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Page 12 of 16 Park et al. Mini-invasive Surg 2020;4:87 I http://dx.doi.org/10.20517/2574-1225.2020.87

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Figure 12. Subgroup meta-analysis of anastomotic leak in left colectomy

DISCUSSION
There is a growing body of evidence in the literature that intracorporeal anastomosis is a safe alternative
[3-5]
to extracorporeal anastomosis in laparoscopic right hemicolectomy . However, we found that currently
published systematic reviews and meta-analyses have not included more recently published studies, and
have only compared right sided colectomies, with little research into left colectomies. As a result, we have
carried out a new meta-analysis in an attempt to evaluate the clinical and oncological appropriateness
of intracorporeal anastomosis technique, combining data on right-sided and left-sided laparoscopic
colectomies and including more recently published studies. The strengths of this meta-analysis are that it
provides more power to the analysis, allows for identification of more patients in each study arm through
meticulous methodology, and offers thorough selection process and critical analysis of the results. To the
best of our knowledge, this is the first systematic review with meta-analysis of the literature evaluating
comprehensive peri-operative outcomes between IA and EA in a combined fashion including both
laparoscopic right and left colectomies. Twenty-four studies were included for analysis, with an overall
sample size of 2,674 patients (1,412 in the IA and 1,262 in the EA arm).

In terms of the primary outcome, the analysis supports the surgical safety of performing intracorporeal
anastomosis in laparoscopic colectomy, with no statistically significant difference observed for the rate of
anastomotic leakage. The quality of data is reinforced by an adequate sample size as well as an absence of
heterogeneity and publication bias.

Concerning the secondary outcomes, our results from meta-analysis appear to favour IA when compared
to EA, as evidenced by improved patient recovery with earlier return of bowel function, and lower rates of
surgical site infections and incisional hernia, all of which were statistically significant. Moreover, this was
without compromising oncological safety and short-term mortality.

Since the most common indication for laparoscopic colon resection is malignancy, it is imperative to
consider the oncological safety of a surgical technique. We have selected the number of lymph nodes
harvested as a surrogate marker for appropriateness of oncological radicality as the data was readily
available in the literature but also an area of debate for many years. Our analysis revealed that IA was
associated with slightly higher number of lymph nodes harvested. However, we acknowledge that the
number of lymph nodes harvested alone does not truly represent the adequacy of oncological resection,
and other crucial factors known to determine oncological safety such as clear multi-dimensional resection
margins, minimal intraoperative manipulation of the tumour, and wound protection during specimen
extraction all need to be considered. Therefore, we believe oncological safety would be better reflected by
[36]
[25]
long-term survival and recurrence outcome. Unfortunately, only two studies, Hanna et al. and Lee et al. ,
published meaningful long-term survival outcome with Kaplan-Meier graphs. Those studies demonstrated
that there was no significant difference in both disease-free survival and overall survival at 5 years and
3 years between IA and EA cohorts respectively.