Linked color imaging versus narrow-band imaging for colorectal polyp detection: a prospective randomized tandem colonoscopy study.

BACKGROUND AND AIMS: Linked color imaging (LCI) is a newly available image-enhanced endoscopy (IEE) system that emphasizes the red mucosal color. No study has yet compared LCI with other available IEE systems. Our aim was to investigate polyp detection rates using LCI compared with narrow-band imaging (NBI). METHODS: This is a prospective randomized tandem colonoscopy study. Eligible patients who underwent colonoscopy for symptoms or screening/surveillance were randomized in a 1:1 ratio to receive tandem colonoscopy with both colonoscope withdrawals using LCI or NBI. The primary outcome was the polyp detection rate. RESULTS: Two hundred seventy-two patients were randomized (mean age, 62 years; 48.2% male; colonoscopy for symptoms, 72.8%) with 136 in each arm. During the first colonoscopy, the polyp detection rate (71.3% vs 55.9%; P = .008), serrated lesion detection rate (34.6% vs 22.1%; P = .02), and mean number of polyps detected (2.04 vs 1.35; P = .02) were significantly higher in the NBI group than in the LCI group. There was also a trend of higher adenoma detection rate in the NBI group compared with the LCI group (51.5% vs 39.7%, respectively; P = .05). Multivariable analysis confirmed that use of NBI (adjusted odds ratio, 1.99; 95% confidence interval, 1.09-3.68) and withdrawal time >8 minutes (adjusted odds ratio, 5.11; 95% confidence interval, 2.79-9.67) were associated with polyp detection. Overall, 20.5% of polyps and 18.1% of adenomas were missed by the first colonoscopy, but there was no significant difference in the miss rates between the 2 groups. CONCLUSION: NBI was significantly better than LCI for colorectal polyp detection. However, both LCI and NBI missed 20.5% of polyps. (Clinical trial registration number: NCT03336359.).

Outcome of laparoscopic resection for colorectal cancer in patients with high operative risk.

BACKGROUND: There is general concern that high-risk patients are more susceptible to the adverse effect of pneumoperitoneum and they are often denied laparoscopic surgery. This study investigated the impact of laparoscopic colorectal cancer resection for patients with high operative risk, which was defined as American Society of Anesthesiologist classes 3 and 4. METHODS: Three hundred thirty-five consecutive high-risk patients who had colorectal cancer resection by open or laparoscopic surgery were included. The patient and tumor characteristics and operative outcomes were recorded prospectively, and comparison was made between the two groups. RESULTS: Compared to open surgery, patients with laparoscopic resection had a shorter hospital stay (8 [6-12] vs. 6 [4-9] days; P < 0.001), less blood loss (200 [100-400] vs. 140 [80-250] mL; P = 0.006), reduced cardiac complication rate (13.2% vs. 3.7%; P = 0.006), overall operative complication rate (36.6% vs. 21.3%; P = 0.006), and a trend toward a lower mortality rate (4.4% vs. 0.9%; P = 0.083). There was no difference in 3-year overall and disease-free survival between two groups. Operative blood loss (P = 0.035; odds ratio = 2.69; 95% confidence interval, 1.00-6.78) and open surgery (P = 0.007; odds ratio = 2.31; 95% confidence interval, 1.26-4.23) were independent factors for occurrence of complication. CONCLUSIONS: Laparoscopic colorectal cancer resection is associated with more favorable short-term results and should be recommended as the preferred treatment option for high-risk patients.

Comparison of outcome of open and laparoscopic resection for stage II and stage III rectal cancer.

BACKGROUND: Laparoscopic resection for advanced rectal cancer has not been widely accepted, and there are only few studies with survival data. This study aimed to compare the survival of patients who underwent laparoscopic and open resection for stage II and III rectal cancer. MATERIALS AND METHODS: Consecutive patients (open resection: n = 310; laparoscopic resection: n = 111) who underwent curative resection for stage II and III rectal cancer from June 2000 to December 2006 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery. RESULTS: The age, gender, medical morbidity, types of operation, and American Society of Anesthesiologists (ASA) status were similar between the two groups. There was also no difference in the mortality, morbidity, and pathological staging. Laparoscopic resection was associated with significantly less blood loss and shorter hospital stay. With the median follow-up of 34 months, there was no difference in local recurrence rates. The 5-year actuarial survivals were 71.1% and 59.3% in the laparoscopic and open groups, respectively (P = .029). In the multivariate analysis, laparoscopic resection was one of the independent significant factors associated with better survival (P = .03, hazards ratio: 0.558, 95% confidence interval: 0.339-0.969). Other independent poor prognostic factors included lymph node metastasis, poor differentiation, perineural invasion, presence of postoperative complications, and no chemotherapy. CONCLUSIONS: Laparoscopic resection for locally advanced rectal cancer is associated with more favorable overall survival when compared with open resection.

Impact of conversion on the long-term outcome in laparoscopic resection of colorectal cancer.

BACKGROUND: Long-term outcome of patients with conversion following laparoscopic resection of colorectal cancer has seldom been reported. This study aimed to evaluate the impact of conversion on the operative outcome and survival of patients who underwent laparoscopic resection for colorectal malignancy. METHODS: An analysis of a prospectively collected database of 470 patients who underwent laparoscopic colectomy between May 2000 and December 2006 was performed. The operative results and long-term outcomes of patients with conversion were compared with those with successful laparoscopic operations. RESULTS: The overall conversion rate to open surgery was 8.7% (41 patients). There was no difference in age, comorbid illness, location of tumor, and stage of disease between the laparoscopic and conversion groups. The most common reasons for conversion include adhesions (34.1%), tumor invasion into adjacent structures (17.1%), bulky tumor (9.8%), and uncontrolled hemorrhage (9.8%). A male preponderance was observed in the conversion group. Tumor size was significantly larger in the conversion group compared with the laparoscopic group (5 versus 4 cm, P = 0.002). Although there was no difference in the operative time between the two groups, increased perioperative blood loss (461.9 vs. 191.2 ml, P < 0.001), increased postoperative complication rate (56.1% versus 16.7%, P = 0.001) and prolonged median hospital stay (10 versus 6 days, P < 0.001) were associated with the conversion group. Consequently, patients in the conversion group were more likely to develop local recurrence (9.8% versus 2.8%, P < 0.001) with a significantly reduced cumulative cancer-free survival. CONCLUSION: The disease-free survival and the local recurrence were significantly worse by the presence of conversion in laparoscopic resection for colorectal malignancy. Adoption of a standardized operative strategy may improve the perioperative outcome after conversion.

Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy.

BACKGROUND: Leakage at the pancreaticoenteric anastomosis remains a common and serious complication after pancreaticoduodenectomy. Over the past decade, various measures directed towards prevention of pancreatic leakage have been studied. This article reviews the available data on the efficacy of these measures. DATA SOURCES: The Medline database from 1990 to 2000 was searched for studies on the prevention of pancreatic anastomotic leakage, and the bibliographies of the articles were reviewed for additional references. RESULTS: A meta-analysis of the results of prophylactic octreotide in preventing pancreatic fistula after pancreaticoduodenectomy from data available in three randomized controlled studies yielded an odds ratio of 1.08 (95% confidence interval 0.64 to 1.84). Pending further trials to clarify its role, the routine use of octreotide in pancreaticoduodenectomy cannot be recommended. Retrospective or nonrandomized prospective studies suggested that technical modifications such as duct-to-mucosa anastomosis, pancreaticogastrostomy and external pancreatic duct stenting may reduce the leakage rate, but there is a paucity of randomized trials. A randomized trial comparing pancreaticogastrostomy and pancreaticojejunostomy did not reveal a significant difference in the leakage rate. CONCLUSIONS: Further randomized controlled studies are required to determine the optimum technique of pancreaticoenteric anastomosis after pancreaticoduodenectomy.