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Isoperistaltic versus antiperistaltic stapled side-to-side anastomosis for colon cancer surgery
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
Isoperistaltic versus antiperistaltic stapled side-to-side anastomosis for colon cancer surgery Dear Sir, We have read with interest the article by Matsuda et al.1 on isoperistaltic versus antiperistaltic anastomoses in colorectal surgery for cancer, concluding there were no differences in short-term complications. However, we noted that the trial had been suspended on detecting excess morbidity in the isoperistaltic “stapled sideto-side” anastomosis group. The authors affirmed that the standard technique for colon surgery is the antiperistaltic configuration. They also suggested isoperistaltic configuration, as an alternative, when intestinal mobility is limited, explaining that isoperistaltic anastomosis reduces the intestinal mobilization up to 6 cm. Forty patients (20 per group) were analyzed, including patients with ileocolic and colocolic anastomoses, open surgery, and laparoscopic approaches. They found no differences between operation times, anastomosis times, and the length of hospital stay, but concluded that the antiperistaltic configuration may be a safer option. We would like to offer our opinion on three critical points. 1. Antiperistaltic configuration does not require a greater mobilization of the intestine. In fact, both isoperistaltic and antiperistaltic configuration may require a traction on the mesentery, if an extracorporeal anastomosis during laparoscopic surgery2 were to be performed. The advantage of the intracorporeal technique prevents traction of the mesentery, externalizes the bowel, and allows freedom to choose the incision site for the specimen extraction.3 2. The patient-mix considered both ileocolic or colocolic anastomosis. Although no significant differences were reported between the two groups, we contest the results because of the variety of procedures included in the trial. In our opinion, important differences exist between right colectomy, sigmoidectomy, and subtotal colectomy. Moreover, the authors did not explain the kinds of operations performed. We would appreciate more clarity on this matter. 3. The surgical procedures used in the study methodology are different. For antiperistaltic anastomosis group, additional hand sutures for reinforcement were used compared with isoperistaltic patients. This could influence results. Also DOI of original article: http://dx.doi.org/10.1016/j.jss.2015.02.059
the nutritional status of the isoperistaltic group was poorer and recorded greater blood loss. We consider that these are proven risk factors for anastomosis leakage and potentially could affect the results.4 We are carrying out a prospective randomized trial (NCT02309931), comparing isoperistaltic and antiperistaltic anastomosis in right colectomy for cancer (n ¼ 108 patients). Our principal findings center on the short-term complications regarding prolonged ileus and anastomotic leakages. Our 12-mo follow-up includes a Gastrointestinal Quality Life Index periodical study. In summary, we congratulate Matsuda et al. for their research but in light of the previously mentioned points suggest caution regarding the interpretation of the results.
Acknowledgment Authors’ contributions: N.I. and J.A. analyzed and interpreted the data. N.I. drafted the article. J.L. revised the article. P.P. contributed to the final approval of the version.
Disclosure Financial disclosure: none reported.
references
1 Matsuda A, Miyashita M, Matsumoto S, et al. Isoperistaltic versus antiperistaltic stapled side-to-side anastomosis for colon cancer surgery: a randomized controlled trial. J Surg Res 2015;196:107e12. 2 Baixauili J, Delaney CP, Senagore AJ, Remzi FH, Fazio VW. Portal vein thrombosis after laparoscopic sigmoid colectomy for diverticulitis: report of a case. Dis Colon Rectum 2003;46:550e3. 3 Abrisqueta J, Iban˜ez N, Luja´n J, Herna´ndez Q, Parrilla P. Intracorporeal ileocolic anastomosis in patients with laparoscopic right hemicolectomy. Surg Endosc 2016;30:65e72.
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
4 Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T. Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17,518 patients. Colorectal Dis 2017; 19:288e98.
Noelia Iba´n˜ez, MD* Jesus Abrisqueta, PhD Juan Luja´n, PhD Pascual Parrilla, PhD Colorectal Unit Department of General Surgery Virgen de la Arrixaca University Hospital
University of Murcia Murcia, Spain *Corresponding author. Departamento de Cirugı´a General, Unidad Colorrectal, Hospital Universitario Virgen de la Arrixaca, CIBEREHD, Ctra. Madrid-Cartagena, El Palmar, Murcia 30120, Spain. Tel.: þ34628443196; fax: þ34968369677. E-mail address: [email protected] (N. Iba´n˜ez) 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.03.046
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Letter to the editor
Isoperistaltic versus antiperistaltic stapled side-to-side anastomosis for colon cancer surgery Dear Sir, We have read with interest the article by Matsuda et al.1 on isoperistaltic versus antiperistaltic anastomoses in colorectal surgery for cancer, concluding there were no differences in short-term complications. However, we noted that the trial had been suspended on detecting excess morbidity in the isoperistaltic “stapled sideto-side” anastomosis group. The authors affirmed that the standard technique for colon surgery is the antiperistaltic configuration. They also suggested isoperistaltic configuration, as an alternative, when intestinal mobility is limited, explaining that isoperistaltic anastomosis reduces the intestinal mobilization up to 6 cm. Forty patients (20 per group) were analyzed, including patients with ileocolic and colocolic anastomoses, open surgery, and laparoscopic approaches. They found no differences between operation times, anastomosis times, and the length of hospital stay, but concluded that the antiperistaltic configuration may be a safer option. We would like to offer our opinion on three critical points. 1. Antiperistaltic configuration does not require a greater mobilization of the intestine. In fact, both isoperistaltic and antiperistaltic configuration may require a traction on the mesentery, if an extracorporeal anastomosis during laparoscopic surgery2 were to be performed. The advantage of the intracorporeal technique prevents traction of the mesentery, externalizes the bowel, and allows freedom to choose the incision site for the specimen extraction.3 2. The patient-mix considered both ileocolic or colocolic anastomosis. Although no significant differences were reported between the two groups, we contest the results because of the variety of procedures included in the trial. In our opinion, important differences exist between right colectomy, sigmoidectomy, and subtotal colectomy. Moreover, the authors did not explain the kinds of operations performed. We would appreciate more clarity on this matter. 3. The surgical procedures used in the study methodology are different. For antiperistaltic anastomosis group, additional hand sutures for reinforcement were used compared with isoperistaltic patients. This could influence results. Also DOI of original article: http://dx.doi.org/10.1016/j.jss.2015.02.059
the nutritional status of the isoperistaltic group was poorer and recorded greater blood loss. We consider that these are proven risk factors for anastomosis leakage and potentially could affect the results.4 We are carrying out a prospective randomized trial (NCT02309931), comparing isoperistaltic and antiperistaltic anastomosis in right colectomy for cancer (n ¼ 108 patients). Our principal findings center on the short-term complications regarding prolonged ileus and anastomotic leakages. Our 12-mo follow-up includes a Gastrointestinal Quality Life Index periodical study. In summary, we congratulate Matsuda et al. for their research but in light of the previously mentioned points suggest caution regarding the interpretation of the results.
Acknowledgment Authors’ contributions: N.I. and J.A. analyzed and interpreted the data. N.I. drafted the article. J.L. revised the article. P.P. contributed to the final approval of the version.
Disclosure Financial disclosure: none reported.
references
1 Matsuda A, Miyashita M, Matsumoto S, et al. Isoperistaltic versus antiperistaltic stapled side-to-side anastomosis for colon cancer surgery: a randomized controlled trial. J Surg Res 2015;196:107e12. 2 Baixauili J, Delaney CP, Senagore AJ, Remzi FH, Fazio VW. Portal vein thrombosis after laparoscopic sigmoid colectomy for diverticulitis: report of a case. Dis Colon Rectum 2003;46:550e3. 3 Abrisqueta J, Iban˜ez N, Luja´n J, Herna´ndez Q, Parrilla P. Intracorporeal ileocolic anastomosis in patients with laparoscopic right hemicolectomy. Surg Endosc 2016;30:65e72.
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
4 Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T. Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17,518 patients. Colorectal Dis 2017; 19:288e98.
Noelia Iba´n˜ez, MD* Jesus Abrisqueta, PhD Juan Luja´n, PhD Pascual Parrilla, PhD Colorectal Unit Department of General Surgery Virgen de la Arrixaca University Hospital
University of Murcia Murcia, Spain *Corresponding author. Departamento de Cirugı´a General, Unidad Colorrectal, Hospital Universitario Virgen de la Arrixaca, CIBEREHD, Ctra. Madrid-Cartagena, El Palmar, Murcia 30120, Spain. Tel.: þ34628443196; fax: þ34968369677. E-mail address: [email protected] (N. Iba´n˜ez) 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.03.046