Intracorporeal vs extracorporeal anastomosis in laparoscopic right colectomy for colon cancer: a prospective multicenter cohort study (the Hemi-D-TREND study)

Abstract

Background: Anastomotic leak (AL) is the most severe complication after laparoscopic right colectomy (RC), with historical median rates around 8%. Whether intracorporeal ileocolic anastomosis (ICA) offers advantages over extracorporeal anastomosis (ECA) under standardized, purely laparoscopic conditions remains uncertain. We aimed to compare AL rates and short-term postoperative outcomes between ICA and ECA in laparoscopic RC for colon cancer. Methods: Prospective multicenter cohort (TREND-compliant) across 11 hospitals (January 2019–June 2022). Adults with non-metastatic right colon cancer undergoing elective laparoscopic RC were included. Exposure (ICA vs ECA) was determined by each hospital’s routine practice. Primary outcome: AL, per predefined clinical, radiologic, or endoscopic criteria. Secondary outcomes: conversion to open surgery, length of stay (LOS), complications (Clavien–Dindo), surgical site infection (SSI), and a composite of severe complications (COSC). Analyses used the full cohort; propensity score matching (PSM) was prespecified as a sensitivity analysis. Results: A total of 438 patients were analyzed: 225 ICA and 213 ECA. AL occurred in 3/225 (1.33%) after ICA and 3/213 (1.41%) after ECA (p = 1.00; risk difference − 0.08 percentage points; 95% CI − 2.1 to 2.3). Conversion was lower with ICA (2.2% vs 7.5%; p = 0.013), while LOS was shorter with ICA (median 4 days; p < 0.001). There were no significant differences in severe morbidity (Clavien–Dindo ≥ III: 5.8% ICA vs 3.8% ECA; p = 0.375), SSI (incisional or organ/space), COSC (6.7% ICA vs 4.2% ECA; p = 0.298), reoperation, or mortality. Findings were consistent in PSM analyses (213:213). Conclusions: In this prospective multicenter laparoscopic cohort, both intracorporeal and extracorporeal anastomosis achieved anastomotic-leak rates below 2%, with no superiority of one technique over the other regarding leak or severe morbidity. ICA was associated with lower conversion and shorter hospital stay. These results confirm the overall safety and feasibility of both approaches in experienced centers. ClinicalTrials.gov Identifier: NCT03918369.