Michele Manigrasso

Recovery after intracorporeal anastomosis in laparoscopic right hemicolectomy: a systematic review and meta-analysis

PurposeAlthough intracorporeal anastomosis (IA) appears to guarantee a faster recovery compared to extracorporeal anastomosis (EA), the data are still unclear. Thus, we performed a systematic review of the literature with meta-analysis to evaluate the recovery benefits of intracorporeal anastomosis.Materials and methodsA systematic search was performed in electronic databases (PubMed, Web of Science, Scopus, EMBASE) using the following search terms in all possible combinations: “laparoscopic,” “right hemicolectomy,” “right colectomy,” “intracorporeal,” “extracorporeal,” and “anastomosis.” According to the pre-specified protocol, all studies evaluating the impact of choice of intra- or extracorporeal anastomosis after right hemicolectomy on time to first flatus and stools, hospital stay, and postoperative complications according to Clavien-Dindo classification were included.ResultsSixteen articles were included in the final analysis, including 1862 patients who had undergone right hemicolectomy: 950 cases (IA) and 912 controls (EA). Patients who underwent IA reported a significantly shorter time to first flatus (MD = − 0.445, p = 0.013, Z = − 2.494, 95% CI − 0.795, 0.095), to first stools (MD = − 0.684, p < 0.001, Z = − 4.597, 95% CI − 0.976, 0.392), and a shorter hospital stay (MD = − 0.782, p < 0.001, Z = −3.867, 95% CI − 1.178, − 0.385) than those who underwent EA. No statistically significant differences in complications between the IA and EA patients were observed in the Clavien-Dindo I-II group (RD = − 0.014, p = 0.797, Z = − 0.257, 95% CI − 0.117, 0.090, number needed to treat (NNT) 74) or in the Clavien-Dindo IV-V (RD = − 0.005, p = 0.361, Z = − 0.933, 95% CI − 0.017, 0.006, NNT 184). The IA procedure led to fewer complications in the Clavien-Dindo III group (RD = − 0.041, p = 0.006, Z = − 2.731, 95% CI − 0.070, 0.012, NNT 24).ConclusionsAlthough intracorporeal anastomosis appears to be safe in terms of postoperative complications and is potentially more effective in terms of recovery after surgery, further ad hoc randomized clinical trials are needed, given the heterogeneity of the data available in the current literature.

Pulmonary Complications after Surgery for Rectal Cancer in Elderly Patients: Evaluation of Laparoscopic versus Open Approach from a Multicenter Study on 477 Consecutive Cases

Aim To evaluate the impact of open or laparoscopic rectal surgery on pulmonary complications in elderly (>75 years old) patients. Methods Data from consecutive patients who underwent elective laparoscopic or open rectal surgery for cancer were collected prospectively from 3 institutions. Pulmonary complications were defined according to the ACS/NSQUIP definition. Results A total of 477 patients (laparoscopic group: 242, open group: 235) were included in the analysis. Postoperative pulmonary complications were significantly more common after open surgery (8 out of 242 patients (3.3%) versus 23 out of 235 patients (9.8%); p = 0.005). In addition, PPC occurrence was associated with the increasing of postoperative pain (5.04 ± 1.62 versus 5.03 ± 1.58; p = 0.001) and the increasing of operative time (270.06 ± 51.49 versus 237.37 ± 65.97; p = 0.001). Conclusion Our results are encouraging to consider laparoscopic surgery a safety and effective way to treat rectal cancer in elderly patients, highlighting that laparoscopic surgery reduces the occurrence of postoperative pulmonary complications.

Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients

Although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. A multi-institutional audit was designed, including 92 patients who underwent laparoscopic left colectomy with intracorporeal anastomosis (IA) compared with 89 matched patients who underwent a laparoscopic left colectomy with extracorporeal anastomosis (EA). There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Post-surgical history and stage of disease according to AJCC/UICC TNM were also similar. IA and EA groups demonstrated similar oncologic radicality in terms of the number of lymph nodes harvested (18.5 ± 9 vs. 17.5 ± 8.4; p = 0.48). Recovery after surgery was also better in patients who underwent IA, as confirmed by the shorter time to flatus in the IA group (2.6 ± 1.1 days vs. 3.4 ± 1.2 days; p < 0.001) and higher post-operative pain expressed in the mean VAS Scale in the EA group (1.7 ± 2.1 vs. 3.5 ± 1.6; p < 0.001). Laparoscopic left colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 6.7, 95% CI 2.2–20; p = 0.001). However, when stratifying according to Clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 7.6, 95% CI 2.5–23, p = 0.001) but not for class III, IV, and V complications (OR 1.8, 95% CI 0.1–16.9; p = 0.59). Our results were consistent to hypothesize that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. Further randomized clinical trials are needed to obtain a more definitive conclusion.

Long-term follow-up for pilonidal sinus surgery: A review of literature with metanalysis

BACKGROUND Sacrococcygeal pilonidal sinus disease (PSD) is a common chronic inflammation of the natal cleft and presents as an abscess or a chronically discharging, painful sinus tract. The management of chronic PSD is variable, contentious, and problematic. Although many surgical procedures have been tried, the best surgical method remains controversial. The aim of this systematic review with meta-analysis of literature is to provide surgeons an objective instrument of decision through an analysis of recurrence rate of various surgical techniques in a long-term follow-up. METHODS Systematic literature searches were performed to identify all available studies. According to the pre-specified protocol, all studies reporting a surgical approach to PSD with a minimum follow-up of 5 years were included. RESULTS Fifteen studies were included in the analysis. The number of patients varied from 50 to 1165 with a mean follow-up from 58.36 to 240 months. The overall incidence of recurrence was of 0.138; the resulting incidence of open healing, midline closure and out-midline closure were of 17.9%, 16.8% and 10% respectively. CONCLUSIONS Interestingly, our data reveal a rate of relapsing disease higher than the one defined in previous studies both for the overall PSD and for each surgical procedure. A long-term follow-up of at least 5 years, should be considered the gold standard in pilonidal sinus surgery benchmarking. From our results, we can state that open healing and midline closure should not be considered effective for their high frequency of relapse disease and midline primary closure should be preferred.

Surgical resection for rectal cancer. Is laparoscopic surgery as successful as open approach? A systematic review with meta-analysis

Background Recently, it has been questioned if minimally invasive surgery for rectal cancer was surgically successful. We decided to perform a meta-analysis to determine if minimally invasive surgery is adequate to obtain a complete resection for curable rectal cancer. Methods A systematic search pertaining to evaluation between laparoscopic and open rectal resection for rectal cancer was performed until 30th November 2016 in the electronic databases (PubMed, Web of Science, Scopus, EMBASE), using the following search terms in all possible combinations: rectal cancer, laparoscopy, minimally invasive and open surgery. Outcomes analyzed were number of clear Distal Resection Margins (DRM or DM), complete Circumferential Resection Margins (CRM) and complete, nearly complete and incomplete Total Mesorectal Excision (TME) and of patients who received laparoscopic or open treatment for rectal cancer. Results 12 articles were included in the final analysis. The prevalence of successful surgical resection was similar between open and laparoscopic surgery. About distance from distal margin of the specimen, clear CRM and complete TME there were no statistically significant difference between the two groups (MD = -0.090 cm, p = 0.364, 95% CI -0.283, 0.104; OR = 1.032, p = 0.821, 95% CI 0.784, 1.360; OR = 0.933, p = 0.720, 95% CI 0.638, 1.364, respectively). The analysis of nearly complete TME showed a significant difference between the two groups (OR = 1.407, p = 0.006, 95% CI 1.103, 1.795), while the analysis of incomplete TME showed a non-significant difference (OR = 1.010, p = 0.964, 95% CI 0.664, 1.534). Conclusions By pooling together data from 5 RCTs and 7 nRCTs, we are able to provide evidence of safety and efficacy of minimally invasive surgery. Waiting for further randomized clinical trials, our results are encouraging to introduce laparoscopic rectal resection in daily practice.

Setting up and exploitation of a nano/technological platform for the evaluation of HMGA1b protein in peripheral blood of cancer patients

Even if cancer specific biomarkers are present in peripheral blood of cancer patients, it is very difficult to detect them with conventional technology because of their low concentration. A potential cancer biomarker is the HMGA1b protein, whose overexpression is a feature of several human malignant neoplasias. By taking advantage of the surface plasmon resonance (SPR) phenomenon, we realized a specific nano/technology-based assay for cancer detection. More in details, anti-HMGA1b monoclonal antibodies, whose affinity was previously defined by ELISA, were immobilized onto metallic surfaces to develop a direct SPR-based assay. After having analyzed blood samples from colorectal cancer patients and healthy people for the presence of HMGA1b, we observed a 2-fold increase of the HMGA1b levels in the blood of cancer patients with respect to the healthy control people. We conclude that the set-up technology might allow to detect a tumoral mass through the evaluation of HMGA1b protein blood levels.

Case report of an uncommon case of drain-site hernia after colorectal surgery

Highlights • Trocar site herniation is a rare but potentially serious complication of laparoscopic surgery.• We report an uncommon case of drain site hernia.• The risk of trocar site hernia in laparoscopy has been known since 1967.• Other two cases are described in literature regarding pediatric and gynaecologic patients.• Drain should not be positioned through the 10 mm trocar in order to avoid any herniation.

Case report of a conservative management of cervical esophageal perforation with acrylic glue injection

Background perforation of the upper aerodigestive tract is a potentially life-threatening condition. The appropriate treatment of cervical esophageal perforation is still controversial. Case presentation we report a case of cervical esophageal perforation that was effectively treated by a conservative management with acrylic glue injection. Discussion the management of cervical esophageal perforations has been controversial and little studied. Various treatment options, including surgical and nonsurgical management have been advocated, and no gold standard surgical treatment has yet been established. Some authors have recommended immediate surgical intervention, especially in penetrating trauma, conversely, several studies support conservative management. Conclusions we consider that the application of acrylic glue can be considered a promising, minimally invasive therapeutic option in the management of cervical esophageal perforation. However, the sufficient accumulation of similarly treated cases is necessary in order to confirm the efficacy and safety of this treatment modality.

Laparoscopic rectal resection—the road to safety surgery

Total mesorectal excision (TME) indicates a surgical technique for the removal of the rectum and mesorectum during an anterior resection for rectal cancer. The concept of complete TME was first described by Heald in 1979. In the past ten years laparoscopic total mesorectal excision (LTME) has been introduced as an alternative to the open technique and proved to be equivalent by many studies. Anyhow, the laparoscopic approach is technically more challenging than the open one, and its learning curve is often longer. The purpose of this study is to suggest a standardization of the procedure by suggesting a critical view of safety for laparoscopic rectal resection, advising some tips and tricks which could benefit its learning and its performance.

Rectal cancer—state of art of laparoscopic versus open surgery

Since its introduction, laparoscopy has gained more and more consent in colorectal surgery, even if its role in rectal cancer surgery is still controversial and widely debated. The aim of this study is to present the ongoing situation of laparoscopic surgery for rectal cancer by a review of current literature. We performed a systematic search in the electronic databases (PubMed, Web of Science, Scopus, EMBASE) according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We limited the search until 31 March 2017 and used the following search terms in all possible combinations: rectal cancer, laparoscopy, minimally invasive and open surgery. A total of 66 articles were include in this review, of which 38 were non-randomized trials, 8 were randomized controlled trials (RCTs) performed in a single center, 5 were multicentric RCTs and 15 were meta-analyses. Laparoscopic approach resulted in a faster and better recovery after surgery and has been proven to be equivalent in terms of short-terms outcomes comparing to the open approach. Nevertheless, the findings concerning oncologic safety of minimally invasive approach are still controversial. This should give the rationale to perform new meta-analyses based on the last evi-dences produced. Moreover, even more multicentric RCTs studies, hypothetically designed on new pathological outcomes, should be performed to finally assess if laparoscopy is a valid choice for the treatment of rectal cancer.