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Author's reply: sliding versus conventional functional end-to-end anastomosis for colon cancer surgery: a randomized controlled trial
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 7 ) 1 e2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Letter to the editor
Author’s reply: sliding versus conventional functional end-to-end anastomosis for colon cancer surgery: a randomized controlled trial To the Editors, The remarks from Iba´n˜ez et al. on our randomized controlled trial comparing isoperistaltic and antiperistaltic stapled sideto-side anastomosis (SSSA) for colon cancer surgery focused a welcome spotlight on a clinically important, but soewhat disregarded, topic for surgeons. Our study included 40 patients (20 patients in each group) and concluded that isoperistaltic SSSA has no short-term advantage or disadvantage compared with antiperistaltic SSSA. However, the fact that only the isoperistaltic SSSA group had anastomotic leakage in two patients warrants further procedural modifications of this anastomosis technique, and future studies on this issue are required.1 Several limitations were also described in our article. The factors of a small and underpowered sample size, background differences (slightly worse nutritional status, longer operation time, and more intraoperative blood loss in the isoperistaltic group, but these differences were not significant), a mixture of different types of anastomosis (ileocolic and colocolic), and different numbers of additional hand sutures applied for reinforcement of anastomosis confounded the results. Iba´n˜ez et al. mentioned additional intellectual and important points to be considered. They advocated that isoperistaltic and antiperistaltic SSSA have similar requirements of intestinal mobility for extracorponeal anastomosis because intestinal mobility is determined by mesenteric mobilization. However, considering that insufficiency of mesenteric mobilization directly leads to insufficiency of intestinal mobilization, both anastomoses do not have equivalent requirements of intestinal mobility (represented in Figure 2). Intracorporeal anastomosis alleviates the limitation of intestinal mobility and allows performance of any anastomotic technique, as Iba´n˜ez et al. mentioned. However, notably, the feasibility and safety of intracorporeal anastomosis during laparoscopic surgery have not been sufficiently proven.2
DOI of original article: http://dx.doi.org/10.1016/j.jss.2017.03.046
We agree with the opinion of Iba´n˜ez et al. that a mixture of different types of anastomosis (ileocolic and colocolic), worse nutritional status, more intraoperative blood loss in the isoperistaltic group than in the antiperistaltic group, and differences in additional hand sutures applied for reinforcement, as already discussed in our article, could affect the results. We hope that the ongoing, randomized, controlled trial by Iba´n˜ez et al., with a large sample size and uniform background of patients, can evaluate the two types of anastomoses without these confounding factors and result in better anastomosis for right colectomy.
Acknowledgment Authors’ contributions: A.M. drafted the article. E.U. contributed to study supervision.
Disclosure Conflict of interest and grant support: none.
references
1 Matsuda A, Miyashita M, Matsumoto S, et al. Isoperistaltic versus antiperistaltic stapled side-toside anastomosis for colon cancer surgery: a randomized controlled trial. J Surg Res 2015;196: 107e12. 2 Wu Q, Jin C, Hu T, Wei M, Wang Z. Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A 2017;27:348e57.
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 7 ) 1 e2
Akihisa Matsuda, MD* Department of Surgery Nippon Medical School Chiba Hokusoh Hospital Inzai, Chiba, Japan Eiji Uchida, MD Department of Surgery Nippon Medical School Tokyo, Japan
*Corresponding author. Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan. Tel.: þ81 476-99-1111; fax: þ81 476-99-1991. E-mail address: [email protected] 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.03.047
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Letter to the editor
Author’s reply: sliding versus conventional functional end-to-end anastomosis for colon cancer surgery: a randomized controlled trial To the Editors, The remarks from Iba´n˜ez et al. on our randomized controlled trial comparing isoperistaltic and antiperistaltic stapled sideto-side anastomosis (SSSA) for colon cancer surgery focused a welcome spotlight on a clinically important, but soewhat disregarded, topic for surgeons. Our study included 40 patients (20 patients in each group) and concluded that isoperistaltic SSSA has no short-term advantage or disadvantage compared with antiperistaltic SSSA. However, the fact that only the isoperistaltic SSSA group had anastomotic leakage in two patients warrants further procedural modifications of this anastomosis technique, and future studies on this issue are required.1 Several limitations were also described in our article. The factors of a small and underpowered sample size, background differences (slightly worse nutritional status, longer operation time, and more intraoperative blood loss in the isoperistaltic group, but these differences were not significant), a mixture of different types of anastomosis (ileocolic and colocolic), and different numbers of additional hand sutures applied for reinforcement of anastomosis confounded the results. Iba´n˜ez et al. mentioned additional intellectual and important points to be considered. They advocated that isoperistaltic and antiperistaltic SSSA have similar requirements of intestinal mobility for extracorponeal anastomosis because intestinal mobility is determined by mesenteric mobilization. However, considering that insufficiency of mesenteric mobilization directly leads to insufficiency of intestinal mobilization, both anastomoses do not have equivalent requirements of intestinal mobility (represented in Figure 2). Intracorporeal anastomosis alleviates the limitation of intestinal mobility and allows performance of any anastomotic technique, as Iba´n˜ez et al. mentioned. However, notably, the feasibility and safety of intracorporeal anastomosis during laparoscopic surgery have not been sufficiently proven.2
DOI of original article: http://dx.doi.org/10.1016/j.jss.2017.03.046
We agree with the opinion of Iba´n˜ez et al. that a mixture of different types of anastomosis (ileocolic and colocolic), worse nutritional status, more intraoperative blood loss in the isoperistaltic group than in the antiperistaltic group, and differences in additional hand sutures applied for reinforcement, as already discussed in our article, could affect the results. We hope that the ongoing, randomized, controlled trial by Iba´n˜ez et al., with a large sample size and uniform background of patients, can evaluate the two types of anastomoses without these confounding factors and result in better anastomosis for right colectomy.
Acknowledgment Authors’ contributions: A.M. drafted the article. E.U. contributed to study supervision.
Disclosure Conflict of interest and grant support: none.
references
1 Matsuda A, Miyashita M, Matsumoto S, et al. Isoperistaltic versus antiperistaltic stapled side-toside anastomosis for colon cancer surgery: a randomized controlled trial. J Surg Res 2015;196: 107e12. 2 Wu Q, Jin C, Hu T, Wei M, Wang Z. Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A 2017;27:348e57.
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 7 ) 1 e2
Akihisa Matsuda, MD* Department of Surgery Nippon Medical School Chiba Hokusoh Hospital Inzai, Chiba, Japan Eiji Uchida, MD Department of Surgery Nippon Medical School Tokyo, Japan
*Corresponding author. Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan. Tel.: þ81 476-99-1111; fax: þ81 476-99-1991. E-mail address: [email protected] 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.03.047