Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a retrospective study

For surgical procedures in LRC, IIA or EIA is debatable. Certain studies [10, 11, 17] indicated that both surgical procedures had similar pathological outcomes and long-term outcomes, including overall survival, disease-free survival, and the rate of peritoneal recurrence. IIA was even found to achieve a more precise tumor excision than EIA [17]. Some studies [12, 17,18,19,20] and meta-analyses [21, 22] concluded that patients who underwent IIA experienced a faster recovery of GI function, less postoperative pain, lower surgical stress response (SSR), fewer medical complications, and shorter LOHS. In contrast, some studies did not support the superiority of IIA over EIA [23, 24]. Our study now provides evidence for the advantages in postoperative recovery and safety of IIA.

Thirty out of 114 patients experienced over 100-ml intraoperative blood loss, with 12 who underwent IIA and 18 underwent EIA. Although the difference (p = 0.24) did not reach significance owing to the small size of our study cohort, in performing EIA, we noticed potential risk of bleeding from excessive traction of mesentery due to inadequate bowel freeing. This was particularly evident in obese patients with thicker subcutaneous abdominal fat and relatively shorter mesentery, where bleeding due to excessive traction of mesentery tended to be more insidious during EIA. Therefore, the surgeon in our retrospective study tended to perform IIA in patients with higher BMI. It was hypothesized that IIA might decrease the incision length, reduce conversion rate, and eliminate the need for bowel exteriorization for anastomosis, so it might be particularly beneficial for obese patients [25, 26]. Some published studies [27,28,29,30] show that obesity is associated with postoperative complications, anastomotic leakage, and reoperation. A negative influence of visceral fat on lymph nodes harvested was observed in patients with colorectal cancer [28]. In contrast, a case-matched study [31] concluded that IIA in patients with obesity (BMI > 30 kg/m2) was associated with similar short-term outcomes and lower incidence of incisional hernias compared to EIA and might reduce the risk of hospital readmission. In our subgroup analysis of patients with BMI ≥ 24 kg/m2, no significant difference was found in rate or severity of postoperative complications between the two groups. Besides, the oncological outcomes in the IIA group were similar to those in the EIA group. Considering the potential advantages of reduced intraoperative risk, we believe that IIA could be a better approach in obese patients.

Under the wide and clear view in TLRC, anastomosis twists are more likely to be avoided. Furthermore, with the evolution of advanced laparoscopic linear staplers, IIA procedure has become simpler and more efficient. Although IIA poses greater technical difficulty and requires advanced technical skills in laparoscopic surgery, we believe that with some training, surgeons can complete TLRC successfully without increasing operative time. In our study, the time to first flatus was deemed as a marker of GI function recovery in patients who underwent surgery. Time to first flatus was significantly shorter in the IIA group compared to the EIA group (p < 0.01). The mean time of first defecation was shorter in the IIA group, but did not reach statistical significance (p = 0.22). One hypothesis was that all patients emptied their bowel contents preoperatively and ate relatively little postoperatively; the formation of stool was interfered in both groups. Meanwhile, time to liquid intake occurred earlier in patients undergoing IIA (p < 0.01). Thus, we inferred that owing to less exteriorization and dissection of bowel and mesentery in IIA, TLRC had a smaller effect on GI motility.

In our study, the surgeon adopted a double-layer enterotomy closure technique, in which a running barbed suture was used for the first layer, and a 3–0 Vicryl interrupted suture was used for the second layer, to fashion an IIA. Previous studies have shown that the use of barbed sutures for enterotomy closure is safe and efficient, and a double-layer closure technique can significantly reduce the incidence of anastomotic leakage compared to the single-layer closure technique [32, 33]. Milone et al. have demonstrated that the use of a running barbed suture in the first layer can significantly reduce bleeding and leakage, while the type of suture thread (braided, non-braided, and barbed) and the method of suturing (running or interrupted) in the second layer did not have a significant effect on bleeding and leakage [34]. Our results showed no anastomotic bleeding or leakage in the IIA group, indicating that our approach to performing IIA was safe and effective.

Patients who underwent IIA suffered less postoperative pain, particularly on the POD 0 (p = 0.02) and POD 2 (p = 0.02). The mean VAS score on POD 1 tended to be lower in the IIA group, without statistical significance. As shown in Table 4, patients experienced significantly less pain from POD 3 onward, and there was no difference in VAS scores between the two groups. The benefit of IIA over EIA in reducing postoperative pain especially within 48 h may be associated with a shorter skin incision for specimen extraction. Data on the length of skin incision was not recorded in our hospital’s electronic medical record system, but this has been confirmed in some other studies [12].

In our study, there was no significant difference in LOHS between the two groups, despite less postoperative pain and faster recovery of GI function in the IIA group. Since our team were very cautious about postoperative complications, especially anastomotic leaks, which often occurred 5–7 days after surgery, we preferred to discharging them after making sure that an anastomotic leak was unlikely to occur. Significant difference in LOHS may be reached within an enhanced recovery (ERAS) program with a different discharge principle.

This study has some limitations. First, the study was limited by its retrospective, single-institution, and single-surgeon nature. Second, the data on postoperative complications included only those during hospitalization, but not the mid- and long-term follow-up outcomes, such as incisional hernia, survival, and recurrence after discharge. Lastly, the low incidence of postoperative complications may suggest that this study is underpowered to identify statistical differences. In order to mitigate these drawbacks, we have designed an RCT which is currently in enrollment. The study was registered with the Chinese Clinical Trials Registry (ChiCTR2100053282). All patients were provided written informed consent before enrollment. The study protocol was approved by the Ruijin Hospital Ethics Committee (Shanghai Jiao Tong University School of Medicine).

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