Porównanie operacji odbytnicy z pierwotnym zespoleniem wykonywanych laparoskopowo i z wykorzystaniem robota zabiegowego : przegląd systematyczny i metaanaliza

Cel: Rak odbytnicy jest jednym z najpowszechniejszych nowotworów przewodu pokarmowego. Złotym standardem pozostaje resekcja chirurgiczna, jednak jego leczenie wciąż budzi kontrowersje. Operacje z wykorzystaniem robota zabiegowego zyskują na popularności w porównaniu z technikami laparoskopowymi. Brakuje badań dotyczących resekcji odbytnicy z pierwotnym zespoleniem. Metody: Przeprowadzono przegląd systematyczny i metaanalizę zgodnie z wytycznymi PRISMA. Głównymi punktami końcowymi były: chorobowość i powikłania krótkoterminowe. Wyniki: Wstępnie przeszukano 1250 opublikowanych artykułów. Ostatecznie wybrano 6 badań przeprowadzonych na grupie 1580 chorych, które poddano analizie ilościowej. W naszym badaniu wykazaliśmy, że zarówno zabieg z wykorzystaniem robota chirurgicznego, jak i zabieg laparoskopowy, są równorzędne w odniesieniu do: zachorowalności (RR = 1,1; 95% CI: 0,89–1,39), liczby poważnych powikłań (RR = 1,01; 95% CI: 0,60–1,69) oraz długości hospitalizacji (MD = 0,15; 95% CI: -0,60–0,90). Wykazano również, że zabieg z wykorzystaniem robota chirurgicznego ma niewielką przewagę przy wycięciu mezorektum (RD = -0,19; 95% CI: -0,35–(-0,03). I2 = 69%) oraz wiąże się z mniejszą częstością nieszczelności zespolenia (OR = 2,25; 95% CI: 1,23–4,09; I2 = 0%). Wnioski: W niektórych przypadkach zabieg z użyciem robota chirurgicznego zapewnia radykalność resekcji oraz mniejsze prawdopodobieństwo nieszczelności zespolenia. Jednakże – ze względu na niejednorodność badań – otrzymane wyniki są niepewne. Potrzeba dalszych zrandomizowanych badań na dużych populacjach pacjentów.Purpose: Rectal cancer is one of the most common malignancies of the gastrointestinal tract. The gold standard method is surgical resection. The approach to rectal cancer is still controversial. Nowadays, robotic approach gains popularity in comparison to traditional laparoscopy. However, there is lack of studies assessing rectal resections with primary anastomosis. Methods: We performed a systematic review and meta-analysis according to the PRISMA guidelines. The primary outcomes of interest were morbidity and short-term complications. Results: An initial reference search yielded 1250 articles. Finally, we chose six studies covering 1580 patients that we included in the quantitative analysis. In our study, we demonstrated that laparoscopic and robotic surgery are non-inferior to one another in terms of morbidity (RR=1.1 95% CI: 0.89-1.39), major complication rate (RR=1.01, 95% CI: 0.60-1.69) or in length of hospitalization (MD=0,15 95% CI: -0.60−0.90). The latter has slight advantage in quality of mesorectal excision (RD = -0.19, 95% CI: -0.35 − -0.03. I2=69%) and anastomotic leakage rate (OR=2.25, 95% CI: 1.23-4.09, I2=0%). Conclusion: In certain cases Robotic Surgery provide better quality of resected specimen and lower leakage ratio, nevertheless due to heterogeneity the results are uncertain. There is substantial need for large randomized controlled studies

The safety of selective use of splenic flexure mobilization in sigmoid and rectal resections -systematic review and meta-analysis

Background: According to traditional textbooks on surgery, splenic flexure mobilization is suggested as a mandatory part of open rectal resection. However, its use in minimally invasive access seems to be limited. This stage of the procedure is considered difficult in the laparoscopic approach. The aim of this study was to systematically review literature on flexure mobilization and perform meta-analysis. Methods: A systematic review of the literature was performed using the Medline, Embase and Scopus databases to identify all eligible studies that compared patients undergoing rectal or sigmoid resection with or without splenic flexure mobilization. Inclusion criteria: (1) comparison of groups of patients with and without mobilization and (2) reports on overall morbidity, anastomotic leakage, operative time, length of specimen, number of harvested lymph nodes, or length of hospital stay. The outcomes of interest were: operative time, conversion rate, number of lymph nodes harvested, overall morbidity, mortality, leakage rate, reoperation rate, and length of stay. Results: Initial search yielded 2282 studies. In the end, we included 10 studies in the meta-analysis. Splenic flexure is associated with longer operative time (95% confidence interval (CI) 23.61⁻41.25; p < 0.001) and higher rate of anastomotic leakage (risk ratios (RR): 1.02; 95% CI 1.10⁻3.35; p = 0.02), however the length of hospital stay is shorter by 0.42 days. There were no differences in remaining outcomes. Conclusions: Not mobilizing the splenic flexure results in a significantly shorter operative time and a longer length of stay. Further research is required to establish whether flexure mobilization is required in minimally invasive surgery

Compliance with the ERAS protocol and 3-year survival after laparoscopic surgery for non-metastatic colorectal cancer

INTRODUCTION: Enhanced recovery after surgery (ERAS) pathways have been proven to enhance postoperative recovery, reduce morbidity, and reduce length of hospital stay after colorectal cancer surgery. However, despite the benefits of the ERAS program on short-term results, little is known about its impact on long-term results.OBJECTIVE: The aim of the study was to determine the association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer.MATERIAL AND METHODOLOGY: Between 2013 and 2016, 350 patients underwent laparoscopic colorectal cancer resection in the 2nd Department of General Surgery, Jagiellonian University Medical College, and were enrolled for further analysis. The relationship between the rate of compliance with the ERAS protocol and 3-year survival was analyzed according to the Kaplan-Meier method with log-rank tests. Patients were divided into two groups according to their degree of adherence to the ERAS interventions: Group 1 (109 patients), &lt; 80% adherence, and Group 2 (241 patients), ≥ 80% adherence. The primary outcome was overall 3-year survival. The secondary outcomes were postoperative complications, length of hospital stay, and recovery parameters.RESULTS: The groups were similar in terms of demographics and surgical parameters. The median compliance to ERAS interventions was 85.2%. The Cox proportional model showed that AJCC III (HR 3.28, 95% CI 1.61-6.59, p = 0.0021), postoperative complications (HR 2.63, 95% CI 1.19-5.52, p = 0.0161), and compliance with ERAS protocol &lt; 80% (HR 3.38, 95% CI 2.23-5.21, p = 0.0102) were independent predictors for poor prognosis. Additionally, analysis revealed that adherence to the ERAS protocol in Group 2 with ≥ 80% adherence was associated with a significantly shorter length of hospital stay (6 vs. 4 days, p &lt; 0.0001), a lower rate of postoperative complications (44.7% vs. 23.3%, p &lt; 0.0001), and improved functional recovery parameters: tolerance of oral diet (53.4% vs. 81.5%, p &lt; 0.0001) and mobilization (77.7% vs. 96.1%, p &lt; 0.0001) on the first postoperative day.CONCLUSIONS AND RELEVANCE: This study reports an association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer. Lower adherence to the protocol, independent from stage of cancer and postoperative complications, was an independent risk factors for poorer survival rates.</p

Immunonutrition changes inflammatory response in colorectal cancer : results from a pilot randomized clinical trial

Introduction: Surgery is the first choice of treatment for colorectal cancer. Nutritional support in the form of oral nutritional supplements (ONSs) in the preoperative period is widely accepted for reducing the incidence of perioperative complications, and immunonutrition is generally recommended. However, there is little clinical data regarding the impact of such treatment on tumor biology. Material and Methods: In this study, tumor tissue and blood samples were collected from 26 patients during preoperative colonoscopy at the time of clinical diagnosis (sample A). Group 1 received standard ONSs (3× Nutricia Nutridrink Protein per day) for 2 weeks before surgery. In group 2, immune ONSs (2× Nestle Impact Oral) were administered for the same duration. Tumor tissue (sample B) was then retrieved from the tumor after resection. Changes in the expression levels of inflammatory cytokines (TNF-α, interleukin 8 or chemokine (C-X-C motif) ligand (CXCL8), stromal cell-derived factor 1 (SDF1a), chemokine (C-X-C motif) ligand 6 (CXCL6), chemokine (C-X-C motif) ligand (CXCL2), myeloperoxidase (MPO), and CXCL1) were assessed during the perioperative course. Results: TNF-α expression differed after intervention between the two groups (immune group 31.63 ± 13.28; control group 21.54 ± 6.84; p = 0.049) and prior to and after intervention in the control group (prior to intervention 35.68 ± 24.41; after intervention 21.54 ± 6.84; p = 0.038). Changes in CXCL8 expression in the control group occurred prior to and after intervention (prior to intervention 2975.93 ± 1484.04; after intervention 1584.85 ± 1659.84; p = 0.041). CXCL1 expression was increased in the immune group and decreased in the control group (immune group 2698.27 (1538.14–5124.70); control group 953.75 (457.85–1534.60); p = 0.032). In both groups, a decrease in superficial neutrophil infiltration was observed, but this was only statistically significant in the immune group. There was no impact of the observed differences between the two groups on surgical outcomes (morbidity, length of stay, readmissions). Conclusions: Immunonutrition in the preoperative period compared with standard nutritional support may influence inflammatory cytokine expression and leukocyte infiltration in patients with colorectal cancer