Meta-analysis of randomised controlled trials comparing intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: upgrading the level of evidence.

Abstract

The need for escalation of level of evidence regarding the comparative outcomes of intracorporeal (ICA) and extracorporeal (ECA) anastomosis in laparoscopic right hemicolectomy has been persistently highlighted by previous meta-analyses of level 2 and 3 evidence. A systematic search of electronic databases and bibliographic reference lists were conducted. Overall perioperative morbidity, anastomotic leak, surgical site infection (SSI), paralytic ileus, bleeding, postoperative pain within 5 days, length of incision, conversion to an open procedure, harvested lymph nodes, procedure time, and length of hospital stay were the evaluated outcome parameters. Four randomised controlled trials reporting a total of 399 patients evaluating outcomes of ICA (n = 199) and ECA (n = 200) in laparoscopic right hemicolectomy were included. The ICA was associated with significantly shorter length of incision (MD - 1.82, p < 0.00001), lower postoperative pain score on day 2 (MD - 0.69, p = 0.0007), day 3 (MD - 0.80, p = 0.02), day 4 (MD - 0.83, p = 0.01) and day 5 (MD - 0.49, p < 0.00001) when compared to ECA. Moreover, it was associated with significantly shorter length of hospital stay (MD - 0.27, p = 0.03). However, there was no significant difference in overall perioperative morbidity (RR 0.79, p = 0.47), anastomotic leak (RR 1.29, p = 0.65), SSI (RR 0.61, p = 0.42), bleeding (RR 0.70, p = 0.71), paralytic ileus (RR 0.60, p = 0.45), conversion to open (RD: - 0.02, p = 0.45), number of harvested lymph nodes (MD 0.82, p = 0.06), and procedure time (MD 16.04, p = 0.06) between two groups. The meta-analysis of level 1 evidence demonstrated that laparoscopic right hemicolectomy with ICA has comparable perioperative morbidity but better postoperative recovery than with ECA. The ICA is safe to be practiced more routinely where technical challenges allow.