Safety and efficacy of overlapping triangular anastomoses in complete laparoscopic colorectal resection: a systematic evaluation and Meta-analysis

doi:10.21203/rs.3.rs-3469853/v1

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Safety and efficacy of overlapping triangular anastomoses in complete laparoscopic colorectal resection: a systematic evaluation and Meta-analysis

https://doi.org/10.21203/rs.3.rs-3469853/v1

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Background

To systematically evaluate and compare the safety and efficacy of overlapping triangular anastomoses and other anastomoses in total laparoscopic colorectal resection for the treatment of colorectal cancer, and to provide evidence-based medical evidence for clinical practice.

Materials and methods

PubMed, Embase, Cochrane Library and Web of Science databases were searched until May 2023, published literature related to total laparoscopic overlapping triangular anastomosis colorectal resection versus colorectal resection with other anastomoses was obtained, progressively screened, and eligible studies were included, and finally Meta-analysis was performed by Stata17 software.

Results

Seven literatures were included. 705 patients were included, including 342 patients who received overlapping triangular anastomoses and 363 patients who received other anastomoses. A meta-analysis of the included metrics showed that overlapping triangular anastomoses and other anastomoses were more effective in terms of operative time (SMD=-0.29, 95%CI-0.82, 0.23, P = 0.278), postoperative exhaust time (SMD=-0.61, 95%CI-0.84,-0.37), P = 0.000), intraoperative blood loss (SMD=-0.06, 95% CI-0.21,0.10, P = 0.493), length of hospital stay (SMD=-0.41, 95% CI-0.86,0.05, P = 0.079), incision length (SMD=-0.70, 95%CI-1.22,-0.19, P = 0.007), anastomosis time (SMD=-0.56, 95%CI-1.09,-0.03, P = 0.040), ground time (SMD=-0.33, 95%CI-0.65,-0.01, P = 0.041), postoperative defecation time (SMD=-0.75, 95%CI-1.39,-0.10, P = 0.023), number of lymph nodes dissection (SMD = 0.21, 95%CI-0.01,0.43, P = 0.063). From the results, it is clear that there was no significant difference between the overlapping triangular anastomosis and other anastomoses in terms of operative time, intraoperative bleeding, length of hospital stay, and number of lymph nodes discharged (P > 0.05). Compared with other anastomoses, the overlapping triangular anastomosis showed a significant difference in terms of shorter postoperative venting time, smaller incision length, shorter anastomosis time, earlier time on the floor, and earlier postoperative defecation time (P < 0.05).

Conclusion

The overlapping triangular anastomosis in complete laparoscopic colorectal resection is safe and effective, and is superior to other anastomoses in terms of postoperative venting time, incision length, and postoperative defecation time.

colorectal cancer

Complete laparoscopic colorectal resection

Overlapping triangular anastomosis

meta-analysis

Currently, colorectal cancer (CRC) is now the third most common cancer and a significant cause of cancer-related deaths worldwide Colorectal adenomas are a significant cause of colorectal cancer^[1].In the early stage of CRC, due to the absence of typical symptoms, it is not easy to detect, and has high morbidity and mortality ^[2].Complete laparoscopic radical resection of colorectal cancer has become one of the important links of digestive tract reconstruction in colorectal cancer due to its safety and feasibility, low surgical trauma, quick postoperative recovery, short hospital stay and other advantages ^[3].At present, the conventional anastomosis method is difficult to operate, which shows the reverse peristaltic anastomosis ^[4],often results in the failure of the operation. In order to make use of the operation simplicity of laparoscopic triangular anastomosis and avoid the opposite direction of intestinal peristalsis after digestive tract reconstruction, so as to be more in line with physiological functions, the author's team modified this anastomosis mode, namely, proximal and distal intestinal tubes were overlapped before anastomosis, overlapped delta-shaped anastomosis (ODA)^[5].Many studies have shown that overlapping triangulation has high safety and good prognosis ^[6–11].However, there is a lack of high-level evidence-based medical evidence for objective evaluation of overlapping triangulation. Therefore, the aim of this study was to investigate the safety and efficacy of the overlapping triangular anastomosis by comparing it with other anastomoses by integrating and analyzing previous studies through Meta-analysis, and to provide evidence-based medical evidence for clinical practice.

2.1. Data sources and retrieval strategies

This Meta-analysis was conducted based on the preferred reporting items of the systematic review and meta-analysis ^[12].The search is carried out independently by the researcher, and the combination of subject words and free words is adopted to ensure the completeness and accuracy of the search. A comprehensive literature search was conducted on PubMed, Embase, the Cochrane Library, and Web of Science. Studies comparing the overlapping triangular anastomosis with other anastomoses were conducted until the search deadline of May 2023.Based on the literature obtained from the above search, we conducted further searches.

2.2. Inclusion and exclusion criteria

2.2.1. Inclusion criteria

·Subjects: Patients diagnosed with colorectal cancer after pathological examination underwent complete laparoscopic colorectal resection, regardless of age, gender, or race

·The study type was randomized controlled study (RCTS)

·Intervention measures: Overlapping triangular anastomosis was performed in the experimental group, and other anastomoses were performed in the control group

·Outcome indexes: Operative time, postoperative exhaustion time, intraoperative bleeding, hospital stay, incision length, anastomosis time, time on the floor, postoperative defecation time, number of lymph nodes cleared

2.2.2. Exclusion criteria

·Studies where raw data cannot be extracted or data is incomplete

·Observational studies, case reports, experience summary, review, meta-analysis, conference literature and other non-clinical controlled studies

·Documents where basic information is not available

·Unpublished, republished literature

2.3. Research options

Two researchers independently investigated PubMed, Embase, Cochrane Library, Web of Science, the literature with a search deadline of May 2023 will be screened, and the literature with different opinions will be decided through discussion. If no consensus can be reached, the third researcher will make the judgment. Ensure that final data meet inclusion and exclusion criteria. Finally, intensive reading of the literature finally included in the study.

2.4. Data extraction

Then, two researchers independently extracted the data and made the literature information table through Excel software. Any differences were discussed and solved by the other two researchers. The extracted data included: (1) basic information: author name, study years, countries, sample size, intervention measures, etc.; (2) Outcome indexes: Operative time, postoperative time to exhaustion, intraoperative bleeding, length of hospital stay, incision length, anastomosis time, time to the floor, postoperative time to defecation, number of lymph nodes cleared, etc.The extracted data information is then checked to ensure its accuracy.

2.5. Quality assessment

Risk of bias assessment using the Cochrane Risk of Bias Assessment Tool for Randomised Controlled Trials ^[13]. The cohort study was evaluated using the Newcastle-Ottawa Scale (NOS), with eight entries in three major areas: selection of study subjects, comparability between groups, and determination of outcomes ^[14]. Scores ranged from 0 to 9, with higher scores indicating higher quality literature. In this study, literature with a score of ≥ 6 was defined as high quality literature.

2.6. Statistical processing

StataMP version 17 was used for data analysis, and the study was considered statistically significant at P < 0.05. Operative time, postoperative time to exhaustion, intraoperative bleeding, length of hospital stay, incision length, anastomosis time, time to floor, postoperative time to defecation, and number of lymph nodes discharged were continuous type variables. Effect sizes and 95% confidence intervals (95% confidence interval, 95% CI) were calculated using a continuous variable random effects model^[15].Egger plot was used to evaluate publication bias based on Cochran Q statistics and I² statistics. In addition, we performed a sensitivity analysis by separately removing each study from the data set and rerunning the threshold analysis described above.

3.1. Literature screening process and results

According to the search, the initial results were 606 articles, and 599 articles were excluded after layer by layer screening and evaluation. Seven articles eventually met the inclusion and exclusion criteria and were included in the meta-analysis, all of which were retrospective studies. The specific literature selection process and study results are shown in Fig. 1 (flowchart). General information about the included studies is summarized in Table 1. A total of 705 patients were included in this meta-analysis, including 342 patients with overlapping triangular anastomoses and 363 patients with other anastomoses.

3.2. Analysis of main outcome indicators

3.2.1 Operation time

Surgery times were reported in seven studies ^{[6, 16–21]} ,including 342 patients in the overlapping triangular anastomosis group and 363 patients in the other anastomosis group. The analysis yielded no significant difference in operative time between the overlapping triangular anastomosis group and the other anastomosis groups (SMD=-0.290, 95% CI (-0.816, 0.235), P = 0.278), and heterogeneity between studies was (I²=91%, P = 0.000), which was analyzed using a random-effects model.See Fig. 2A(a). Egger chart showed no significant publication bias P = 0.197 (P > 0.05). See Fig. 2A(b).

3.2.2. Postoperative exhaust time

Postoperative exhaust time was reported in seven studies ^{[6, 16–21]} ,including 342 patients in the overlapping triangular anastomosis group and 363 patients in the other anastomosis group. There was a significant difference in postoperative exhaust time between the overlapping triangular anastomosis group and other anastomosis groups(SMD = 0.61, 95%CI (-0.84, -0.37), P = 0.000), and the heterogeneity among studies was (I² = 54.6%, P = 0.040). However, the sensitivity analysis of postoperative exhaust time is stable. See Fig. 2B(a).The Egger plot showed no significant publication bias,P=(0.238)P > 0.05. Figure 2B(b).

3.2.3 Intraoperative blood loss

A total of 7 studies reported intraoperative blood loss ^{[6, 16–21]}, including 342 patients in the overlapping triangular anastomosis group and 363 patients in the other anastomosis group. There was no significant difference in intraoperative blood loss between the overlapping triangular anastomosis group and the other anastomosis groups, (SMD=-0.06, 95%CI (-0.21, 0.102), P = 0.493), and the heterogeneity among studies was (I² = 7.7%, P = 0.369). See Fig. 2C(a). Egger chart showed no significant publication bias (P = 0.472) P > 0.05. See Fig. 2C (b).

3.2.4. Postoperative defecation time

Postoperative defecation time was reported in four studies ^{[16, 18, 19, 21]}, including 229 patients in the overlapping triangular anastomosis group and 235 patients in the other anastomosis group. A significant difference in incision length was obtained between the overlapping triangular anastomosis group and the other anastomosis groups, (SMD=-0.746,95% CI (-1.39, -0.10), P = 0.023), with heterogeneity between studies (I² = 90.1%, P = 0.000). See Fig. 2D(a). Egger chart showed no significant publication bias (P = 0.146)P > 0.05. See Fig. 2D(b).

3.3 Secondary outcome indicators

3.2.5. Length of hospital stay

Length of stay was reported in six studies ^{[6, 16–19, 21]}, including 301 patients in the overlapping triangular anastomosis group and 322 patients in the other anastomosis group. No significant difference in length of stay was obtained between the overlapping triangular anastomosis group and the other anastomosis groups, (SMD=-0.41,95% CI (-0.86, 0.05), P = 0.079), with heterogeneity between studies (I²=86.2%, P = 0.000).See Fig. 2E(a). Egger chart showed no significant publication bias (P = 0.148)P > 0.05. See Fig. 2E(b).

3.2.6. Incision length

Incision length was reported in six studies ^{[6, 16–19, 21]}, including 301 patients in the overlapping triangular anastomosis group and 322 patients in the other anastomosis group. A significant difference in incision length was obtained between the overlapping triangular anastomosis group and the other anastomosis groups, (SMD = -0.704,95% CI (-1.22, -0.19), P = 0.007), with heterogeneity between studies (I² = 88.9%, P = 0.000) .See Fig. 2F(a). Egger chart showed no significant publication bias (P = 0.916)P > 0.05. See Fig. 2F(b).

3.2.7. Match time

Anastomosis time was reported in six studies ^{[6, 16–18, 20, 21]}, including 307 patients in the overlapping triangular anastomosis group and 328 patients in the other anastomosis group. A significant difference in incision length was obtained between the overlapping triangular anastomosis group and the other anastomosis groups, (SMD = -0.56,95% CI (-1.09, -0.03), P = 0.040), with heterogeneity between studies (I² = 90.0%, P = 0.000). See Fig. 2G(a). Egger chart showed no significant publication bias (P = 0.148)P > 0.05. See Fig. 2G(b).

3.2.8. Time to go to the ground

A total of five studies reported time to go underground ^{[6, 16, 18, 19, 21]}, including 249 patients in the overlapping triangular anastomosis group and 266 patients in the other anastomosis group. There was a significant difference in incision length between the overlapping triangulation group and the other anastomosis groups, (SMD=-0.33, 95%CI (-0.65, -0.01), P = 0.041), and the heterogeneity among studies was (I² = 65.6%, P = 0.020). See Fig. 2H(a). Egger chart showed no significant publication bias (P = 0.426)P > 0.05. See Fig. 2H(b).

3.2.9. Number of lymph nodes dissected

A total of 4 studies reported the number of lymph node dissections ^{[16, 18, 19, 21]}, included 229 patients in the overlapping triangular anastomosis group and 235 patients in the other anastomosis group. No significant difference in incision length was obtained between the overlapping triangular anastomosis group and the other anastomosis group, (SMD = 0.21,95% CI (-0.01, 0.43), P = 0.063), with heterogeneity between studies (I²=26.6%, P = 0.252).See Fig. 2I(a). Egger chart showed no significant publication bias (P = 0.778)P > 0.05. See Fig. 2I(b).

3.4 Sensitive graph analysis

As shown in the figure, the results of the original meta-analysis were statistically significant. Operation time OR (95%CI) =-0.29 (-0.82,0.23), as shown in Fig. 3A (c); Postoperative exhaust time OR (95%CI) =-0.61 (-0.84,-0.37), as shown in Fig. 3B (c); Intraoperative blood loss OR (95%CI) =-0.05 (-0.21,0.10), as shown in Fig. 3C (c); Postoperative defecation time OR (95%CI) =-0.75 (-1.39,-0.10), as shown in Fig. 3D (c); Length of stay OR (95%CI) =-0.41 (-0.86,0.05), as shown in Fig. 3E (c); Incision length OR (95%CI) =-0.70 (-1.22,-0.19), as shown in Fig. 3F(c); Anastomotic time OR (95%CI) =-0.56 (-1.09,-0.03), as shown in Fig. 3G (c) ;OR (95%CI) =-0.33 (-0.65,-0.01), as shown in Fig. 3H (c); The number of lymph nodes dissected OR (95%CI) = 0.21 (-0.01,0.43), as shown in Fig. 3I (c). 95%CI did not include 1, indicating that the results of meta-analysis were significantly different and had stability and reliability.

Clinically, it has been found that there are various methods of anastomosis in colorectal resection^[22–25],and the reconstruction method of overlapping triangular anastomosis ^[26],in peristalsis is more conducive to the recovery of digestive function ^[27].Overlap is one of the most commonly used linear anastomosis methods by surgeons ^{[5, 28, 29]},but the choice depends on the surgeon's experience and bias. To better answer this question, we need to analyze the clinical outcomes of overlapping triangulation and other anastomosis procedures in terms of surgical efficacy. Because the operation is performed in pneumoperitoneum ^[30],there is no need to add another opening in the abdominal wall, reducing the pain of the patient ^[31] .However, the location of intracavitary bleeding can be easily determined by using the linear stapler of esophagojejunum under endoscope.

A meta-analysis was used to evaluate the efficacy of overlapping triangulation and other anastomosis procedures. No statistically significant differences were found between overlapping triangular anastomosis and other anastomoses in terms of operative time, intraoperative bleeding and number of lymph nodes dissected after analysis by randomized controlled study through a multicenter study ^[32],it is suggested that different anastomosis methods have little influence on these outcome indexes. In this study, we pooled 7 studies and found that there was no significant difference in operation time between overlapping triangular anastomosis and other anastomosis procedures. In a complete laparoscopic overlapped anastomosis, superior anastomosis techniques and patient - to - patient coordination are required, otherwise this may prolong the operation time ^[33]. In this paper, 7 studies reported intraoperative bleeding. Overlapping triangular anastomosis reduced abdominal puncture holes and avoided puncture related vascular and intraperitoneal organ damage. In recent years, it has been found that overlapping triangular anastomosis significantly reduces the intraoperative tissue dissociation and bleeding ^[34], however, due to the time span of the collected relevant literature, which may be related to the immaturity of the operator's technique at the time of early performance, there was no significant difference in intraoperative bleeding between the overlapping triangular anastomosis and other anastomoses.

It was found that the advent of overlapping triangular anastomosis had significant advantages over other anastomosis procedures in terms of postoperative exhaust time, incision length, postoperative defecation time, etc. The results of Meta-analysis showed statistically significant differences in patients' postoperative time to exhaustion, incision length, postoperative time to defecation, and time to floor.In this paper, 7 studies have reported the postoperative exhaust time, and the results show that the exhaust time after overlapping triangular anastomosis is significantly shorter than that after other anastomosis, indicating that overlapping triangular anastomosis is a reliable method of gastrointestinal reanastomosis after gastrointestinal surgery ^[35]. In recent years, with the development of various new tube types and staplers, it is simple to operate, easy to learn and master, and has been widely recognized and trusted by surgeons. Anastomat anastomosis in gastrointestinal tract after operation has obvious effect and prominent effect. Compared with other traditional anastomosis methods, anastomosis time and incision length of overlapping triangle anastomosis are significantly shorter, and patients' postoperative time of going to the ground and defecation time are significantly shortened, patients' costs are reduced, and patients' postoperative recovery is faster ^[36], These results indicate that overlapping triangular anastomosis is a safe and good prognostic method in total laparoscopic colorectal resection, and it is of high application value in total laparoscopic colorectal resection ^[37]. At the same time, we also look forward to the follow-up large sample, multi-center, high-quality clinical studies to further verify.

In this paper, the safety and efficacy of total laparoscopic overlapping triangular anastomosis colorectal resection were initially investigated through a systematic review and Meta-analysis. In terms of postoperative exhaust time, incision length and postoperative defecation time, the total laparoscopic overlapping triangulation anastomosis is significantly better than other anastomosis, and the total laparoscopic overlapping triangulation anastomosis is more in line with the concept of rapid rehabilitation, so it is worthy of further clinical promotion. Of course, we also expect more patient-friendly anastomosis procedures to emerge, because the ultimate goal of all research is to benefit patients.

Acknowledgements:Not applicable.

Authors’ contributions:Junjing Li wrote the main manuscript, Junjing Li and Pengjie Yu co-authored the concepts, Junjing Li, Jingjun Han, and Chengwu Zhang co-authored the design, Junjing Li, Jingjun Han, and Pengjie Yu co-authored the DEFINITION of the intellectual content, the literature review was done by Junjing Li, Shengmao Zhu, Baojia Cai, and Kaimin Wang, the clinical study was done by Junjing Li and Lei Shao, the data collection was done by Junjing Li and Baojia Cai, and the analysis of the data was done by Junjing Li, Lei Shao, and Shengmao Zhu together, and all the authors reviewed the manuscript, with the guarantor being Pengjie Yu.

Funding:This study was funded by the Department of Science and Technology of Qinghai Province, China (2023-ZJ-787).

Availability of data and materials:All data generated and analysed is included in this publication

Ethics approval and consent to participate:Not Applicable.

Consent for publication:Not Applicable.

Competing interests:The authors declare no competing interests.

Author details:^1,3-9Qinghai University Affiliated Hospital 29 Tongren Road, Chengxi District, Xining,Qinghai Province，China;²Weifang Yidu Central Hospital

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Tables 1-2 are available in the Supplementary Files section.

No competing interests reported.

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Safety and efficacy of overlapping triangular anastomoses in complete laparoscopic colorectal resection: a systematic evaluation and Meta-analysis

Status:

Version 1

Abstract

Background

Materials and methods

Results

Conclusion

Figures

1. Introduction

2. Materials and methods

2.1. Data sources and retrieval strategies

2.2. Inclusion and exclusion criteria

2.2.1. Inclusion criteria

2.2.2. Exclusion criteria

2.3. Research options

2.4. Data extraction

2.5. Quality assessment

2.6. Statistical processing

3. Results

3.1. Literature screening process and results

3.2. Analysis of main outcome indicators

3.2.1 Operation time

3.2.2. Postoperative exhaust time

3.2.3 Intraoperative blood loss

3.2.4. Postoperative defecation time

3.3 Secondary outcome indicators

3.2.5. Length of hospital stay

3.2.6. Incision length

3.2.7. Match time

3.2.8. Time to go to the ground

3.2.9. Number of lymph nodes dissected

3.4 Sensitive graph analysis

4. Discuss

5. Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

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