For LRC, surgical procedures involving anastomosis (IIA or EIA) are still under debate. A growing number of studies7,8,12 have indicated that both of these surgical procedures are pathologically equivalent and have similar 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 EIA12. Some studies9,12−15 and meta-analyses 16,17 show that patients undergoing IIA may show a faster recovery of GI function, less postoperative pain, lower surgical stress response (SSR), fewer medical complications and shorter LOHS. In line with these studies, our study now provides evidence for the safety and effectiveness of IIA.
No significant differences were detected in operative time, intraoperative blood loss, oncological outcomes, overall morbidity rates or LOHS. Our findings were in concordance with the RCT of Allaix 8. Due to the wide and clear field of view in TLRC, operations go smoothly and anastomosis twists can be avoided. Furthermore, with the invention and application of advanced laparoscopic linear staplers, IIA has become simpler and more efficient. Although IIA poses greater technical difficulty and requires advanced technical skills in laparoscopic surgery, we believe that after a period of practice, the safety of the surgery can be guaranteed without increasing operative time.
Previously published studies paid little attention to costs for hospitalization. In our study, we found that patients in the IIA group paid more for hospitalization than the EIA group, but patients had a high degree of acceptance regarding this. This difference could be explained by the different equipment used in the surgery. During TLRC, one linear stapler and three surgical staples were used in order to perform transection of the bowels and overlap anastomosis. In contrast, EIA could be completed using one linear cutter and two surgical staples. We believe that with the popularization of the equipment and the advancement of medical care, equipment costs can be reduced.
GI function recovered earlier in patients in the IIA group, particularly in terms of first flatus (p < 0.01). The time of first stool passage did not show a significant difference in our study (p = 0.22), but the mean time was shorter in the IIA group. Meanwhile, tolerance of a soft diet occurred earlier in patients undergoing IIA (p < 0.01). This result can be explained by the reduced surgical injury in IIA procedures. Owing to less exteriorization and dissection of bowel and mesocolon in IIA, TLRC was thought to have a smaller effect on GI motility.
Patients with an IIA suffered less postoperative pain, particularly on the day of surgery. The benefit of IIA over EIA in reducing postoperative pain may be associated with a shorter skin incision for extracting the specimen. Data on the length of skin incision was not recorded in our hospital’s electronic database, but this has been confirmed in some other studies9.
As already known, sufficient bowel and mesentery exteriorization must be completed so that the bowel can be pulled out of the body in EIA, which may increase the probability of bleeding and cause additional damage to the tissue (Fig. 3). It is more difficult for surgeons to perform EIA in patients with obesity because of the presence of thick and short mesentery. It was hypothesized that IIA could decrease the incision length, reduce conversion rate and eliminate the need for bowel exteriorization for anastomosis, so it may be particularly beneficial for patients with obesity18,19. This may explain why our medical team tended to adopt IIA for patients with higher BMI. A case-matched study20 has concluded that IIA in patients with obesity (BMI > 30kg/m2) was associated with similar short-term outcomes and lower incidence of incisional hernias, and may possibly reduce the risk of hospital readmission. However, some published studies21–24 show that obesity is associated with postoperative complications, anastomotic leakage and re-operation. A negative influence of visceral fat on lymph nodes harvested was observed in patients with colorectal cancer22. In our subgroup analysis of patients with BMI ≥ 24 kg/m2, there was no significant difference found in rate or severity of postoperative complications in the two groups. Besides, the oncological outcomes in the IIA group were similar to those in the EIA group. Based on the potential advantages of lower surgical difficulty and reduced intraoperative risk, we believe that IIA may be a better approach for LRC in patients with obesity.
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. Third, the faster recovery of GI function and lower postoperative pain did not lead to a decrease in LOHS. Significant difference in LOHS may be reached within an enhanced recovery (ERAS) program, which we will consider adopting in a subsequent RCT. Lastly, the low incidence of postoperative complications may mean that this study was underpowered to identify statistical differences. In order to mitigate these drawbacks, we have designed an RCT and are enrolling patients. The study was registered with the Chinese Clinical Trials Registry (ChiCTR2100053282). All patients provided written informed consent before enrollment. The study protocol was approved by the Ruijin Hospital Ethics Committee (Shanghai Jiao Tong University School of Medicine).