[Medial approach versus lateral approach in laparoscopic colorectal resection: a meta-analysis].

OBJECTIVE: To compare the safety and efficacy of the medial approach(MA) and the lateral approach (LA) in the treatment of colorectal disease. METHODS: Studies published from January 1994 to April 2013 that compared MA to LA in laparoscopic colorectal resection were collected. Publications in English were mainly identified from Medline, Embase, Cochrane Library, and those in Chinese from Wanfang database and CNKI database. Conversion rate, operative time, blood loss, number of harvested lymph nodes, hospital stay, complication, mortality, recurrence, and hospitalization costs of MA and LA were meta-analyzed using fixed-effect and random-effect models. RESULTS: Five cohort studies (2 randomized controlled trials and 3 retrospective studies) including 881 patients were enrolled and analyzed. Of these patients, 416 and 465 underwent laparoscopic colorectal resection with MA and LA respectively. As compared to LA, MA had significantly lower conversion rate (OR=0.42, 95%CI:0.25-0.72, P=0.001), shorter operative time (WMD=-52.62, 95%CI:-63.23--42.01, P<0.01), less number of harvested lymph nodes (WMD=-1.17, 95%CI:-1.89--0.45, P=0.001), while blood loss was less and hospitalization cost lower. Significant differences in intraoperative complications and postoperative complications were not found between the two group (OR:0.57, 95%CI:0.15-2.18, P=0.41; OR:0.78, 95%CI:0.52-1.17, P=0.23). CONCLUSIONS: Compared with LA, MA has the advantages of shorter operative time and lower conversion rate with similar safety. Differences in blood loss, hospitalization cost and oncological safety between the two approaches warrant further investigation.

Is there a role of surgery in patients with recurrent or metastatic gastrointestinal stromal tumours responding to imatinib: a prospective randomised trial in China.

OBJECTIVES: For advanced gastrointestinal stromal tumour (GIST) patients who are responding to imatinib mesylate, the role of surgery has not been formally demonstrated. This multicenter randomised controlled trial was designed to assess whether surgery to treat residual disease for patients with recurrent/metastatic GISTs responding to imatinib mesylate (IM) improved progression free survival (PFS) compared with IM treatment alone. METHODS: Between 3 and 12months after starting IM for recurrent/metastatic GISTs, eligible patients were randomised to two arms: Arm A (surgery for residual disease) and Arm B (IM treatment alone). In Arm A (19pts), surgery was performed to remove residual macroscopic lesions as completely as possible, and IM treatment continued after surgery. In Arm B (22pts), IM was given alone at a dose of 400mg per day until disease progression. The primary end-point was PFS measured from the date IM started. This study was registered in the ChiCTR registry with the ID number ChiCTR-TRC-00000244. RESULTS: This randomised trial was closed early due to poor accrual. Only 41 patients were enrolled as opposed to 210 patients planned. 2-year PFS was 88.4% in the surgery arm and 57.7% in the IM-alone arm (P=0.089). Median overall survival (mOS) was not reached in the surgery arm and 49months in patients with IM-alone arm (P=0.024). CONCLUSIONS: While no significant differences were observed in the two arms, this study suggests that surgical removal of the metastatic lesion may improve the outcome of advanced GIST patients and should stimulate additional research on this topic.

Treatment strategy of rectal gastrointestinal stromal tumor (GIST).

BACKGROUND: Rectal gastrointestinal stromal tumor (GIST) is a rare entity. A retrospective analysis of outcomes from a single institution to identify treatment strategies associated with improved outcomes. METHODS: Records of patients with GIST of the rectum were retrospectively reviewed. Patient and tumor characteristics, treatment details, and outcome were evaluated. RESULTS: Compared with the trans-abdominal approach group, the local excision group patients had smaller size and lower location tumors (P < 0.05). Positive resection margin was an important hazard factor for DFS (OR, 7.63; P = 0.015). Among the patients with the tumor size >5 cm, those with preoperative Imatinib therapy had higher rate of a negative resection margin than those without (100% vs. 20%, P = 0.048). Among the patients with intermediate and high-risk tumors, those who received peri-operative Imatinib therapy had longer DFS compared with those without (61.3 ± 6.1 months vs. 20.2 ± 4.4 months, P = 0.030). CONCLUSIONS: The location of rectal GIST impacts the choice of resection type. Most patients with tumors within 5 cm of the anal verge can be treated with local excision. Positive resection margin is the independent hazard factor for poorer survival. Peri-operative Imatinib therapy is associated with a prolonged DFS in patients with intermediate and high-risk tumors.

Hand-assisted laparoscopic surgery versus open surgery for colorectal disease: a systematic review and meta-analysis.

BACKGROUND: Laparoscopic colorectal surgery remains one of the most challenging techniques to learn. METHODS: The authors collected studies that have compared hand-assisted laparoscopic surgery (HALS) and open surgery for the treatment of colorectal disease over the past 17 years. Data of interest for HALS and open surgery were subjected to meta-analysis. RESULTS: Twelve studies that included 1,362 patients were studied. In total, 2.66% of HALS procedures were converted to laparotomy. Compared with the open surgery group, blood loss, rate of wound infection, and ileus in the HALS group decreased, and incision length, recovery of gastrointestinal function, and hospitalization period were shorter. There were no significant differences in operating time, hospitalization costs, mortality, and complications, including urinary tract infection, pneumonia, and anastomotic leak, between the groups. CONCLUSIONS: HALS has the advantages of minimal invasion, lower blood loss, shorter incision length, and faster recovery, and it can shorten the length of hospitalization without an increase in costs. The drawbacks are that a small number of patients who undergo HALS may need to be converted to laparotomy, and the oncologic safety and long-term prognosis are not clear.

Single-incision versus conventional three-incision laparoscopic appendicectomy for appendicitis: a systematic review and meta-analysis.

BACKGROUND: This meta-analysis was designed to investigate the safety and efficacy of single-incision laparoscopic appendicectomy (SILA) and three-incision laparoscopic appendicectomy (TILA) in the treatment of appendicitis. MATERIALS AND METHODS: Studies published since 1992 that compared SILA versus TILA in laparoscopic appendicectomy were collected. Data on operative parameters, postoperative recovery, postoperative pain and complications, and hospitalization costs for SILA and TILA were meta-analyzed using fixed-effect and random-effect models. RESULTS: Seventeen studies (1 randomized controlled trial and 16 retrospective studies) that included 1809 patients were studied. Of these patients, 793 and 1016 had undergone SILA and TILA, respectively. There was significantly shorter length of hospital stay; however, there were evidently higher conversion rate, and perhaps higher surgical difficulty and hospitalization costs for SILA compared with TILA. Other outcome variables such as operative time, blood loss, time to first oral intake, postoperative pain and complications were not found to be statistically significant for either group. CONCLUSIONS: Compared with TILA, SILA has the advantage of shorter hospital stay, and it can achieve comparable operative time, blood loss, postoperative recovery, postoperative pain and complications with TILA. The drawback is that SILA is associated with higher conversion rate, and perhaps higher surgical difficulty and hospitalization costs. Whether it can achieve improvement in cosmesis remains to be confirmed.

Laparoscopic versus open right hemicolectomy for colon cancer: a meta-analysis.

OBJECTIVE: This meta-analysis was designed to assess the feasibility and safety of laparoscopic right hemicolectomy for colon cancer. RESEARCH DESIGN: A systematic search of the MEDLINE, EMBASE, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction. Publications that compared laparoscopic right hemicolectomy and open right hemicolectomy for treatment of colon cancer in the past 20 years were collected for review. The primary outcomes used for meta-analysis were operating time, blood loss, number of harvested lymph nodes, time to first flatus, postoperative hospital stay, postoperative complications, mortality, and rate of recurrence. RESULTS: Twelve studies that included 1057 patients were examined. Of these patients, 475 and 582 had undergone laparoscopic right hemicolectomy and open right hemicolectomy, respectively. There were significant reductions in blood loss, time to first flatus, postoperative hospital stay, and rate of wound but a operating time for laparoscopic right hemicolectomy compared with open right hemicolectomy. Other outcome variables such as number of harvested lymph nodes, postoperative complications except wound infection, mortality, and rate of recurrence were not found to be statistically significant for either group. CONCLUSIONS: Compared with open right hemicolectomy, laparoscopic right hemicolectomy has the advantages of minimal invasion, faster recovery, and a lower rate of wound infection, and it can achieve the same degree of radicality and short-term prognosis as open right hemicolectomy. The drawback is that the operative time is longer.

The necessity of indwelling gastrointestinal decompression after gastrectomy: a meta-analysis.

BACKGROUND: This meta-analysis was designed to evaluate the necessity of indwelling gastrointestinal decompression after gastrectomy. METHODS: Medline, Embase, and the Cochrane Library were searched. We identified randomized controlled trials that compared individuals with or without gastrointestinal decompression after gastrectomy, and a meta-analysis was performed on data regarding the recovery time of gastrointestinal function, length of hospital stay, complications, and mortality using fixed effect and random effect models. RESULTS: Eight randomized controlled trials that had enrolled 975 patients were included in the present study. The difference in the interval to oral intake (weighted mean difference 0.56, 95% confidence interval [CI] 0.16-0.96, P = 0.006) between the decompression group and nondecompression group was significant, but no significant differences were found in the interval to flatus (weighted mean difference 0.24, 95% CI -0.13 to 0.61, P = 0.20) or length of hospital stay (weighted mean difference 1.04, 95% CI -0.05 to 2.14, P = 0.06). Additionally, no significant differences were found in complications, including nausea or vomiting (odds ratio [OR] 1.23, 95% CI 0.57-2.65, P = 0.59), fever (OR 1.55, 95% CI 0.96-2.51, P = 0.07), pulmonary complications (OR 1.41, 95% CI 0.82-2.43, P = 0.22), anastomotic leakage (OR 1.15, 95% CI 0.55-2.40, P = 0.70), paralytic ileus or small bowel obstruction (OR 1.80, 95% CI 0.57-5.70, P = 0.32), intra-abdominal abscess (OR 1.08, 95% CI 0.50-2.34, P = 0.84), wound infection (OR 1.29, 95% CI 0.56-2.96, P = 0.55), or wound dehiscence (OR 1.47, 95% CI 0.43-4.95, P = 0.54) between the two groups. A sensitivity analysis of the pooled data from high-quality studies and studies with >20 cases per group showed that the length of hospital stay was prolonged significantly in the decompression group compared with the nondecompression group. CONCLUSIONS: Routine gastrointestinal decompression after gastrectomy does not promote the recovery of gastrointestinal function or reduce the incidence of postoperative complications. In our series, decompression was correlated with a prolonged interval to oral intake, a longer duration of hospitalization, and increased patient discomfort.

Medial versus lateral approach in laparoscopic colorectal resection: a systematic review and meta-analysis.

BACKGROUND: The aim of this study was to investigate the safety and efficacy of the medial approach (MA) and the lateral approach (LA) in the treatment of colorectal disease. METHODS: Studies published since 1994 that compared MA versus LA in laparoscopic colorectal resection were collected. Data on conversion rate, operative time, blood loss, number of harvested lymph nodes, hospital stay, complications, mortality, rate of recurrence, and hospitalization costs for MA and LA were meta-analyzed using fixed-effect and random-effect models. RESULTS: Five cohort studies (2 randomized controlled trials and 3 retrospective studies) that included 881 patients were studied. Of these patients, 475 and 582 had undergone laparoscopic colorectal resection via MA and LA, respectively. There were significant reductions in conversion rate and operative time and possible reductions in blood loss and hospitalization costs for MA compared to LA; however, there were fewer harvested lymph nodes for MA compared with LA, which remains to be further studied. Other outcome variables such as postoperative complications, postoperative immune function, mortality, and rate of recurrence were not found to be statistically significant for either group. Sensitivity analysis on the pooled data from randomized controlled trials showed that the conversion rates were not significantly different between MA and LA. CONCLUSIONS: Compared with the lateral approach, the medial approach has the advantages of shorter operative time and possibly lower conversion rate; it also can be as safe as the lateral approach. Whether the MA has less blood loss and lower hospitalization costs remains to be confirmed, and its oncological safety and long-term prognosis are not clear. Due to insufficient data from a limited number of studies, inadequate assessment of the results may arise.

Surgical treatment of familial adenomatous polyposis: experience from a single institution in China.

AIM: Surgical options for familiar adenomatous polyposis (FAP) have been standardized in developed countries but are still controversial in China. The aim of this study was to retrospectively evaluate the results of patients with FAP treated in a university hospital. METHODS: In all 42 consecutive patients with FAP were operated on between May 1988 and June 2008. Median follow up was 7.2 years (2.2-20 years). Of these 33 patients were treated by proctocolectomy and ileal pouch anal anastomosis. A total colectomy with ileorectal anastomosis was undertaken in six and a proctocolectomy with ileostomy in three patients who had invasive rectal cancer. RESULTS: Postoperative morbidity was insignificant. There were five wound infections, one intestinal obstruction, one anastomotic leakage, one anastomotic stenosis and one refractory pouchitis. One patient died from stroke. Five died from FAP-related disorders, namely, abdominal desmoids, liver metastases and advanced rectal cancer. Desmoid tumor occurred in five patients. Periampullary adenoma and carcinoma developed in four patients. In those with pouch procedure the 24-h bowel movement was 7.14 ± 1.28 (range 5-11) and their 10-year overall survival was 87.5%. CONCLUSION: A proctocolectomy with ileal pouch anal anastomosis maybe the best choice for FAP patients in China. Surgical expertise, good teamwork and careful long-term follow up are mandatory.

Gynecomastia during imatinib mesylate treatment for gastrointestinal stromal tumor: a rare adverse event.

BACKGROUND: Imatinib mesylate has been the standard therapeutic treatment for chronic myeloid leukemia, advanced and metastatic gastrointestinal stromal tumor (GIST). It is well tolerated with mild adverse effects. Gynecomastia development during the course of treatment has been rarely reported. METHODS: Ninety-eight patients with advanced or recurrent GIST were treated with imatinib mesylate. Among the fifty-seven male patients six developed gynecomastia during the treatment. The lesions were confirmed by sonography. Sex hormone levels were determined in six patients with and without the presence of gynecomastia respectively. The patients with gynecomatia were treated with tamoxifene and the sex hormones were assayed before and after tamoxifene treatment. RESULTS: In patients with gynecomastia the lump underneath the bilateral nipples was 2.5 to 5 centimeters in diameter. Their serum free testosterone levels ranged between 356.61 and 574.60 ng/dl with a mean ± SD of 408.64 ± 82.06 ng/dl (95% CI 343.03~474.25 ng/dl), which is within the normal range. The level of serum estradiol was 42.89 ± 16.54 pg/ml (95% CI 29.66~56.12 pg/ml). Three patients had higher levels (43.79~71.21 pg/ml) and the others' were within normal range of 27.00~34.91 pg/ml. Six patients without the development of gynecomastia had normal free testosterone. One patient died because of large tumor burden. The sex hormones had no significant changes before and after tamoxifene treatment.(P > 0.05) CONCLUSIONS: Testosterone levels were not decreased in the six GIST patients with gynecomastia. Three patients had increased serum estradiol level which suggests that imbalance of sex hormones may be the cause of gynecomastia during treatment with imatinib mesylate.

[Meta-analysis of proximal gastrectomy and total gastrectomy for cancer of cardia and fundus].

OBJECTIVE: To assess the value of proximal gastrectomy (PG) and total gastrectomy (TG) for the treatment of cancer of cardia and fundus. METHODS: Publications on comparision between PG and TG in the treatment of cancer of cardia and fundus were collected, the data from the publications were matched with the PG group and the TG group respectively according to its corresponding surgical resection, and the data on postoperative complications, motality and 5-year survival rate were meta-analyzed by fixed effect model and random effect model. RESULTS: Thirteen reseaches on 2 219 patients were included in this study, 2 of which were randomly controlled studies. There were no significant differences in the postoperative complications (OR=1.00, 95%CI: 0.44-2.28,P>0.05) and mortality (OR=1.25, 95%CI: 0.62-2.48,P>0.05) between the PG group and the TG group, while there was significant difference in the 5-year survival rate (HR=0.87, 95%CI: 0.76-0.99,P=0.04). The 5-year survival rate in the TG group was higher than that in the PG group. CONCLUSION: Total gastrectomy for the treatment of cancer of cardia and fundus has better long-term therapetic effect.

[Clinicopathologic characteristics, diagnosis, and treatment of 30 patients with hereditary nonpolyposis colorectal cancer].

OBJECTIVE: To explore the clinicopathologic and molecular characteristics of hereditary nonpolyposis colorectal cancer (HNPCC), and to improve the level of diagnosis and treatments of HNPCC. METHODS: Thirty HNPCC patients (HNPCC group) who were treated in Xiangya Hospital were retrospectively analyzed, and 25 patients with sporadic colorectal cancer in the same duration were randomly chosen as a control group. The onset of age, location of tumor, pathological type, treatment method, and prognosis were compared in the 2 groups. The expression loss rate of mismatch repair gene (MMR) MLH1 and MSH2 in the 2 groups was detected by immunohistochemistry. RESULTS: The onset age in the HNPCC group was earlier than that in the control group (P<0.05). The rate of proximal colonic tumor the occurrence of multiple tumors, and the proportion of well differentiated adenocarcinoma in the HNPCC group were all higher than those in the control group (P<0.05). The expression loss rate of MLH1 and MSH2 in the HNPCC group was higher than that in the control group (P<0.05). One third in the HNPCC group received subtotal proctocolectomy. The prognosis of HNPCC patients was comparable with that of patients with sporadic colorectal cancer (P>0.05). CONCLUSION: HNPCC patients are characterized with early onset associating with multiple tumors. The accuracy of diagnosis can be improved by combining the detection of MMR gene. Optimal surgical treatment and close follow-up may bring good result to HNPCC patients.

Colovaginal anastomosis: an unusual complication of stapler use in restorative procedure after Hartmann operation.

BACKGROUND: Rectovaginal fistula is uncommon after lower anterior resection for rectal cancer. The most leading cause of this complication is involvement of the posterior wall of the vagina into the staple line when firing the circular stapler. CASE PRESENTATION: A 50-year-old women underwent resection for obstructed carcinoma of the sigmoid colon with Hartmann procedure. Four months later she underwent restorative surgery with circular stapler. Following which she developed rectovaginal fistula. A transvaginal repair was performed but stool passing from vagina not per rectum. Laporotomy revealed colovaginal anastomosis, which was corrected accordingly. Patient had an uneventful recovery. CONCLUSION: Inadvertent formation of colovaginal anastomosis associated with a rectovaginal fistula is a rare complication caused by the operator's error. The present case again highlights the importance of ensuring that the posterior wall of vagina is away from the staple line.