Comparison of short-term outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis

Comparison of short-term outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of short-term outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis Mitsuyoshi Tei, Yozo Suzuki, Toshinori Sueda, Kazuya Iwamoto, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1520397/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Single-incision laparoscopic surgery (SILS) for descending colon cancer (DCC) is a technically challenging procedure with unclear clinical impact. The aim of this study was to evaluate the short-term outcomes of SILS for DCC compared with multi-port laparoscopic surgery (MPLS). Methods: We retrospectively analyzed 137 consecutive patients with stage I–III DCC who underwent SILS or MPLS at two high-volume multidisciplinary tertiary hospitals between April 2008 and December 2018, using propensity score-matched analysis. Results: After propensity score-matching, we enrolled 88 patients (n=44 in each group). Median follow-up period was 48 months. The completion rate for SILS was 98.1% in the overall cohort and 97.7% in the matched cohort. One patient was converted to open surgery in the MPLS group. Compared with the MPLS group, the SILS group showed significantly less blood loss and a greater number of harvested lymph nodes in both the entire patient cohort and the matched cohort. Morbidity rates did not differ significantly between groups before and after matching. R0 resection was achieved in the entire patient cohort. In terms of the incidence of recurrence, both groups were similar before and after matching. No significant differences were found between groups in terms of 3-year disease-free and overall survival rates in either the entire patient cohort or the matched cohort. Conclusions: SILS appears safe and feasible and can provide satisfactory oncological outcomes for selected patients with DCC. single-incision laparoscopic surgery descending cancer outcome Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Single-incision laparoscopic surgery (SILS) represents a recent advance in minimally invasive techniques. The first case of SILS was described for right colectomy in 2008 [1]. The benefits reportedly included better cosmetic outcomes, less postoperative pain, faster postoperative recovery, and earlier discharge from the hospital compared to multi-port laparoscopic surgery (MPLS) [2-5]. In several retrospective studies, SILS has been identified as a feasible and safe method of treating colon cancer in terms of both short- and long-term oncological outcomes [5-7]. In recent randomized controlled trials comparing SILS with MPLS, SILS has been shown to be equivalent to MPLS in term of short-term outcomes and can be considered an option for selected patients with colon cancer [8-10]. However, cases of descending colon cancers (DCC) were excluded from the above retrospective [5,6] and randomized studies [8-10] because of technical difficulties, particularly mobilization of the splenic flexure, and judgment of the area for lymph node dissection due to the anatomical complexity of the region. The impact of SILS on DCC is unclear. The aim of this study was thus to evaluate the clinical outcomes of SILS for DCC compared with MPLS in our institutions. PATIENTS AND METHODS Patient populations and surgeons Consecutive patients who underwent laparoscopic surgery (including MPLS and SILS) for DCC between April 2008 and December 2018 at Osaka Police Hospital and Osaka Rosai Hospital were assessed. Cases of obstruction or perforation that required emergent operation were excluded from this study. The first case of SILS for DCC was carried out in March 2011. Since then, the indications for SILS have gradually been expanded to include advanced cancers. Patients received a sheet describing the differences between MPLS and SILS, and also received a thorough explanation of each operative procedure. All patients agreed to undergo SILS, and provided written informed consent. Surgical procedures for DCC according to the tumor location According to the Japanese Society for Cancer of the Colon and Rectum Guideline for the Treatment of Colorectal Cancer [11], D2 lymph node dissection was performed for clinical T1 tumor and D3 lymph node dissection for clinical T2 or greater tumors. In principle, at least 10 cm of normal bowel both proximal and distal to the tumor was resected. For patients with tumor located in the proximal one-third of the descending colon [12,13], we performed left hemicolectomy with D3 lymphadenectomy, which involves complete dissection of the pericolic lymph nodes (node station 221, 231, and 241), intermediate lymph nodes (nodes 222, 232, 242, and 252), main lymph nodes (node 223) along the middle colic artery (MCA), and main lymph nodes (node 253) along the inferior mesenteric artery (IMA) as defined by the Japanese Society for Cancer of the Colon and Rectum [14]. On the other hand, segmental colectomy was performed for DCC located in the distal two-thirds of the descending colon [12,13]. In segmental colectomy, D3 lymphadenectomy involves complete dissection of regional lymph nodes, including the pericolic lymph nodes (nodes 221, 231, and 241), intermediate lymph nodes (nodes 232, 242, and 252), and main lymph nodes (node 253) along the IMA as defined by the Japanese Society for Cancer of the Colon and Rectum [14]. Data collection Patient age, sex, body mass index (BMI), Eastern Cooperative Oncology Group performance status (ECOG-PS), American Society of Anesthesiologists (ASA) score, previous abdominal surgery, clinical TNM classification, and comorbidities were obtained from the medical records. As listed in Table 1, cardiac disease consisted of ischemic disease, chronic heart failure or cardiomyopathy. Pulmonary disease consisted of asthma, chronic obstructive pulmonary disease or interstitial pneumonia. Cerebrovascular disease consisted of a history of transient ischemic attacks or cerebrovascular events with or without neurological deficit. Postoperative complications were classified according to the Clavien-Dindo classification [15]. Infectious complications consisted of abscess, colitis, urinary tract infection, nephritis, catheter-related infection, or cholecystitis. Operative mortality was defined as death during the same admission or within 30 days of surgery. All patients were followed-up for at least 30 days after surgery. This study was approved by the institutional review boards at Osaka Police Hospital (approval number 1468) and Osaka Rosai Hospital (approval number 2021-82). Statistical methods Prior to propensity score-matching, the t test or Wilcoxon rank-sum test was used for continuous variables, and the χ 2 test or Fisher’s exact test was applied for categorical variables. Propensity score-matching was then applied to minimize the possibility of selection bias and to adjust for significant differences in the baseline characteristics of patients (Fig. 1). The first step in the matching process was to complete a multivariate logistic regression analysis to obtain propensity scores. The following 9 covariates that might affect short- and long-term outcomes for SILS were included in the model for calculating the propensity score: age, sex, ECOG-PS, ASA score, previous abdominal surgery, and clinical TNM classification. The next step was the 1:1 matching process, using calipers set at 0.2. This propensity score-matching was used to evaluate the effects of SILS on surgical and pathological outcomes. After propensity score-matching, baseline characteristics, including covariates not entered into the propensity score model, were compared between groups using bivariate analyses. Data are presented as the median and interquartile range (IQR) for continuous variables and as the frequency and percentage for categorical variables. The c 2 test was used for comparisons of categorical variables. Student’s t test was used to determine the significance of differences between continuous variables. Survival curves were calculated using the Kaplan-Meier method and were then compared by log-rank testing. Values of p<0.05 were considered statistically significant. All statistical analyses were performed using JMP version 16.0 software (SAS Institute, Cary, NC, USA). RESULTS Baseline patient profiles An overview of our study is shown in Figure 1. Among 152 consecutive patients who underwent primary tumor resection for DCC, 15 patients were excluded. These exclusions were due to open surgery in 12 patients, emergency surgery due to perforation in 1 patient, and simultaneous resection of another tumor in 2 patients (ascending colon cancer in 1, gastrointestinal tumor in 1). The total sample size was thus 137 patients who underwent SILS (n=52) or MPLS (n=85) for DCC. Table 1 lists the demographic characteristics of the overall cohort and for propensity score-matched patients. After matching, 44 matched pairs were selected. Baseline characteristics of patients were conserved between the two matched groups. Comparison of short-term outcomes between groups Table 2 summarizes the details of operative findings between groups. Compared with the MPLS group, blood loss was significantly less in the SILS group both before (p<0.001) and after matching (p=0.011). In the overall cohort, D3 lymph node dissection rate was significantly larger in the SILS group before matching (p<0.001), but was not significant after matching (p=0.085). In the MPLS group, 1 patient was converted to open surgery because of intraoperative bleeding. In the SILS group, 1 patient required an additional port for development of the operative field. No relevant differences were found between groups in terms of procedure, operative time or multivisceral resection rate before or after matching. Table 3 depicts the postoperative complications that occurred in each group. The rate of Clavien-Dindo grade ≥2 events did not differ between groups before or after matching. Two patients in the MPLS group and 1 patient in the SILS group underwent reoperation due to anastomotic leakage. Perioperative death was not found in the overall cohort. Median duration of hospitalization was 10 days in both groups after matching. The pathological features and oncological outcomes are summarized in Table 4. The number of harvested lymph nodes was significantly larger in the SILS group than in the MPLS group, both before (p<0.001) and after matching (p=0.043). Tumor size, proximal margin, distal margin, tumor invasion, lymph node metastasis, pathological TNM classification, and number of patients who received adjuvant chemotherapy were similar in both groups. Radial margin positivity was not found in any patients. Comparison of long-term oncological outcomes between groups The median follow-up was 41 months (range, 22-53 months) in the SILS group and 60 months (rage, 37-34 months) (p=0.001). In the overall cohort, 11 patients in the MPLS group experienced recurrence (liver, n=5; lung, n=2; peritoneum, n=1; distant lymph node metastases, n=2; adrenal glands, n=1), compared to 8 patients in the SILS group (liver, n=4; lung, n=1; peritoneum, n=2; ovary, n=1). The 3-year disease-free survival rate was 89.1% in the MPLS group and 83.8% in the SILS group (Fig. 2a), and the 3-year overall survival rate was 94.8% in the MPLS group and 95.6% in the SILS group (Fig. 3a). After matching, the 3-year disease-free survival rate was 88.3% in the MPLS group and 80.8% in the SILS group (Fig. 2b), and the 3-year overall survival rate was 97.4% in the MPLS group and 95.2% in the SILS group (Fig. 3), showing no significant differences between groups. DISCUSSION The present study appears to be the first to compare clinical outcomes between SILS and MPLS for DCC. The results suggest that, in selected patients, SILS for DCC can be performed safely and feasibly (as per the 98.1% SILS completion rate) and yields adequate short-term surgical outcomes (e.g., 25.0% morbidity, 0% mortality) in the entire patient cohort. In terms of oncological outcomes, we achieved a 100% R0 resection rate, and satisfactory 3-year disease-free and overall survival rates in patients with DCC who underwent SILS in both the entire patient cohort and matched cohort. In this study, SILS was successfully performed in 98.1% of patients, including 17 patients (32.7%) with a history of prior abdominal surgery. In a previous systematic review of SILS for colorectal cancer [16], the rate of conversion to open surgery was 0.9%, and 13.3% of patients who underwent SILS procedures required insertion of an additional port to allow completion of the operation. Those findings were comparable with the present results. Median operative time was about 10 min longer in the SILS group both before and after matching, but this was not significant. In previous studies [17-22], the operative time of laparoscopic surgery for splenic flexure colon cancer ranged from 178 to 283 min, comparable with our findings regardless of SILS or MPLS. Generally, SILS is technically limited due to factors such as instrument crowding, inline positioning of the laparoscope, and insufficient triangulation [23,24], especially in mobilization of the splenic flexure and regional lymph node dissection; these issues would contribute to extend the operative time. The volume of blood loss was significantly lower in the SILS group than in the MPLS group for both the entire cohort (p<0.001) and matched cohort (p=0.011). In our study, patients with DCC who underwent MPLS were enrolled between April 2008 and December 2018, while SILS was performed for patients from March 2011 to December 2018. This difference in historical background may have affected the results. Other perioperative outcomes, including multivisceral resection rate and postoperative complications, did not differ between groups, and were comparable with findings from previous studies [5-10]. Although this study analyzed only 137 patients and used a retrospective design to investigate patients from two hospitals, our results with SILS showed high reliability in terms of successful completion rate and perioperative outcomes in patients with DCC. In cancer treatment, oncological clearance must take precedence over cosmetic advantages or reduced invasiveness. The number of harvested lymph nodes was significantly larger in the SILS group than in the MPLS group for the entire patient cohort (p<0.001) and matched cohort (p=0.043). In this study, the D3 lymph node dissection rate was significantly higher for the SILS group than for the MPLS group (p=0.021) in the entire patient cohort, and also tended to be high in the matched cohort (p=0.085). This may have affected the difference in number of harvested lymph nodes. The oncological outcomes, including proximal margin, distal margin, and residual tumor status, were comparable to those from randomized control trials comparing open and MPLS for colorectal cancer [25-28], as well as those comparing MPLS and SILS for colon cancer [5-10]. In the present study, the 3-year disease-free survival rate, 3-year overall survival rate, and recurrence pattern did not differ between groups. Our results are comparable to findings from previous studies that have reported long-term outcomes of SILS for colon cancer [29,30] or oncological outcomes of DCC [31,32]. Several limitations warrant consideration when interpreting the results of this investigation. First, data were obtained retrospectively, and the sample size was small. Second, this study showed bias in terms of the dates of operations. To overcome this limitation, we matched cases using several clinical variables, balancing groups and reducing selection bias. However, the potential for selection bias remains, despite the propensity score-matching. Third, BMI in our cohort was typical of a Japanese population, and may have significantly affected the surgical results of SILS. Fourth, the duration of follow-up was significantly shorter in the SILS group (41 months) than in the MPLS group (60 months, p=0.001). Long-term oncological outcomes and rates of later complications such as umbilical incisional hernia thus could not be assessed in the SILS group. Despite these limitations, we consider that this analysis using propensity score-matching confirmed SILS as a safe and feasible option for DCC. Further analyses are required to validate our results, and to evaluate the long-term oncological outcomes in future randomized clinical trials. Conclusions SILS is a safe, feasible method that can provide satisfactory oncological outcomes in selected patients with DCC. Declarations The present manuscript is an original contribution not previously published and not under consideration for publication elsewhere, and, if accepted, will not be published anywhere in similar form, in any language. All authors have read and approved the manuscript, and the study was approved by the institutional research ethics committee. Contributions of each author: MT and YS conceived and designed the study. MT, YS, TS, KI, AN, MN, YY, MO, MI, TM and HA acquired the data. MT and YS analyzed and interpreted the data. MT drafted the manuscript. YS, TS, KI, AN, MN, YY, MO, MI, TM and HA critically revised the article. MT, YS, TS, KI, AN, MN, YY, MO, MI, TM and HA approved the final version of the manuscript to be published. Acknowledgments: none Funding/Support This research did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of Interest and Financial Disclosure Mitsuyoshi Tei, Yozo Suzuki, Toshinori Sueda, Kazuya Iwamoto, Atsushi Naito, Yukihiro Yoshikawa, Masatoshi Nomura, Masahisa Ohtsuka, Mitsunobu Imasato, Tsunekazu Mizushima, and Hiroki Akamatsu have no conflicts of interest or financial ties to disclose. References Remzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port laparoscopy in colorectal surgery. Colorectal Dis. 2008; 10:823–826. Papaconstantinou HT, Thomas JS. Single-incision laparoscopic colectomy for cancer: assessment of oncologic resection and short-term outcomes in a case-matched comparison with standard laparoscopy. Surgery. 2011; 150:820–827. Champagne BJ, Papaconstantinou HT, Parmar SS, Nagle DA, Young-Fadok TM, Lee EC, et al. Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg. 2012; 255:66–69. Poon JT, Cheung CW, Fan JK, Lo OS, Law WL. 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Demographic characteristics of patients Overall (n=137) Propensity score-matched pairs (n=88) Lap (n=85) SILS (n=52) P value Lap (n=44) SILS (n=44) P value Age, years, median (IQR) 71 (63-78) 69 (63-74) 0.444 67 (57-75) 69 (60-74) 0.551 Gender, male, n (%) 57 (67.1) 27 (51.9) 0.104 19 (43.2) 19 (43.2) 1 BMI, kg/m 2 , median (IQR) 23.0 (20.9-24.9) 23.1 (20.9-25.1) 0.982 22.8 (20.0-25.5) 23.3 (20.9-25.0) 0.679 ECOG-PS, 0 or 1, n (%) 84 (98.8) 50 (96.2) 0.557 43 (97.7) 43 (97.7) 1 ASA score, 1 or 2, n (%) 72 (84.7) 42 (80.8) 0.639 37 (84.1) 36 (81.8) 1 Previous abdominal surgery, n (%) 17 (20) 17 (32.7) 0.107 12 (27.3) 11 (25) 1 Clinical TNM stage, n (%) I II III 33 (38.8) 26 (30.6) 26 (30.6) 15 (28.9) 17 (32.7) 20 (38.5) 0.456 17 (38.6) 14 (31.8) 13 (29.6) 15 (34.1) 15 (34.1) 14 (31.8) 0.906 *Comorbidities, n (%) Cardiac Pulmonary Diabetes Cerebrovascular Anticoagulant therapy 11 (12.9) 13 (15.3) 19 (22.4) 8 (9.4) 12 (14.1) 8 (15.4) 7 (13.5) 7 (13.5) 9 (17.3) 9 (17.3) 0.800 0.809 0.263 0.191 0.632 2 (4.6) 6 (13.6) 8 (18.2) 4 (9.1) 3 (6.8) 6 (13.6) 6 (13.6) 5 (11.4) 7 (15.9) 8 (18.2) 0.266 1 0.549 0.521 0.196 ECOG-PS, Eastern Cooperative Oncology Group Performance Status Scale; ASA score, American Society of Anesthesiologists Score; BMI, body mass index; *Comorbidities: Cardiac = ischemic disease, chronic heart failure and cardiomyopathy, excluded hypertension; Pulmonary = asthma, chronic obstructive pulmonary disease, and interstitial pneumonia Cerebrovascular = history of transient ischemic attacks and cerebrovascular event with or without neurological deficit. Table 2. Operative findings Overall (n=137) Propensity score-matched pairs (n=88) Lap (n=85) SILS (n=52) P value Lap (n=44) SILS (n=44) P value Procedure Left hemicolectomy Segmental colectomy Subtotal colectomy 33 (24.1) 49 (57.7) 3 (3.5) 15 (28.9) 37 (71.2) 0 0.158 12 (27.3) 32 (72.7) 13 (29.6) 31 (70.5) 1 Blood loss, ml, median (IQR) 30 (5-100) 5 (5-67) <0.001 26 (5-90) 5 (5-67) 0.011 Operative time, minutes, median (IQR) 227 (191-274) 240 (189-258) 0.678 234 (192-294) 240 (192-262) 0.900 Extent of lymph node dissection, D3, n (%) 41 (48.2) 36 (69.2) 0.021 20 (45.5) 29 (65.9) 0.085 Multivisceral resection, n (%) 6 (7.1) 3 (5.8) 1 1 (2.3) 2 (4.6) 1 Conversion to open surgery, n (%) 1 (1.2) 0 - 1 (2.3) 0 - Required an additional port, n (%) 0 1 (1.9) - 0 1 (2.3) - Table 3. Postoperative complications Clavien-Dindo classification (Grade ≥2), n (%) Overall (n=137) Propensity score-matched pairs (n=88) Lap (n=85) SILS (n=52) P value Lap (n=44) SILS (n=44) P value Anastomotic leakage 3 (3.5) 1 (1.9) 1 1 (2.3) 1 (2.3) 1 Wound infection 6 (7.1) 4 (7.7) 1 5 (11.4) 3 (6.8) 0.713 Bowel obstruction 2 (2.4) 5 (9.6) 0.105 2 (4.5) 3 (6.8) 1 Pneumonia 1 (1.2) 1 (1.9) 1 1 (2.3) 1 (2.3) 1 *infectious complications 2 (2.4) 7 (13.5) 0.026 2 (4.5) 5 (11.4) 0.260 Reoperation 2 (2.4) 1 (1.9) 1 0 1 (2.3) - Perioperative death 0 0 - 0 0 - Overall complication 13 (15.3) 13 (25) 0.182 7 (15.9) 10 (22.7) 0.435 Postoperative hospital stay, days, median (IQR) 11 (9-15) 9 (7-13) 0.025 10 (8-14) 10 (7-13) 0.432 *infectious complications= abscess, colitis, urinary tract infection, nephritis, catheter-related infection, cholecystitis Table 4. Pathological features and oncological outcomes Overall (n=137) Propensity score-matched pairs (n=88) Lap (n=85) SILS (n=52) P value Lap (n=44) SILS (n=44) P value Tumor size, mm, median (IQR) 25 (16-45) 40 (26-50) 0.038 25 (15-50) 38 (23-45) 0.128 Proximal margin, mm, median (IQR) 105 (95-110) 110 (105-118) 0.749 105 (90-115) 110 (95-110) 0.648 Distal margin, mm, median (IQR) 95 (80-110) 90 (85-108) 0.545 95 (88-110) 90 (85-110) 0.701 Number of harvested lymph nodes, median (IQR) 14 (8-22) 21 (12-29) <0.001 14 (8-22) 20 (11-27) 0.043 Tumor invasion, n (%) pT1 pT2 pT3 pT4 25 (29.4) 12 (14.1) 34 (40) 14 (16.5) 10 (19.2) 5 (9.6) 28 (53.9) 9 (17.3) 0.353 14 (31.8) 6 (13.6) 16 (36.4) 8 (18.2) 10 (22.7) 4 (9.1) 22 (50) 8 (18.2) 0.568 Lymph node metastasis, n (%) pN0 pN1 pN2 62 (72.9) 18 (21.2) 5 (5.9) 32 (61.5) 14 (26.9) 6 (11.5) 0.315 33 (75) 8 (18.2) 3 (6.8) 27 (61.4) 12 (27.3) 5 (11.4) 0.385 Positive radial margin, n (%) 0 0 - 0 0 - pTNM stage, n (%) I II III IV 32 (37.7) 30 (35.3) 22 (25.9) 1 (1.2) 14 (26.9) 18 (34.6) 20 (38.5) 0 0.293 18 (40.9) 15 (34.1) 11 (25) 13 (29.6) 14 (31.8) 17 (38.6) 0.343 Adjuvant chemotherapy (stage II or III), n (%) 19 (36.5) 14 (36.8) 1 10 (22.7) 11 (25) 1 Recurrence Liver Lung Peritoneum Distant lymph node Other organ 5 2 1 2 1 4 1 2 0 1 1 1 0 2 1 4 1 2 0 1 Additional Declarations No competing interests reported. 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05:14:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1520397/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1520397/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":20074429,"identity":"56b00e44-52a4-4041-96ce-8d9398b1f242","added_by":"auto","created_at":"2022-04-07 16:01:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38957,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patients who underwent SILS or MPLS for DCC describing the patient-matching process.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-1520397/v1/56647d9152c82bec762bb40b.png"},{"id":20074430,"identity":"3804ee23-c4a2-4ffa-9b05-e9d038138053","added_by":"auto","created_at":"2022-04-07 16:01:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28813,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier analysis of disease-free survival rates between groups before (a) and after (b) matching.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-1520397/v1/17188e0eb687b784ce4941cf.png"},{"id":20074431,"identity":"38c54e14-c35a-4b66-978a-ad225f466245","added_by":"auto","created_at":"2022-04-07 16:01:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":26309,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier analysis of overall survival rates between groups before (a) and after (b) matching.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-1520397/v1/5ab989cbd606752f235289f6.png"},{"id":20074482,"identity":"fb724846-45c2-422b-8fe1-d9898a3631cf","added_by":"auto","created_at":"2022-04-07 16:01:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":514683,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1520397/v1/2f9cd46a-725d-4bf5-b0ad-e18bdc20627e.pdf"},{"id":20074468,"identity":"b1a4a1e3-a59d-4827-98ac-7ae7e3d445cc","added_by":"auto","created_at":"2022-04-07 16:01:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":514683,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1520397/v1/52022691-4d3c-44ef-81ff-31b8d1e68b14.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of short-term outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSingle-incision laparoscopic surgery (SILS) represents a recent advance in minimally invasive techniques.\u0026nbsp;The first case of SILS was described for right colectomy in 2008 [1]. The benefits reportedly included better cosmetic outcomes, less postoperative pain, faster postoperative recovery, and earlier discharge from the hospital compared to multi-port laparoscopic surgery (MPLS) [2-5]. In several retrospective studies, SILS has been identified as a feasible and safe method of treating colon cancer in terms of both short- and long-term oncological outcomes [5-7]. In recent randomized controlled trials comparing SILS with MPLS, SILS has been shown to be equivalent to MPLS in term of short-term outcomes and can be considered an option for selected patients with colon cancer [8-10].\u003c/p\u003e\n\u003cp\u003eHowever, cases of descending colon cancers (DCC) were excluded from the above retrospective [5,6] and randomized studies [8-10] because of technical difficulties, particularly mobilization of the splenic flexure, and judgment of the area for lymph node dissection due to the anatomical complexity of the region. The impact of SILS on DCC is unclear. The aim of this study was thus to evaluate the clinical outcomes of SILS for DCC compared with MPLS in our institutions.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003ePatient populations and surgeons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsecutive patients who underwent laparoscopic surgery (including MPLS and SILS) for DCC between April 2008 and\u0026nbsp;December\u0026nbsp;2018 at Osaka Police Hospital and Osaka Rosai Hospital were assessed. Cases of obstruction or perforation that required emergent operation were excluded from this study.\u003c/p\u003e\n\u003cp\u003eThe first case of SILS for DCC was carried out in March 2011. Since then, the indications for SILS have gradually been expanded to include advanced cancers.\u0026nbsp;Patients received a sheet describing the differences between MPLS and SILS, and also received a thorough explanation of each operative procedure. All\u0026nbsp;patients\u0026nbsp;agreed to undergo SILS, and provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedures for DCC according to the tumor location\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording\u0026nbsp;to the Japanese Society for Cancer of the Colon and Rectum Guideline for the Treatment of Colorectal Cancer [11], D2 lymph node dissection was performed for clinical T1 tumor and D3 lymph node dissection for clinical T2 or greater tumors. In principle, at least 10 cm of normal bowel both proximal and distal to the tumor was resected. For patients with tumor located in the proximal one-third of the descending colon [12,13], we performed left hemicolectomy with D3 lymphadenectomy, which involves complete dissection of the pericolic lymph nodes (node station 221, 231, and 241), intermediate lymph nodes (nodes 222, 232, 242, and 252), main lymph nodes (node 223) along the middle colic artery (MCA), and main lymph nodes (node 253) along the inferior mesenteric artery (IMA) as defined by the Japanese Society for Cancer of the Colon and Rectum [14]. On the other hand, segmental colectomy was performed for DCC located in the distal two-thirds of the descending colon [12,13]. In segmental colectomy, D3 lymphadenectomy involves complete dissection of regional lymph nodes, including the pericolic lymph nodes (nodes 221, 231, and 241), intermediate lymph nodes (nodes 232, 242, and 252), and main lymph nodes (node 253) along the IMA as defined by the Japanese Society for Cancer of the Colon and Rectum [14].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient age, sex,\u0026nbsp;body mass index (BMI), Eastern Cooperative Oncology Group performance status (ECOG-PS),\u0026nbsp;American Society of Anesthesiologists (ASA) score, previous abdominal surgery,\u0026nbsp;clinical TNM classification, and comorbidities were obtained from the medical records. As listed in Table 1, cardiac disease consisted of ischemic disease, chronic heart failure or cardiomyopathy. Pulmonary disease consisted of asthma, chronic obstructive pulmonary disease or interstitial pneumonia. Cerebrovascular disease consisted of a\u0026nbsp;history of transient ischemic attacks or cerebrovascular events with or without neurological deficit. Postoperative complications were classified according to the Clavien-Dindo classification [15]. Infectious complications consisted of abscess, colitis, urinary tract infection, nephritis, catheter-related infection, or cholecystitis. Operative mortality was defined as death during the same admission or within 30 days of surgery. All patients were followed-up for at least 30\u0026nbsp;days\u0026nbsp;after surgery.\u0026nbsp;This study was approved by the institutional review boards at Osaka Police Hospital (approval number 1468) and Osaka Rosai Hospital\u0026nbsp;(approval number 2021-82).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to propensity score-matching, the t test or Wilcoxon rank-sum test was used for continuous variables, and the χ\u003csup\u003e2\u003c/sup\u003e test or Fisher’s exact test was applied for categorical variables. Propensity score-matching was then applied to minimize the possibility of selection bias and to adjust for significant differences in the baseline characteristics of patients (Fig. 1). The first step in the matching process was to complete a multivariate logistic regression analysis to obtain propensity scores. The following 9 covariates that might affect short- and long-term outcomes for SILS were included in the model for calculating the propensity score: age, sex, ECOG-PS, ASA score, previous abdominal surgery, and clinical TNM classification. The next step was the 1:1 matching process, using calipers set at 0.2. This propensity score-matching was used to evaluate the effects of SILS on surgical and pathological outcomes. After propensity score-matching, baseline characteristics, including covariates not entered into the propensity score model,\u0026nbsp;were\u0026nbsp;compared between groups using bivariate analyses.\u003c/p\u003e\n\u003cp\u003eData are presented as the median and\u0026nbsp;interquartile range (IQR) for continuous variables and as the frequency and percentage for categorical variables. The\u0026nbsp;c\u003csup\u003e2\u003c/sup\u003e test was used for comparisons of categorical variables. Student’s t test was used to determine the significance of differences between continuous variables. Survival curves were calculated using the Kaplan-Meier method and were then compared by log-rank testing. Values of p\u0026lt;0.05 were considered statistically significant. All statistical analyses were performed using JMP version 16.0 software (SAS Institute, Cary, NC, USA).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eBaseline patient profiles\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn overview of our study is shown in Figure 1. Among 152 consecutive patients who underwent primary tumor resection for DCC, 15 patients were excluded. These exclusions were due to open surgery in 12 patients, emergency surgery due to perforation in 1 patient, and simultaneous resection of another tumor in 2 patients (ascending colon cancer in 1, gastrointestinal tumor in 1). The total sample size was thus 137 patients who underwent SILS (n=52) or MPLS (n=85) for DCC. Table 1 lists the demographic characteristics of the overall cohort and\u0026nbsp;for propensity score-matched patients.\u0026nbsp;After matching, 44 matched pairs were selected. Baseline characteristics of patients were conserved between the two matched groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of short-term outcomes between groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 summarizes the details of operative findings between groups. Compared with the MPLS group, blood loss was significantly less in the SILS group both before (p\u0026lt;0.001) and after matching (p=0.011).\u0026nbsp;In the overall cohort, D3 lymph node dissection rate was significantly larger in the SILS group before matching (p\u0026lt;0.001), but was not significant after matching (p=0.085). In the MPLS group, 1 patient was converted to open surgery because of intraoperative bleeding. In the SILS group, 1 patient required an additional port for development of the operative field.\u0026nbsp;No relevant differences were found between groups in terms of procedure, operative time or multivisceral resection rate before or after matching.\u003c/p\u003e\n\u003cp\u003eTable 3 depicts the postoperative complications that occurred in each group. The rate of Clavien-Dindo grade ≥2 events did not differ between groups before or after matching. Two patients in the MPLS group and 1 patient in the SILS group underwent reoperation due to anastomotic leakage. Perioperative death was not found in the overall cohort. Median duration of hospitalization was 10 days in both groups after matching.\u003c/p\u003e\n\u003cp\u003eThe pathological features and oncological outcomes are summarized in Table\u0026nbsp;4.\u0026nbsp;The number of harvested lymph nodes was significantly larger in the SILS group than in the MPLS group, both before (p\u0026lt;0.001) and after matching (p=0.043). Tumor size, proximal margin, distal margin, tumor invasion, lymph node metastasis, pathological TNM classification, and number of patients who received adjuvant chemotherapy were similar in both groups. Radial margin positivity was not found in any patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of long-term oncological outcomes between groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe median follow-up was 41 months (range, 22-53 months) in the SILS group and 60 months (rage, 37-34 months) (p=0.001). In the overall cohort, 11 patients in the MPLS group experienced recurrence (liver, n=5; lung, n=2; peritoneum, n=1; distant lymph node metastases, n=2; adrenal glands, n=1), compared to 8 patients in the SILS group (liver, n=4; lung, n=1; peritoneum, n=2; ovary, n=1). The 3-year disease-free survival rate was 89.1% in the MPLS group and 83.8% in the SILS group (Fig. 2a), and the 3-year overall survival rate was 94.8% in the MPLS group and 95.6% in the SILS group (Fig. 3a). After matching, the 3-year disease-free survival rate was 88.3% in the MPLS group and 80.8% in the SILS group (Fig. 2b), and the 3-year overall survival rate was 97.4% in the MPLS group and 95.2% in the SILS group (Fig. 3), showing no significant differences between groups.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study appears to be the first to compare clinical outcomes between SILS and MPLS for DCC. The results suggest that, in selected patients, SILS for DCC can be performed safely and feasibly (as per the 98.1% SILS completion rate) and yields adequate short-term surgical outcomes (e.g., 25.0% morbidity, 0% mortality) in the entire patient cohort. In terms of oncological outcomes, we achieved a 100% R0 resection rate, and satisfactory 3-year disease-free and overall survival rates in patients with DCC who underwent SILS in both the entire patient cohort and matched cohort.\u003c/p\u003e\n\u003cp\u003eIn this study, SILS was successfully performed in 98.1% of patients, including 17 patients (32.7%) with a history of prior abdominal surgery. In a previous systematic review of SILS for colorectal cancer [16], the rate of conversion to open surgery was 0.9%, and 13.3% of patients who underwent SILS procedures required insertion of an additional port to allow completion of the operation. Those findings were comparable with the present results.\u0026nbsp;Median operative time was about 10 min longer in the SILS group both before and after matching, but this was not significant. In previous studies [17-22], the operative time of laparoscopic surgery for splenic flexure colon cancer ranged from 178 to 283 min, comparable with our findings regardless of SILS or MPLS. Generally, SILS is technically limited due to factors such as instrument crowding, inline positioning of the laparoscope, and insufficient triangulation [23,24], especially in mobilization of the splenic flexure and regional lymph node dissection; these issues would contribute to extend the operative time. The volume of blood loss was significantly lower in the SILS group than in the MPLS group for both the entire cohort (p\u0026lt;0.001) and matched cohort (p=0.011). In our study, patients with DCC who underwent MPLS were enrolled between April 2008 and December 2018, while SILS was performed for patients from March 2011 to December 2018. This difference in historical background may have affected the results. Other perioperative outcomes, including multivisceral resection rate and postoperative complications, did not differ between groups, and were comparable with findings from previous studies [5-10].\u0026nbsp;Although this study analyzed only 137 patients and used a retrospective design to investigate patients from two hospitals, our results with SILS showed high reliability in terms of successful completion rate and perioperative outcomes in patients with DCC.\u003c/p\u003e\n\u003cp\u003eIn cancer treatment, oncological clearance must take precedence over cosmetic advantages or reduced invasiveness. The number of harvested lymph nodes was significantly larger in the SILS group than in the MPLS group for the entire patient cohort (p\u0026lt;0.001) and matched cohort (p=0.043). In this study, the D3 lymph node dissection rate was significantly higher for the SILS group than for the MPLS group (p=0.021) in the entire patient cohort, and also tended to be high in the matched cohort (p=0.085). This may have affected the difference in number of harvested lymph nodes. The oncological outcomes, including proximal margin, distal margin, and residual tumor status, were comparable to those from randomized control trials comparing open and MPLS for colorectal cancer [25-28], as well as those comparing MPLS and SILS for colon cancer [5-10].\u0026nbsp;In the present study, the 3-year disease-free survival rate, 3-year overall survival rate, and recurrence pattern did not differ between groups. Our results are comparable to findings from previous studies that have reported long-term outcomes of SILS for\u0026nbsp;colon\u0026nbsp;cancer [29,30] or oncological outcomes of DCC [31,32].\u003c/p\u003e\n\u003cp\u003eSeveral limitations warrant consideration when interpreting the results of this investigation. First, data were obtained retrospectively, and the sample size was small. Second, this study showed bias in terms of the dates of operations. To overcome this limitation, we matched cases using several clinical variables, balancing groups and reducing selection bias. However, the potential for selection bias remains, despite the propensity score-matching. Third, BMI in our cohort was typical of a Japanese population, and may have significantly affected the surgical results of SILS. Fourth, the duration of follow-up was significantly shorter in the SILS group (41 months) than in the MPLS group (60 months, p=0.001). Long-term oncological outcomes and rates of later complications such as umbilical incisional hernia thus could not be assessed in the SILS group. Despite these limitations, we consider that this analysis using propensity score-matching confirmed SILS as a safe and feasible option for DCC. Further analyses are required to validate our results, and to evaluate the long-term oncological outcomes in future randomized clinical trials.\u003c/p\u003e"},{"header":"Conclusions","content":"SILS is a safe, feasible method that can provide satisfactory oncological outcomes in selected patients with DCC."},{"header":"Declarations","content":"\u003cp\u003eThe present manuscript is an original contribution not previously published and not under consideration for publication elsewhere, and, if accepted, will not be published anywhere in similar form, in any language. All authors have read and approved the manuscript, and the study was approved by the institutional research ethics committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContributions of each author:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMT and YS conceived and designed the study. MT, YS, TS, KI, AN, MN, YY, MO, MI, TM and HA acquired the data. MT and YS analyzed and interpreted the data. MT drafted the manuscript. YS, TS, KI, AN, MN, YY, MO, MI, TM and HA critically revised the article. MT, YS, TS, KI, AN, MN, YY, MO, MI, TM and HA approved the final version of the manuscript to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003enone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest and Financial Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMitsuyoshi Tei, Yozo Suzuki, Toshinori Sueda, Kazuya Iwamoto, Atsushi Naito, Yukihiro Yoshikawa, Masatoshi Nomura, Masahisa Ohtsuka, Mitsunobu Imasato, Tsunekazu Mizushima, and Hiroki Akamatsu have no conflicts of interest or financial ties to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRemzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port laparoscopy in colorectal surgery. Colorectal Dis. 2008; 10:823\u0026ndash;826.\u003c/li\u003e\n \u003cli\u003ePapaconstantinou HT, Thomas JS. Single-incision laparoscopic colectomy for cancer: assessment of oncologic resection and short-term outcomes in a case-matched comparison with standard laparoscopy. Surgery. 2011; 150:820\u0026ndash;827.\u003c/li\u003e\n \u003cli\u003eChampagne BJ, Papaconstantinou HT, Parmar SS, Nagle DA, Young-Fadok TM, Lee EC, et al. Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg. 2012; 255:66\u0026ndash;69.\u003c/li\u003e\n \u003cli\u003ePoon JT, Cheung CW, Fan JK, Lo OS, Law WL. Single-incision versus conventional laparoscopic colectomy for colonic neoplasm: a randomized, controlled trial. Surg Endosc. 2012; 26:2729\u0026ndash;2734.\u003c/li\u003e\n \u003cli\u003eTakemasa I, Uemura M, Nishimura J, Mizushima T, Yamamoto H, Ikeda M, et al. Feasibility of single-site laparoscopic colectomy with complete mesocolic excision for colon cancer: a prospective case-control comparison. Surg Endosc. 2014; 28:1110-1118.\u003c/li\u003e\n \u003cli\u003eKatsuno G, Fukunaga M, Nagakari K, Yoshikawa S, Azuma D, Kohama S. Short-term and long-term outcomes of single-incision versus multi-incision laparoscopic resection for colorectal cancer: a propensity-score-matched analysis of 214 cases. Surg Endosc. 2016; 30:1317-1325.\u003c/li\u003e\n \u003cli\u003eTei M, Wakasugi M, Akamatsu H. Comparison of the perioperative and short-term oncological outcome after single- or multi-port surgery for colorectal cancer. Colorectal Dis. 2015; 17: O141-147.\u003c/li\u003e\n \u003cli\u003eWatanabe J, Ota M, Fujii S, Suwa H, Ishibe A, Endo I. Randomized clinical trial of single-incision versus multiport laparoscopic colectomy. Br J Surg. 2016; 103:1276-1281.\u003c/li\u003e\n \u003cli\u003eMaggiori L, Tuech JJ, Cotte E, Lelong B, Denost Q, Karoui M, et al. Single-incision laparoscopy versus multiport laparoscopy for colonic surgery: a multicenter, double-blinded, randomized controlled trial. Ann Surg. 2018; 268:740-746.\u003c/li\u003e\n \u003cli\u003eLee YS, Kim JH, Kim HJ, Lee SC, Kang BM, Kim CW, et al. Short-term outcomes of single-port versus multiport laparoscopic surgery for colon cancer: the SIMPLE multicenter randomized clinical trial. Ann Surg. 2021; 273:217-223.\u003c/li\u003e\n \u003cli\u003eHashiguchi Y, Muro K, Saito Y, Ito Y, Ajioka Y, Hamaguchi T, et al; Japanese Society for Cancer of the Colon and Rectum. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol. 2020; 25:1-42.\u003c/li\u003e\n \u003cli\u003eMart\u0026iacute;n Ar\u0026eacute;valo J, Moro-Valdezate D, Garc\u0026iacute;a-Botello SA, Pla-Mart\u0026iacute; V, Garc\u0026eacute;s-Albir M, P\u0026eacute;rez Santiago L, et al. Propensity score analysis of postoperative and oncological outcomes after surgical treatment for splenic flexure colon cancer. Int J Colorectal Dis. 2018; 33:1201\u0026ndash;1213.\u003c/li\u003e\n \u003cli\u003eSteffen C, Bokey EL, Chapuis PH. Carcinoma of the splenic flexure. Dis Colon Rectum. 1987; 30:872\u0026ndash;874.\u003c/li\u003e\n \u003cli\u003eJapanese Society for Cancer of the Colon and Rectum. Japanese classification of colorectal, appendiceal, and anal carcinoma, third. English. Tokyo: Kanehara \u0026amp; CO., Ltd.; 2019.\u003c/li\u003e\n \u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240: 205\u0026ndash;213.\u003c/li\u003e\n \u003cli\u003eHirano Y, Hattori M, Douden K, Ishiyama Y, Hashizume Y. Single-incision laparoscopic surgery for colorectal cancer. World J Gastrointest Surg. 2016; 8:95-100.\u003c/li\u003e\n \u003cli\u003eHashida H, Kondo M, Kita R, Kitamura K, Uryuhara K, Kobayashi H, et al. Laparoscopic Colectomy for Splenic Flexure Cancer Approached from Four Directions. J Laparoendosc Adv Surg Tech A. 2021; 31:1014-1018.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePanaccio P, Grottola T, Ricciardiello M, di Sebastiano P, di Mola FF. How we do it: totally laparoscopic complete mesocolon excision for splenic flexure cancer. Langenbecks Arch Surg. 2018; 403:769-775.\u003c/li\u003e\n \u003cli\u003eMatsuda T, Sumi Y, Yamashita K, Hasegawa H, Yamamoto M, Matsuda Y, et al. Anatomical and embryological perspectives in laparoscopic complete mesocoloic excision of splenic flexure cancers. Surg Endosc. 2018; 32:1202-1208.\u003c/li\u003e\n \u003cli\u003eMatsumura N, Tokumura H, Saijo F, Katayose Y. Strategy of laparoscopic surgery for colon cancer of the splenic flexure: a novel approach. Surg Endosc. 2018; 32:2559.\u003c/li\u003e\n \u003cli\u003eChenevas-Paule Q, Trilling B, Sage PY, Girard E, Faucheron JL. Laparoscopic segmental left colectomy for splenic flexure carcinoma: a single institution experience. Tech Coloproctol. 2020; 24:41-48.\u003c/li\u003e\n \u003cli\u003eUeda K, Daito K, Ushijima H, Yane Y, Yoshioka Y, Tokoro T,et al. Laparoscopic complete mesocolic excision with central vascular ligation for splenic flexure colon cancer: short- and long-term outcomes. Surg Endosc. 2021 May 24. doi: 10.1007/s00464-021-08559-y. Online ahead of print.\u003c/li\u003e\n \u003cli\u003ePapaconstantinou HT, Thomas JS. Single-incision laparoscopic colectomy for cancer: assessment of oncologic resection and short-term outcomes in a case-matched comparison with standard laparoscopy. Surgery. 2011; 150:820\u0026ndash;827.\u003c/li\u003e\n \u003cli\u003eChampagne BJ, Papaconstantinou HT, Parmar SS, Nagle DA, Young-Fadok TM, Lee EC, et al. Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg. 2012; 255:66\u0026ndash;69.\u003c/li\u003e\n \u003cli\u003eLacy AM, Garc\u0026iacute;a-Valdecasas JC, Delgado S, Castells A, Taur\u0026aacute; P, Piqu\u0026eacute; JM, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet. 2002; 359:2224\u0026ndash;2229.\u003c/li\u003e\n \u003cli\u003eMilsom JW, B\u0026ouml;hm B, Hammerhofer KA, Fazio V, Steiger E, Elson P. A prospective, randomized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary report. J Am Coll Surg. 1998; 187:46\u0026ndash;54 (discussion54\u0026ndash;45)\u003c/li\u003e\n \u003cli\u003eLeung KL, Kwok SP, Lam SC, Lee JF, Yiu RY, Ng SS, et al. Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. Lancet. 2004; 363:1187\u0026ndash;1192.\u003c/li\u003e\n \u003cli\u003eThe Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004; 350:2050\u0026ndash;2059.\u003c/li\u003e\n \u003cli\u003eMiyo M, Takemasa I, Ishihara H, Hata T, Mizushima T, Ohno Y, et al. Long-term outcomes of single-site laparoscopic colectomy with complete mesocolic excision for colon cancer: comparison with conventional multiport laparoscopic colectomy using propensity score matching.\u0026nbsp;Dis Colon Rectum. 2017; 60:664-673\u003c/li\u003e\n \u003cli\u003eSuzuki Y, Tei M, Wakasugi M, Nakahara Y, Naito A, Mikamori M, et al. Long-term outcomes of single-incision versus multiport laparoscopic colectomy for colon cancer: results of a propensity score-based analysis. Surg Endosc. 2021 doi: 10.1007/s00464-021-08367-4. Online ahead of print.\u003c/li\u003e\n \u003cli\u003eNakagoe T, Sawai T, Tsuji T, Jibiki M, Ohbatake M, Nanashima A, et al. Surgical treatment and subsequent outcome of patients with carcinoma of the splenic flexure. Surg Today. 2001; 31:204-209.\u003c/li\u003e\n \u003cli\u003eYamaoka Y, Shiomi A, Kagawa H, Hino H, Manabe S, Kato S, et al. Which is more important in the management of splenic flexure colon cancer: strict central lymph node dissection or adequate bowel resection margin? Tech Coloproctol. 2020; 24:873-882.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Demographic characteristics of patients\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.141552511415526%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"36.529680365296805%\"\u003e\n \u003cp\u003eOverall (n=137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"37.32876712328767%\"\u003e\n \u003cp\u003ePropensity score-matched pairs (n=88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003eLap\u003c/p\u003e\n \u003cp\u003e(n=85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003eSILS\u003c/p\u003e\n \u003cp\u003e(n=52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003eLap\u003c/p\u003e\n \u003cp\u003e(n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003eSILS\u003c/p\u003e\n \u003cp\u003e(n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003eAge, years, median (IQR)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e71 (63-78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e69 (63-74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.444\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003e67 (57-75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e69 (60-74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.551\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003eGender, male, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e57 (67.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e27 (51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003e19 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e19 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e23.0 (20.9-24.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e23.1 (20.9-25.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.982\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003e22.8 (20.0-25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e23.3 (20.9-25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003eECOG-PS, 0 or 1, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e84 (98.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e50 (96.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.557\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003e43 (97.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e43 (97.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003eASA score, 1 or 2, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e72 (84.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e42 (80.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.639\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003e37 (84.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e36 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003ePrevious abdominal surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e17 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e17 (32.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003e12 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e11 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003eClinical TNM stage, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;I\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;II\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33 (38.8)\u003c/p\u003e\n \u003cp\u003e26 (30.6)\u003c/p\u003e\n \u003cp\u003e26 (30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (28.9)\u003c/p\u003e\n \u003cp\u003e17 (32.7)\u003c/p\u003e\n \u003cp\u003e20 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.456\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (38.6)\u003c/p\u003e\n \u003cp\u003e14 (31.8)\u003c/p\u003e\n \u003cp\u003e13 (29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (34.1)\u003c/p\u003e\n \u003cp\u003e15 (34.1)\u003c/p\u003e\n \u003cp\u003e14 (31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e0.906\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.111744583808438%\"\u003e\n \u003cp\u003e*Comorbidities, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Cardiac\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Pulmonary\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Diabetes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Cerebrovascular\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Anticoagulant therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (12.9)\u003c/p\u003e\n \u003cp\u003e13 (15.3)\u003c/p\u003e\n \u003cp\u003e19 (22.4)\u003c/p\u003e\n \u003cp\u003e8 (9.4)\u003c/p\u003e\n \u003cp\u003e12 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (15.4)\u003c/p\u003e\n \u003cp\u003e7 (13.5)\u003c/p\u003e\n \u003cp\u003e7 (13.5)\u003c/p\u003e\n \u003cp\u003e9 (17.3)\u003c/p\u003e\n \u003cp\u003e9 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.800\u003c/p\u003e\n \u003cp\u003e0.809\u003c/p\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.823261117445838%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (4.6)\u003c/p\u003e\n \u003cp\u003e6 (13.6)\u003c/p\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003cp\u003e4 (9.1)\u003c/p\u003e\n \u003cp\u003e3 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.139110604332954%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (13.6)\u003c/p\u003e\n \u003cp\u003e6 (13.6)\u003c/p\u003e\n \u003cp\u003e5 (11.4)\u003c/p\u003e\n \u003cp\u003e7 (15.9)\u003c/p\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.323831242873432%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.549\u003c/p\u003e\n \u003cp\u003e0.521\u003c/p\u003e\n \u003cp\u003e0.196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eECOG-PS, Eastern Cooperative Oncology Group Performance Status Scale; ASA score, American Society of Anesthesiologists Score; BMI, body mass index; *Comorbidities: Cardiac = ischemic disease, chronic heart failure and cardiomyopathy, excluded hypertension; Pulmonary = asthma, chronic obstructive pulmonary disease, and interstitial pneumonia Cerebrovascular = history of transient ischemic attacks and cerebrovascular event with or without neurological deficit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Operative findings\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.444697833523374%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"34.77765108323831%\"\u003e\n \u003cp\u003eOverall (n=137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"34.77765108323831%\"\u003e\n \u003cp\u003ePropensity score-matched pairs (n=88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.514285714285716%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003eLap\u003c/p\u003e\n \u003cp\u003e(n=85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003eSILS\u003c/p\u003e\n \u003cp\u003e(n=52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003eLap\u003c/p\u003e\n \u003cp\u003e(n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003eSILS\u003c/p\u003e\n \u003cp\u003e(n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.514285714285716%\"\u003e\n \u003cp\u003eProcedure\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Left hemicolectomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Segmental colectomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Subtotal colectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33 (24.1)\u003c/p\u003e\n \u003cp\u003e49 (57.7)\u003c/p\u003e\n \u003cp\u003e3 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (28.9)\u003c/p\u003e\n \u003cp\u003e37 (71.2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (27.3)\u003c/p\u003e\n \u003cp\u003e32 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (29.6)\u003c/p\u003e\n \u003cp\u003e31 (70.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.514285714285716%\"\u003e\n \u003cp\u003eBlood loss, ml, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e30 (5-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e5 (5-67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e26 (5-90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e5 (5-67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.514285714285716%\"\u003e\n \u003cp\u003eOperative time, minutes, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e227 (191-274)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e240 (189-258)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e0.678\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e234 (192-294)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e240 (192-262)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e0.900\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.514285714285716%\"\u003e\n \u003cp\u003eExtent of lymph node dissection, D3, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e41 (48.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e36 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e20 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e29 (65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.514285714285716%\"\u003e\n \u003cp\u003eMultivisceral resection, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e6 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e3 (5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e2 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.514285714285716%\"\u003e\n \u003cp\u003eConversion to open surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.514285714285716%\"\u003e\n \u003cp\u003eRequired an additional port, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e1 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.485714285714286%\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.771428571428571%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Postoperative complications\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003eClavien-Dindo classification (Grade \u0026ge;2), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"31.34328358208955%\"\u003e\n \u003cp\u003eOverall (n=137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"32.95063145809414%\"\u003e\n \u003cp\u003ePropensity score-matched pairs (n=88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.607142857142858%\"\u003e\n \u003cp\u003eLap\u003c/p\u003e\n \u003cp\u003e(n=85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.857142857142858%\"\u003e\n \u003cp\u003eSILS\u003c/p\u003e\n \u003cp\u003e(n=52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.607142857142858%\"\u003e\n \u003cp\u003eLap\u003c/p\u003e\n \u003cp\u003e(n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.214285714285715%\"\u003e\n \u003cp\u003eSILS\u003c/p\u003e\n \u003cp\u003e(n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.428571428571427%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003eAnastomotic leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e3 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e1 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003eWound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e6 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e4 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e5 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e3 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e0.713\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003eBowel obstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e2 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e5 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e2 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e3 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003ePneumonia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e1 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003e*infectious complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e2 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e7 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e2 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e5 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003eReoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e2 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e1 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003ePerioperative death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003eOverall complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e13 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e13 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e7 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e10 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e0.435\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.7060849598163%\"\u003e\n \u003cp\u003ePostoperative hospital stay, days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e11 (9-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.481056257175661%\"\u003e\n \u003cp\u003e9 (7-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.184845005740527%\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.677382319173365%\"\u003e\n \u003cp\u003e10 (8-14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.710677382319174%\"\u003e\n \u003cp\u003e10 (7-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.562571756601608%\"\u003e\n \u003cp\u003e0.432\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*infectious complications= abscess, colitis, urinary tract infection, nephritis, catheter-related infection, cholecystitis\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4. Pathological features and oncological outcomes\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"34.70982142857143%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"33.370535714285715%\"\u003e\n \u003cp\u003eOverall (n=137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"31.919642857142858%\"\u003e\n \u003cp\u003ePropensity score-matched pairs (n=88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.70940170940171%\"\u003e\n \u003cp\u003eLap\u003c/p\u003e\n \u003cp\u003e(n=85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.435897435897434%\"\u003e\n \u003cp\u003eSILS\u003c/p\u003e\n \u003cp\u003e(n=52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.965811965811966%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.70940170940171%\"\u003e\n \u003cp\u003eLap\u003c/p\u003e\n \u003cp\u003e(n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.213675213675213%\"\u003e\n \u003cp\u003eSILS\u003c/p\u003e\n \u003cp\u003e(n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.965811965811966%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.70982142857143%\"\u003e\n \u003cp\u003eTumor size, mm, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e25 (16-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e40 (26-50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e25 (15-50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e38 (23-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.8125%\"\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.70982142857143%\"\u003e\n \u003cp\u003eProximal margin, mm, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e105 (95-110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e110 (105-118)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.749\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e105 (90-115)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e110 (95-110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.8125%\"\u003e\n \u003cp\u003e0.648\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.70982142857143%\"\u003e\n \u003cp\u003eDistal margin, mm, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e95 (80-110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e90 (85-108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.545\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e95 (88-110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e90 (85-110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.8125%\"\u003e\n \u003cp\u003e0.701\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.70982142857143%\"\u003e\n \u003cp\u003eNumber of harvested lymph nodes, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e14 (8-22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e21 (12-29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e14 (8-22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e20 (11-27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.70982142857143%\"\u003e\n \u003cp\u003eTumor invasion, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;pT1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;pT2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;pT3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;pT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 (29.4)\u003c/p\u003e\n \u003cp\u003e12 (14.1)\u003c/p\u003e\n \u003cp\u003e34 (40)\u003c/p\u003e\n \u003cp\u003e14 (16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (19.2)\u003c/p\u003e\n \u003cp\u003e5 (9.6)\u003c/p\u003e\n \u003cp\u003e28 (53.9)\u003c/p\u003e\n \u003cp\u003e9 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (31.8)\u003c/p\u003e\n \u003cp\u003e6 (13.6)\u003c/p\u003e\n \u003cp\u003e16 (36.4)\u003c/p\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (22.7)\u003c/p\u003e\n \u003cp\u003e4 (9.1)\u003c/p\u003e\n \u003cp\u003e22 (50)\u003c/p\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.568\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.70982142857143%\"\u003e\n \u003cp\u003eLymph node metastasis, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;pN0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;pN1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;pN2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62 (72.9)\u003c/p\u003e\n \u003cp\u003e18 (21.2)\u003c/p\u003e\n \u003cp\u003e5 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 (61.5)\u003c/p\u003e\n \u003cp\u003e14 (26.9)\u003c/p\u003e\n \u003cp\u003e6 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33 (75)\u003c/p\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003cp\u003e3 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27 (61.4)\u003c/p\u003e\n \u003cp\u003e12 (27.3)\u003c/p\u003e\n \u003cp\u003e5 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.70982142857143%\"\u003e\n \u003cp\u003ePositive radial margin, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.70982142857143%\"\u003e\n \u003cp\u003epTNM stage, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; I\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; II\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; III\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 (37.7)\u003c/p\u003e\n \u003cp\u003e30 (35.3)\u003c/p\u003e\n \u003cp\u003e22 (25.9)\u003c/p\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (26.9)\u003c/p\u003e\n \u003cp\u003e18 (34.6)\u003c/p\u003e\n \u003cp\u003e20 (38.5)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 (40.9)\u003c/p\u003e\n \u003cp\u003e15 (34.1)\u003c/p\u003e\n \u003cp\u003e11 (25)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (29.6)\u003c/p\u003e\n \u003cp\u003e14 (31.8)\u003c/p\u003e\n \u003cp\u003e17 (38.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.70982142857143%\"\u003e\n \u003cp\u003eAdjuvant chemotherapy (stage II or III), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e19 (36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e14 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e10 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e11 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.70982142857143%\"\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Liver\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Lung\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Peritoneum\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Distant lymph node\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Other organ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.383928571428571%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.174107142857142%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.933035714285714%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.8125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"single-incision laparoscopic surgery, descending cancer, outcome","lastPublishedDoi":"10.21203/rs.3.rs-1520397/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1520397/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Single-incision laparoscopic surgery (SILS) for descending colon cancer (DCC) is a technically challenging procedure with unclear clinical impact. The aim of this study was to evaluate the short-term outcomes of SILS for DCC compared with multi-port laparoscopic surgery (MPLS).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We retrospectively analyzed 137 consecutive patients with stage I–III DCC who underwent SILS or MPLS at two high-volume multidisciplinary tertiary hospitals between April 2008 and December 2018, using propensity score-matched analysis.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e After propensity score-matching, we enrolled 88 patients (n=44 in each group). Median follow-up period was 48 months. The completion rate for SILS was 98.1% in the overall cohort and 97.7% in the matched cohort. One patient was converted to open surgery in the MPLS group. Compared with the MPLS group, the SILS group showed significantly less blood loss and a greater number of harvested lymph nodes in both the entire patient cohort and the matched cohort. Morbidity rates did not differ significantly between groups before and after matching. R0 resection was achieved in the entire patient cohort. In terms of the incidence of recurrence, both groups were similar before and after matching. No significant differences were found between groups in terms of 3-year disease-free and overall survival rates in either the entire patient cohort or the matched cohort.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e SILS appears safe and feasible and can provide satisfactory oncological outcomes for selected patients with DCC.\u003c/p\u003e","manuscriptTitle":"Comparison of short-term outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-04-07 16:01:09","doi":"10.21203/rs.3.rs-1520397/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"493c31f7-af02-4a98-b130-02d2c7a563d2","owner":[],"postedDate":"April 7th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-04-07T16:01:10+00:00","versionOfRecord":[],"versionCreatedAt":"2022-04-07 16:01:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1520397","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1520397","identity":"rs-1520397","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}