compared Karydakis/Bascom versus Limberg. No difference was found in recurrence or wound complications rate. Six RCT compared sinusectomy/sinotomy versus primary closure. Recurrence rate was significantly lower after sinusectomy/sinotomy; no significant differences were found in other outcomes.

Conclusion

Our meta-analysis suggest that some of the questions of which is the best surgical technique for CPD have now been answered: open radical excision and primary midline closure should be abandoned. Sinusotomy/sinectomy or en bloc resection with off midline primary closure are the preferred approaches.     

S3-Leitlinie: Sinus pilonidalis

Background

The pilonidal sinus is an acquired disease of hair follicles. The aim of the present guidelines is to compare various treatment methods and to assist physicians with evidence-based recommendations.

Methods

A systemic literature review was carried out. The present guidelines were reviewed and accepted by a consensus conference.

Results

There are three types of disease manifestation: an asymptomatic condition, acute abscess and chronic pilonidal disease. The latter is the most frequent type of presentation. At present, there is no treatment method fulfilling all desired criteria: a simple, painless procedure associated with rapid wound healing and a low recurrence rate.

Conclusion

An asymptomatic pilonidal disease does not necessitate any treatment. A pilonidal abscess should initially be locally incised followed by one of the definitive treatment methods after regression of the acute inflammation. A primary complete excision of the abscess and open wound treatment is associated with a prolonged healing time. An excision of the pilonidal abscess and primary wound closure is associated with increased morbidity and recurrence rate and should be avoided. The basic treatment method of chronic pilonidal disease is surgical excision. Open wound treatment after pilonidal excision is associated with a low postoperative morbidity; however, this method is complicated by a considerably prolonged wound healing. Minimally invasive procedures (e.g. pit picking surgery) represent a treatment option for chronic pilonidal disease; however, the recurrence rate is higher compared to open procedures. Excision followed by a primary midline wound closure bears no advantages to other methods and should be avoided. An off-midline surgical approach can be adopted as a primary treatment option in chronic pilonidal disease. At present, there is no evidence of any outcome differences between various off-midline procedures. The Limberg flap and the Karydakis procedure are the two best described methods.     

The short- and long-term outcomes of laparoscopic versus open surgery for colorectal cancer: a meta-analysis

Purpose

The aim of the study was to compare short- and long-term outcomes of laparoscopic surgery and conventional open surgery for colorectal cancer.

Methods

Published randomized controlled trial (RCT) reports of laparoscopic surgery and open surgery for colorectal cancer were searched, and short- and long-term factors were extracted to perform meta-analysis.

Results

A total of 15 RCT reports (6,557 colorectal cancer patients) were included in this study. Blood loss of laparoscopic surgery was less by 91.06 ml than open surgery (p?=?0.044). Operation time was longer by 49.34 min (p?=?0.000). The length of hospital stay was shorter by 2.64 days (p?=?0.003). Incisional length was shorter by 9.23 cm (p?=?0.000). Fluid intake was shorter by 0.70 day (p?=?0.001). Bowel movement was earlier by 0.95 day (p?=?0.000). Incidence of complications, blood transfusion, and 30 days death were significantly lower in laparoscopic surgery than in open surgery (p?=?0.011, 0.000, 0.01). But there was no significant difference in lymph nodes (p?=?0.535) and anastomotic leak (p?=?0.924). There was also no significant difference in 3 and 5 years overall survival (p?=?0.298, 0.966), disease-free survival (p?=?0.487, 0.356), local recurrence (p?=?0.270, 0.649), and no difference in 5 years distant recurrence (p?=?0.838).

Conclusions

Laparoscopic surgery is a mini-injured approach which can cure colorectal cancer safely and radically, and it is not different from conventional open surgery in long-term effectiveness, so laparoscopic surgery can be tried to widely use in colorectal cancer.     

Risk of infection and hernia recurrence for patients undergoing ventral hernia repair with non-absorbable or biological mesh during open bowel procedures

Background

Ventral hernia repair (VHR) with mesh performed concurrently with colorectal surgery is presumably associated with significant risks of infection and recurrence. The purpose of this study is to evaluate the outcomes of patients undergoing VHR with non-absorbable mesh (NAM) or biological mesh (BM) at the same time as open colorectal surgery.

Methods

A retrospective review of short- and long-term outcomes for 25 patients undergoing repair of VHR with NAM or BM at the same time as an open colorectal procedure from 1991 to 2007 was performed.

Results

The mean age of the patients was 50.8 ± 12.7 years. Fifteen patients (60 %) underwent VHR with NAM versus 10 (40 %) with BM at the time of colorectal surgery. Mean follow-up after surgery was 32.9 ± 38.2 months. Overall wound infection, mesh infection and hernia recurrence rates were 44, 36 and 36 %, respectively. There was no difference between the NAM and BM mesh repair groups in terms of operative indications (p = 0.23) and operations performed (p = 0.47). Both groups had similar gender, ASA score, age, BMI, operating time, hernia recurrence rate, wound infection and follow-up.

Conclusions

Although a proportion of patients who undergo concomitant use of mesh for VHR during colorectal resection has reasonable outcomes, there is a high associated risk of wound and mesh infection. Thus, a judicious decision regarding the use of mesh for hernia repair needs to be made on a case-by-case basis for patients undergoing open bowel surgery at the same time.     

Perineal reconstruction after extra-levator abdominoperineal excision (eLAPE): a systematic review

Purpose

Extra-levator abdominal perineal excision of rectum (eLAPE) for low rectal tumours is associated with a lower incidence of circumferential resection involvement. However, there is no consensus on the ideal technique for perineal reconstruction following eLAPE. We thereby conducted a 5-year review of perineal closure outcomes following eLAPE.

Methods

A systematic review of the literature was conducted between 2006 and July 2012. Perineal wound healing and complications in the post-operative period were examined.

Results

Original data following eLAPE were found in 27 studies involving 963 individuals to inform a qualitative synthesis. Pooled analysis revealed that investigators most commonly employed either biomesh closure (12 studies, n?=?149), myocutaneous flap closure (9 studies, n?=?201) and primary closure (4, n?=?578). The incidence of minor and major wound complications and perineal hernias across the latter groups was (27.5, 13.4 and 2.7 %), (29.4, 19.4 and 0 %) and (17.1, 6.4 and 1.2 %), respectively. Two studies utilised synthetic mesh closure (n?=?4) and omentoplasty (n?=?31). Objective assessment of wound healing was strikingly deficient across most studies, largely due to low level retrospective evidence lacking randomised controls. Modest cohort sizes with short follow-up data were evident due to the relative novelty of eLAPE.

Conclusion

The paucity of high quality data, suggests that a prospective, randomised trial is needed to determine the ideal technique for perineal reconstruction following eLAPE.     

Atrial fibrillation following open heart surgery: long-term incidence and prognosis

Introduction

While early postoperative atrial fibrillation (post op AF) following valve and coronary artery bypass surgery is a known common cause of increased morbidity and mortality, the late recurrence of AF long term in this group of patients has not been well studied.

Objective

The objective of this study was to assess the late recurrence and predictors of AF in patients undergoing open heart surgery.

Methods

From a prospective cardiovascular surgery registry, 519 patients with no prior history of AF who underwent open heart surgery for cardiac bypass/valvular surgeries between May 2000 and April 2004 were followed until May 2009. A Cox proportional hazards model was used to assess the impact of early post op AF on the long-term AF after adjusting for significant covariates

Results

Of these patients, 25.6 % (133) had early (0–3 months) post op AF (group A). The remainder of patients were considered as controls (group B, n?=?386). Late occurrence of AF (3–84 months) was 5.3 % (n?=?28) after a mean follow up duration of 5?±?1.9 years. The late occurrence of AF in group A (recurrent AF) was significantly higher than in group B (11 vs 3 % n?=?15 vs 13, p?=?0.0002). Early postoperative AF was a significant predictor of late recurrence of AF in multivariate analysis (hazard ratio (HR) 3.9, CI 1.8–8.4, p?=?0.0003). Group A also had higher mortality compared to group B (21 vs 13 %, n?=?28 vs n?=?51, p?=?0.003) with early postoperative AF showing a trend towards higher mortality on multivariate analysis (HR 1.7, p?=?0.06).

Conclusions

Late recurrence of AF is higher than was previously thought to be in patients experiencing early post operative AF with a trend towards higher long-term mortality. Post op AF should not be dismissed as a benign entity and these patients should be followed closely.     

Factors predicting stomal wound closure infection rates

Background

Stoma closure is associated with high wound infection rates. The aim of this study was to evaluate risk factors for infection rates in such wounds, with particular emphasis on assessing the importance of the stomal wound closure technique.

Methods

A retrospective analysis of 142 patients who had undergone ileostomy or colostomy closure between 2002 and 2011 was performed. Postoperative outcome as measured by wound infection rate was recorded. Three different closure techniques were identified: primary closure (PC), primary closure with Penrose drain (PCP) and purse-string circumferential wound approximation technique (PSC). Other factors such as age, sex, ASA score, type of prophylactic antibiotics used, diabetes, smoking and obesity were also analysed. All other techniques were excluded.

Results

Our series consisted of 142 stomal closures (90 ileostomy and 52 colostomy closures). The patients had a median age of 63.5 years with an interquartile range of 50.1–73.2 years. The overall wound infection rate was 10.7 %. PC, PCP and PSC were associated with wound infection rates of 17.9, 10.5 and 3.6 %, respectively. Compared to PSC, PC and PCP were associated with significantly higher wound infection rates (p = 0.027 and p = 0.068, respectively). Obesity was a significant risk factor for wound infection (p = 0.024). Use of triple-agent antibiotics prophylactically had a protective effect on the infection rate (p = 0.012).

Conclusions

To reduce stomal wound closure infection rates, we recommend institution of closure techniques other than PC with or without a drain. Risk factors such as obesity should be addressed, and prophylactic triple antibiotics should be administered.     

The roles of surgery and EMA/CO chemotherapy regimen in primary refractory and non-refractory gestational trophoblastic neoplasia

Purpose

To determine the characteristics and outcome of patients with refractory gestational trophoblastic neoplasia (GTN) after primary chemotherapy (CTx).

Methods

The outcome of low- and high-risk patients with refractory GTN (n?=?14, 37%) was compared to those with non-refractory GTN (n?=?24, 63%). Methotrexate treatment was used for patients with low-risk disease and EMA/CO for patients with high-risk disease.

Results

Median follow-up time was 53?months (range 1–173?months). All non-refractory patients and 11 refractory patients (79%) survived (p?=?0.015). Factors related to resistance to primary CTx was age (p?=?0.012), duration between causal pregnancy and initial treatment (p?=?0.003), surgery (p?=?0.014), hCG level before CTx (p?=?0.09) and half-life of hCG (p?=?0.061). Six out of 10 low-risk refractory patients treated with EMA/CO regimen in the second-line setting had been followed by no evidence of disease. Nine of 38 (24%) patients underwent surgery (TAH?±?BSO) for GTN. All of the patients treated with surgery were in the non-refractory group, but none of refractory patients underwent surgery (p?=?0.014).

Conclusions

Surgery and EMA/CO regimen are one of the main factors that play a role in the management of refractory low-risk GTN.     

Laparoscopic resection for sigmoid and rectosigmoid colon cancer performed by trainees: impact on short-term outcomes and selection of suitable patients

Purpose

This study aimed (1) to evaluate the impact of clinical factors, particularly operation by trainees, on the short-term outcomes of laparoscopic resection for sigmoid and rectosigmoid cancer, and (2) to determine patients suitable for operation by trainees.

Methods

From a prospectively maintained single-institution database, we identified 133 patients who underwent laparoscopic resection for sigmoid or rectosigmoid cancer between 2007 and 2010. Gender, age, body mass index (BMI), previous abdominal surgery, tumor location, tumor size, tumor stage, extent of lymph node dissection, and primary surgeon were evaluated using univariate and multivariate analyses to determine the predictive significance of these variables on surgical outcomes including operative time, blood loss, complication, postoperative stay, and retrieved lymph nodes.

Results

Multivariate analysis showed that location of the tumor in the rectosigmoid (p?p?p?p?=?0.002), and greater tumor depth (p?=?0.011) were independently predictive of longer operative time. Larger tumor size (p?=?0.025) and higher BMI (p?=?0.040) were independently predictive of greater blood loss. Larger tumor size was also related to longer postoperative stay (p?=?0.001) and a greater number of retrieved lymph nodes (p?=?0.001).

Conclusions

This study identified operation by trainees as an independent risk factor for longer operative time but with no negative impact on any of the other outcomes. Female patients with a low BMI, sigmoid cancer, shallow tumor depth, and/or small tumor are suitable for operation by trainees.     

Higher rate of perineural invasion in stent–laparoscopic approach in comparison to emergent open resection for obstructing left-sided colon cancer

Purpose

We compared oncologic outcomes of laparoscopic surgery following self-expandable metallic stent (SEMS) insertion with one-stage emergency surgical treatment of obstructive left-sided colon and rectal cancers.

Methods

From April 1996 to October 2007, 95 consecutive patients with left-sided obstructive colorectal cancers were included: 25 underwent preoperative stenting and elective laparoscopic surgery (SLAP) and 70 underwent emergency open surgery with intraoperative colon lavage (OLAV). Long-term oncologic outcomes were analyzed on an intention-to-treat basis.

Results

There were no significant differences in baseline characteristics of patients between groups. Perineural invasion of the primary tumor was more frequent with SLAP (76 vs. 51.4 %, p?=?0.033). The median follow-up was 51 months (range, 4–139 months). There were no significant differences between groups in 5-year overall survival rates (SLAP vs. OLAV, 67.2 vs. 61.6 %, p?=?0.385). Five-year disease-free survival rates were also similar between groups (SLAP vs. OLAV, 61.2 vs. 60.0 %, p?=?0.932).

Conclusions

Laparoscopic surgery after SEMS was feasible and safe for patients with obstructive left-sided colorectal cancer, and oncologic outcomes were comparable to emergency open surgery with intraoperative colon lavage. These results support the continued use of SLAP in this setting. Further large-scale study is needed to investigate any clinical impact attached to the higher rates of perineural invasion observed in SLAP.     

Does preoperative total parenteral nutrition in patients with ulcerative colitis produce better outcomes?

Purpose

Malnutrition is a frequent problem in patients with ulcerative colitis (UC) leading to increased postoperative complication rates. Preoperative total parenteral nutrition (TPN) has been shown to reduce complications in some subgroups of patients, but has not been studied in UC. We investigated the impact of preoperative TPN on postoperative complication rates in patients undergoing surgery for UC.

Methods

This paper is a review of 235 patients who underwent surgery for UC; 56 received preoperative TPN and 179 did not. Postoperative complication rates were compared.

Results

Both had similar rates of anastomotic leak (5.4 vs. 2.8?%, p?=?0.356), infection (12.5 vs. 20.1?%, p?=?0.199), ileus/bowel obstruction (21.4 vs. 15.6?%, p?=?0.315), cardiac complications (3.6 vs. 0?%, p?=?0.056), wound dehiscence (3.6 vs. 1.7?%, p?=?0.595), reoperation (10.7 vs. 3.9?%, p?=?0.086), and death (1.8 vs. 0?%, p?=?0.238). The TPN group was more malnourished (albumin 2.49 vs. 3.45, p?<?0.001), more often on steroids (83.9 vs. 57.5?%, p?<?0.001), had more emergent surgery (10.7 vs. 3.4?%, p?=?0.029), more severe colitis (89.3 vs. 65.9?%, p?=?0.001), and lower Surgical Apgar Score (6.15 vs. 6.57, p?=?0.033). After controlling for these with logistic regression, the TPN group still had higher complication rates (OR 2.32, p?=?0.04). When line infections were excluded, TPN did not significantly affect outcomes (OR 1.5, p?=?0.311)

Conclusion

There were no differences in postoperative complications when line infections were excluded. Our data does not support routine preoperative TPN in patients with UC. However, it may lead to equal surgical outcomes in the sickest and most malnourished patients at the cost of line-related morbidity.     

Role of 0.4% glyceryl trinitrate ointment after haemorrhoidectomy: results of a prospective randomised study

Introduction

Conventional haemorrhoidectomy (CH) is well known to cause significant post-operative pain and delayed return to daily activities. Both surgical wounds and sphincterial apparatus spasms are likely responsible for the pain. In this study, we evaluated the role of glyceryl trinitrate ointment (GTN) in reducing post-operative pain, ameliorating wound healing and recovery after CH.

Patients and methods

Between 01/08 and 12/11, 203 patients with symptomatic haemorrhoids were enrolled in the study and received (103 patients) or not (100 patients) 0.4 % GTN ointment for 6 weeks after surgery. Pain was assessed using a 10-cm linear visual analogue scale (VAS). Data on post-operative pain, wound secretion and bleeding, return to normal activities and complications were recorded. Data were analysed using Fisher’s exact and Mann–Whitney tests.

Results

GTN-treated group experienced significantly less pain during the first week after surgery (p?<?0.0001). This difference was more evident starting from post-operative day 4 (p?<?0.0001). A significant higher percentage of untreated patients experienced severe pain (mean VAS score?>?7) (10 % vs 31 %). There were significant differences in terms of secretion time (p?=?0.0052) and bleeding time (p?=?0.02) in favor of GTN. In addition, the duration of itching was less in the GTN group (p?=?0.0145). Patients treated with GTN were able to an early return to daily activities compared to untreated (p?<?0.0001). Fifteen GTN-treated patients (14.6 %) discontinued the application because of local discomfort and headache.

Conclusions

GTN ointment enhances significantly post-operative recovery, reducing pain in terms of duration and intensity. This effect might be secondary to a faster wound healing expressed by reduced secretion, bleeding and itching time.     

Diversion stoma after colorectal surgery: loop colostomy or ileostomy?

Background

The total rate as well as the clinical outcome of anastomotic leakage in colorectal and coloanal anastomosis necessitates a loop stoma for fecal diversion. The aim of this study was to determine the outcome of loop transverse colostomy compared to loop ileostomy as a temporary defunctioning stoma following colorectal surgery with colorectal or coloanal anastomosis.

Methods

Data of 200 patients between January 2003 and January 2009 were analyzed in this two-center study to determine the surgical outcome in patients with loop colostomy (n?=?100) in comparison to loop ileostomy (n?=?100) for fecal diversion including outcome of stoma creation and complication rates during stoma reversal.

Results

During stoma placement, dermatitis and renal insufficiency occurred significantly more often in the loop ileostomy group than in the loop transverse colostomy group (15% vs. 0%; p?p?=?0.005). During stoma reversal, wound infection occurred significantly more often in the loop transverse colostomy group than in the loop ileostomy group (27% vs. 8%; p?p?p?p?Conclusions Both methods provide a good operative outcome with low complication rates. We do recommend the loop ileostomy in all patients in which dehydration is not to be expected since wound infection rate is lower and hospital stay is shorter during stoma reversal.     

Preoperative elevation of carcinoembryonic antigen predicts poor tumor response and frequent distant recurrence for patients with rectal cancer who receive preoperative chemoradiotherapy and total mesorectal excision: a multi-institutional analysis in an Asian population

Purpose

This study was conducted to evaluate the significance of carcinoembryonic antigen (CEA) level as a predictor for tumor response to chemoradiotherapy (CRT) and a prognosticator for survival in Asian patients with advanced rectal cancer.

Materials and methods

We enrolled 345 patients with primary rectal cancer who had undergone preoperative CRT and total mesorectal excision. We analyzed clinicopathological factors that could be associated with pathologically complete response (ypCR) and disease-free survival (DFS).

Results

A cutoff level of 5 ng/mL (p?=?0.002) for CEA was found to be significant for prediction of ypCR. Increased CEA level (p?=?0.025) was a significant negative predictor of ypCR after CRT in patients with rectal cancer. The 5-year DFS rate was significantly higher in the CEA ≤5-ng/mL group than in the CEA >5-ng/mL group (73.2 vs. 60.9 %, p?=?0.002). This is mainly due to the higher chance of distant recurrence (p?=?0.013), not locoregional recurrence (p?=?0.732), in the CEA >5-ng/mL group.

Conclusions

Elevated CEA (>5 ng/mL) is a negative predictor of ypCR and has a negative impact on DFS in Asian rectal cancer patients who underwent preoperative CRT and surgery due to an increased chance of distant recurrences.     

Abdominoperineal resection and perineal wound healing in recurrent,persistent, or primary anal carcinoma

Purpose

Chemoradiotherapy is the standard treatment for squamous cell anal cancer. Salvage abdominoperineal resection (APR) is usually reserved for patients presenting with recurrent or persistent disease. Aim of our study was to review the outcomes of salvage surgery and perineal wound healing with or without a vertical rectus abdominis myocutaneous (VRAM) flap in a single institution over a 6-year period.

Methods

Data of all patients with biopsy-proven squamous cell anal cancer treated with chemoradiation at the University Medical Center Mannheim were recorded prospectively. Medical records of all patients who underwent salvage surgery for anal carcinoma between June 2008 and June 2014 were reviewed with regard to surgical and oncological outcomes.

Results

One hundred twenty-four patients received chemoradiation with a 5-year overall survival of 79 %. Seventeen patients required (salvage) APR for recurrent (n?=?8), persistent (n?=?7), or primary anal carcinoma (n?=?2). Median overall survival was 33.4 months. Median duration until completion of perineal wound healing was shorter in the VRAM group (17 vs. 24.5 weeks; p?=?0.0541).

Conclusions

Salvage APR has a reasonable chance of long-time survival. Perineal reconstruction with a VRAM flap may reduce the duration until completion of perineal wound healing.

     

A comparison of short-term outcome after laparoscopic, transverse, and midline right-sided colectomy

Aim

The aim of the present study was to compare the laparoscopy, transverse, and midline laparotomy in right-sided colectomies with respect to short- and long-term outcome.

Methods

The short- and long-term results of all patients who had an elective right-sided hemicolectomy, from January 2006 to April 2009 for malignant or benign disease, were evaluated according to the surgical technique: laparoscopic, midline, or transverse incision laparotomy.

Results

The 75 included patients (41% male) had laparoscopy (n?=?30), midline (n?=?22), or transverse incision laparotomy (n?=?23). Median operating time in the laparoscopy group was significantly longer in comparison to the midline and transverse incision groups (129, 105, and 101?min respectively, p?p?=?0.026). Thirty-day morbidity was less in the laparoscopy and transverse incision groups compared to the midline laparotomy group (15%, 20%, and 41%; p?=?0.06). After excluding patients who had a previous midline incision, an earlier return of bowel function was seen for laparoscopy and transverse hemicolectomy (3 vs. 5?days, p?=?0.017). At a median follow-up of 40?months (21–58), four incisional hernias occurred, two in the midline laparotomy group (one operatively corrected) and two in the laparoscopy group.

Conclusions

Although the results of this study need to be interpreted with care, our study shows that laparoscopic and transverse right hemicolectomy are equivalent and have a significant better short-term outcome compared to an open midline approach. In particular, laparoscopy and transverse laparotomy result in >50% reduction in 30-day morbidity, no reoperations, and a shorter median total hospital stay of 2?days.     

Characteristics of recurrence after curative resection for T1 colorectal cancer: Japanese multicenter study

Background

Because the rate of recurrence after curative resection for T1 colorectal cancer is low, the characteristics of recurrence remain obscure. This multicenter study attempted to clarify the characteristics of recurrence after curative resection for T1 colorectal cancer.

Methods

We analyzed the associations between recurrence and various clinicopathological features in 798 patients who had undergone curative resection alone for T1 colorectal cancer at 14 hospitals between 1991 and 1996.

Results

The rate of lymph node metastasis (LNM) in patients with T1 colorectal cancer was 10.5% (84/798), and 18 (2.3%) of the 798 patients developed recurrence during the median follow-up of 7.8?years. The recurrence rates in patients with colon cancer with and without LNM were 3.6 and 1.3%, respectively (p?=?0.19). These rates in patients with cancer of the rectum were 25.0 and 1.1% (p?p?p?=?0.025), LNM (p?p?=?0.0013) were risk factors for recurrence. Among them, LNM (p?=?0.0008) and histological grade (p?=?0.041) were independent risk factors for recurrence after curative resection for T1 colorectal cancer. Time to recurrence was more likely to be shorter for patients with, than without nodal involvement. In patients with an unfavorable histological grade, all recurrences developed within 1?year.

Conclusions

The recurrence rate after curative resection for node-negative T1 colorectal cancer was very low. The effectiveness of surveillance to detect recurrence after curative resection for T1 colorectal cancer should be validated in further studies.     

Does laparoscopic intracorporeal ileocolic anastomosis decreases surgical site infection rate? A propensity score-matched cohort study

Aim

Foreshortened mesentery or thick abdominal wall constitutes a rationale for laparoscopic intracorporeal ileocolic anastomoses (ICA). The aim of this study was to compare intracorporeal to extracorporeal ICA in terms of surgical site infections in patients with Crohn’s ileitis and overweight patients with right colon tumors.

Method

This was a prospective propensity score-matched cohort study enrolling consecutive patients with Crohn’s terminal ileitis and overweight patients with right colon tumors undergoing elective laparoscopic right colon resection with intracorporeal or extracorporeal ICA. Propensity score matching with a 1:1 ratio was employed to compare diagnosis-matched patients for age, BMI, ASA, and previous abdominal surgery.

Results

Overall, 453 patients were enrolled: 233 intracorporeal vs. 220 extracorporeal. Propensity score matching left 195 intracorporeal and 195 extracorporeal patients comparable for age (p?=?0.294), gender (p?=?0.683), ASA (p?=?0.545), BMI (p?=?0.079), previous abdominal surgery (p?=?0.348), and diagnosis (p?=?0.301). Conversion rates (5.1 vs. 3.6%; p?=?0.457) and intraoperative complications (1 vs. 2.1%; p?=?0.45) were similar. Overall morbidity (5.1 vs. 12.8%; p?=?0.008) and re-intervention rates (3.1 vs. 8.7%; p?=?0.029) were significantly higher in extracorporeal patients. Anastomotic leak rates (0.5 vs. 1.5%; p?=?0.623) did not differ. Incisional SSI rate was significantly higher in extracorporeal patients (p?=?0.01).

Conclusion

Laparoscopic intracorporeal ICA reduced incisional SSI rates as compared to its extracorporeal counterpart.

     

Short-term outcome of laparoscopic versus robotic ventral mesh rectopexy for full-thickness rectal prolapse. Is robotic superior?

Purpose

Short term morbidity, functional outcome, recurrence and quality of life outcomes after robotic assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) were compared.

Methods

This study includes 51 consecutive patients having operations for external rectal prolapse (ERP) in a tertiary centre between October 2009 and December 2012. Of these, 17 patients had RVMR and 34 underwent LVMR. The groups were matched for age, gender, body mass index (BMI), and American Society of Anesthesiologists (ASA) grades. The same operative technique and mesh was used and follow up was 12 months. Data was collected on patient demographics, surgery duration, blood loss, duration of hospital stay and operative complications. Functional outcomes were measured using the faecal incontinence severity index (FISI) and Wexner faecal incontinence scoring. Quality of life was scored using SF36 questionnaires pre and postoperatively.

Results

All patients were female except three (median 59, range 25–89). There was one laparoscopic converted to open procedure. RVMR procedures were longer in duration (p?=?0.013) but with no difference in blood loss between the groups. The average duration of stay was 2 days in both groups. There were six minor postoperative complications in LVMR procedures and none in the RVMR group. Pre and postoperative Wexner and FISI scoring were significantly lower in the RVMR group (p?=?0.042 and p?=?0.024, respectively). SF-36 questionnaires showed better scoring in physical and emotional component in RVMR group (p?=?0.015). There was no recurrence in either group during follow-up.

Conclusions

Both LVMR and RVMR are similar in terms of safety and efficacy. Although not randomized, this data may suggest a better functional outcome and quality of life in patients having RVMR for ERP.     

Clinical implication of additional selective lateral lymph node excision in patients with locally advanced rectal cancer who underwent preoperative chemoradiotherapy

Purpose

To identify the indication and prognostic significance of lateral lymph node (LLN) excision in locally advanced rectal cancer patients underwent preoperative chemoradiotherapy.

Methods

Included were 67 consecutive patients with suspicious LLN metastasis who underwent chemoradiotherapy and surgery including selective LLN excision (82 excisions). The excisions were grouped according to the presence of LLN metastasis and compared in terms of the clinicopathological findings and oncological results. The correlation between the largest short-axis diameter of LLN measured by imaging and metastasis rates was explored.

Results

LLN metastases were identified in 32 excisions (40.0 %). The calculated short-axis LLN diameter predicting metastasis was 11.7 mm (before chemoradiotherapy) and 11.4 mm (before surgery). LLN metastasis was observed more frequently in the low rectum (p?=?0.031) and associated with higher CEA levels (p?=?0.048). The 3-year overall survival rates for patients with and without LLN metastasis were 60.3 % and 90.3 % (p?=?0.048), while the 3-year disease-free survival rates were 31.4 % and 70.5 % (p?=?0.009). The hazard ratio of LLN metastasis for recurrence was 2.938 (95 % CI?=?1.258–6.863).

Conclusions

LLN metastasis in rectal cancer patients underwent chemoradiotherapy was a distinct poor prognostic factor. Selective LLN excision based on imaging studies may have a role for such patients.