A systematic review and meta-analysis comparing intracorporeal anastomosis and extracorporeal anastomosis in minimally invasive colectomies

Abstract

Aim: This systemic review aims to determine if intracorporeal anastomosis (IA) adds value to patient outcomes without compromising operative and oncological safety when compared to extracorporeal anastomosis (EA) in laparoscopic colectomies. This is the first systematic review with meta-analysis to evaluate the outcomes in a combined fashion including both laparoscopic right and left colectomies.

Methods: A systematic review of Medline, EMBASE, Cochrane Library, and PubMed was performed on studies analysing direct comparison between IA and EA. The primary outcome was anastomotic leakage. Quality assessment was carried out using a modified Institute of Health Economics appraisal tool. Meta-analysis was performed using a random-effects model.

Results: A total of 24 papers with 2,674 patients were included in the analysis. No significant difference was found in anastomotic leakage (OR = 0.84; 95%CI: 0.54-1.31; P = 0.44) and short-term mortality (OR = 0.56; 95%CI: 0.20-1.58; P = 0.27) between the IA and EA cohorts. The IA cohort was associated with faster return of bowel function [MD = -0.53 days; 95%CI: -0.67-(-0.39); P < 0.00001] and lower incidence of surgical site infection (OR = 0.52; 95%CI: 0.31-0.85; P = 0.009). The number of lymph nodes harvested was higher in IA (MD = 1.05; 95%CI: 0.19-1.91; P = 0.02; I² = 83%) with considerable heterogeneity.

Conclusion: Intracorporeal anastomosis can be considered a safe alternative technique in laparoscopic colectomies, with potential benefits in patient outcomes. A lack of randomised studies and heterogeneity need to be addressed by additional high-quality trials.

Keywords

Laparoscopic / intracorporeal / extracorporeal / colectomy / outcome

References

[1] Feroci F,Garzi A,Cantafio S.Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis..Int J Colorectal Dis2013;28:1177-86

[2] World Health Organization. Cancer Geneva: World Health Organization; 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/cancer. [Last accessed on 2 Nov 2020]

[3] Wu Q,Hu T,Wang Z.Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a systematic review and meta-analysis..J Laparoendosc Adv Surg Tech A2017;27:348-57

[4] Ricci C,Alagna V.A critical and comprehensive systematic review and meta-analysis of studies comparing intracorporeal and extracorporeal anastomosis in laparoscopic right hemicolectomy..Langenbecks Arch Surg2017;402:417-27

[5] Carnuccio P,Pares D.Laparoscopic right colectomy: a systematic review and meta-analysis of observational studies comparing two types of anastomosis..Tech Coloproctol2014;18:5-12

[6] Cirocchi R,Farinella E.Intracorporeal versus extracorporeal anastomosis during laparoscopic right hemicolectomy - systematic review and meta-analysis..Surg Oncol2013;22:1-13

[7] Milone M,Di Salvo E.Intracorporeal versus extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided colorectal cancers..Surg Endosc2015;29:2314-20

[8] Iorio T.A case-control study examining the benefits of laparoscopic colectomy using a totally intracorporeal technique for left-sided colon tumors..Surg Laparosc Endosc Percutan Tech2014;24:381-4

[9] Kayaalp C,Yagci MA.Laparoscopic right-sided colonic resection with transluminal colonoscopic specimen extraction..World J Gastrointest Endosc2015;7:1078-82 PMCID:PMC4564835

[10] Rahbari NN,Hohenberger W.Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer..Surgery2010;147:339-51

[11] Wan X,Liu J.Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range..BMC Med Res Methodol2014;14:135 PMCID:PMC4383202

[12] Vignali A,Lemma M,Radaelli G.Intracorporeal versus extracorporeal anastomoses following laparoscopic right colectomy in obese patients: a case-matched study..Dig Surg2018;35:236-42

[13] Vignali A,De Nardi P,Staudacher C.Extracorporeal vs. intracorporeal ileocolic stapled anastomoses in laparoscopic right colectomy: an interim analysis of a randomized clinical trial..J Laparoendosc Adv Surg Tech A2016;26:343-8

[14] Allaix ME,Bonino MA.Intracorporeal or extracorporeal ileocolic anastomosis after laparoscopic right colectomy: a double-blinded randomized controlled trial..Ann Surg2019;270:762-7

[15] Anania G,Scagliarini L.A totally mini-invasive approach for colorectal laparoscopic surgery..World J Gastroenterol2012;18:3869-74 PMCID:PMC3413059

[16] Biondi A,Pennestrì F,D’Ugo D.Totally laparoscopic right colectomy versus laparoscopically assisted right colectomy: a propensity score analysis..Surg Endosc2017;31:5275-82

[17] Chaves JA,Fons JB.A case-control study of extracorporeal versus intracorporeal anastomosis in patients subjected to right laparoscopic hemicolectomy..Cir Esp2011;89:24-30

[18] Jian-Cheng T,Bo Z,Liang Z.Total laparoscopic right hemicolectomy with 3-step stapled intracorporeal isoperistaltic ileocolic anastomosis for colon cancer: an evaluation of short-term outcomes..Medicine (Baltimore)2016;95:e5538 PMCID:PMC5134775

[19] Erguner I,Baca B,Karahasanoglu T.Total laparoscopic approach for the treatment of right colon cancer: a technical critique..Asian J Surg2013;36:58-63

[20] Fabozzi M,Brachet Contul R.Comparison of short- and medium-term results between laparoscopically assisted and totally laparoscopic right hemicolectomy: a case-control study..Surg Endosc2010;24:2085-91

[21] Franklin ME Jr,Miter DB.Laparoscopic right hemicolectomy for cancer: 11-year experience..Rev Gastroenterol Mex.2004;69 Suppl 1:65-72

[22] Grams J,Greenstein AJ.Comparison of intracorporeal versus extracorporeal anastomosis in laparoscopic-assisted hemicolectomy..Surg Endosc2010;24:1886-91

[23] Hanna MH,Phelan MJ.Laparoscopic surgery for inflammatory bowel disease: a nationwide analysis of trends and outcomes..Surg Endosc Other Interventional Tech2015;1:S330

[24] Hellan M,Pigazzi A.Extracorporeal versus intracorporeal anastomosis for laparoscopic right hemicolectomy..JSLS2009;13:312-7 PMCID:PMC3015972

[25] Lee KH,Akmal Y,Pigazzi A.Short- and long-term outcomes of intracorporeal versus extracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for colon cancer..Surg Endosc2013;27:1986-90

[26] Magistro C,Ferrari G.Totally laparoscopic versus laparoscopic-assisted right colectomy for colon cancer: is there any advantage in short-term outcomes? A prospective comparative assessment in our center..Surg Endosc2013;27:2613-8

[27] Marchesi F,Percalli L.Totally laparoscopic right colectomy: theoretical and practical advantages over the laparo-assisted approach..J Laparoendosc Adv Surg Tech A2013;23:418-24

[28] Mari GM,Costanzi ATM.Intracorporeal anastomosis reduces surgical stress response in laparoscopic right hemicolectomy: a prospective randomized trial..Surg Laparosc Endosc Percutan Tech2018;28:77-81

[29] Milone M,Berardi G.Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients..Surg Endosc2018;32:3467-73

[30] Roscio F,De Luca A,Scandroglio I.Totally laparoscopic versus laparoscopic assisted right colectomy for cancer..Int J Surg2012;10:290-5

[31] Scatizzi M,Borrelli A,Lenzi E.Extracorporeal versus intracorporeal anastomosis after laparoscopic right colectomy for cancer: a case-control study..World J Surg2010;34:2902-8

[32] Shapiro R,Segev L,Hatib K.Laparoscopic right hemicolectomy with intracorporeal anastomosis: short- and long-term benefits in comparison with extracorporeal anastomosis..Surg Endosc2016;30:3823-9

[33] Swaid F,Madi H,Somri M.Totally laparoscopic versus laparoscopic-assisted left colectomy for cancer: a retrospective review..Surg Endosc2016;30:2481-8

[34] Vergis AS,Bhojani FD,Hardy KM.Laparoscopic right hemicolectomy with intracorporeal versus extracorporeal anastamosis: a comparison of short-term outcomes..Can J Surg2015;58:63-8 PMCID:PMC4309767

[35] (IHE) IoHE. Quality Appraisal of Case Series Studies Checklist. 2014. Available from: http://www.ihe.ca/research-programs/rmd/cssqac/cssqac-about. [Last accessed on 2 Nov 2020]

[36] Hanna MH,Phelan MJ.Laparoscopic right hemicolectomy: short- and long-term outcomes of intracorporeal versus extracorporeal anastomosis..Surg Endosc2016;30:3933-42

[37] Singh R,Hegge S.Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates?.Surg Endosc2008;22:2596-600

[38] Genova P,Cipolla C.Laparoscopic versus robotic right colectomy with extra-corporeal or intra-corporeal anastomosis: a systematic review and meta-analysis..Langenbeck Arch Surg2020;

[39] Di Saverio S,Mandrioli M,Binda GA.Intracorporeal anastomoses in emergency laparoscopic colorectal surgery from a series of 59 cases: where and how to do it - a technical note and video..Colorectal Dis2017;19:O103-7