Short-term outcomes of delta-shaped anastomosis versus functional end-to-end anastomosis using linear staplers for colon cancer

Short-term outcomes of delta-shaped anastomosis versus functional end-to-end anastomosis using linear staplers for colon cancer | 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 Short-term outcomes of delta-shaped anastomosis versus functional end-to-end anastomosis using linear staplers for colon cancer Rika Ono, Tetsuro Tominaga, Mitsutoshi Ishii, Makoto Hisanaga, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4438895/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Sep, 2024 Read the published version in Techniques in Coloproctology → Version 1 posted 9 You are reading this latest preprint version Abstract Background Several methods are used for reconstruction in colon cancer surgery, including hand-sewn or stapled anastomosis. However, few reports have compared short-term outcomes among reconstruction methods. This study compared short-term outcomes between delta-shaped anastomosis (Delta) and functional end-to-end anastomosis (FEEA). Methods We retrospectively reviewed 1314 consecutive patients who underwent colorectal surgery with FEEA or Delta reconstruction between January 2016 and December 2023. Patients were divided into two groups according to reconstruction by FEEA (F group; n = 1242) or Delta (D group; n = 72). Propensity score matching was applied to minimize the possibility of selection bias and to balance covariates that could affect postoperative complications. Short-term outcomes were compared between groups. Results Postoperative complications occurred in 215 patients (17.3%) in F group and 8 patients (11.1%) in D group. Before matching, transverse colon cancer was more frequent (p = 0.002), clinical N-positive status was less frequent (44.1% vs 16.7%, p < 0.001), distant metastasis was less frequent (11.7% vs 1.4%, p = 0.003), and laparoscopic approach was more frequent (87.8% vs 100%, p < 0.001) in D group. After matching, no differences in any clinical factor were evident between groups. Blood loss was lower (28 mL vs 10 mL, p = 0.002) in D group. However, operation time and postoperative complication rates were similar between groups. Conclusions Delta and FEEA were both considered safe as reconstruction methods. Delta anastomosis may be more useful for patients with transverse colon cancer for whom transfusion should be minimized. colon cancer functional end-to-end anastomosis delta-shaped anastomosis postoperative complication Introduction Bowel reconstruction in the treatment of colorectal cancer, particularly right-sided colon cancer, used to be performed by hand-sewn anastomosis, but recent improvements in devices and standardization of techniques have led to the use of mechanical anastomosis. Compared to hand-sewn anastomosis, instrumented anastomosis is considered to offer the advantages of a simpler technique, shorter time requirements, and wider caliber [ 1 – 3 ]. Functional end-to-end anastomosis (FEEA) is a type of instrumented anastomosis first reported by Steichen [ 4 ]. As one of the most popular reconstruction methods, FEEA is reported to maintain the same intestinal function as manual anastomosis with a lower rate of anastomotic leakage compared to hand-sewn anastomosis [ 5 ]. Another method is delta-shaped anastomosis (Delta), reported by Kanaya et al. in 2002 as a reconstruction method following laparoscopic distal gastrectomy for gastric cancer [ 6 ]. Various clinical experiences and instrumentation improvements have improved the safety of this anastomosis, mainly in the field of gastric cancer [ 7 , 8 ]. There is a paucity of publications comparing short-term prognosis between methods of bowel reconstruction in cases of colorectal cancer [ 9 , 10 ]. Further, most previous reports have been single-center studies that could have had several sources of bias. The present study therefore compared short-term outcomes between FEEA and Delta using a multicenter database. Materials and Methods We retrospectively reviewed 1314 consecutive patients who underwent colorectal surgery with FEEA/Delta in seven participating hospitals (Nagasaki University Hospital, Sasebo City General Hospital, Nagasaki Medical Center, and Isahaya General Hospital, Ureshino Medical Center, Saiseikai Nagasaki Hospital, and Sasebo Chuo Hospital) between January 2016 and December 2023. Patients with hand-sewn anastomosis were excluded. The study protocol was reviewed and approved by the clinical research review boards of the participating hospitals (approval no. 16062715-5). FEEA is performed by making a small hole with an electrocautery scalpel in the contralateral mesentery, well away from the tumor. A stapler is inserted to create a common hole, which is then closed with a thread. The intestine is resected with another stapler so that the common hole is on the tumor side, completing tumor resection and intestinal reconstruction at the same time. For Delta, a stapler is first used to remove the intestinal tract on the oral and anal sides of the tumor. The stapler is inserted through a small hole made with an electrocautery scalpel at each mesenteric side of the dissected segment, and a common hole is created. The common hole is then closed with another stapler to complete the reconstruction. Patients were divided into two groups: patients who underwent reconstruction by FEEA (F group; n = 1242) and by Delta (D group; n = 72). Propensity score matching (PSM) was applied to minimize the possibility of selection bias and balance covariates that could affect postoperative complications. The following covariates were included in score matching: sex, age, body mass index, American Society of Anesthesiologists (ASA) performance status (PS), comorbidity, presence or absence of colonic stent insertion, tumor location, clinical tumor/node/metastasis (T/N/M) status, surgical approach, and presence or absence of multivisceral resection. Nearest neighbor matching was performed in a 1:1 ratio, with the caliper set at 0.2. Finally, 72 patients in each group were matched. Clinical features were compared between groups before and after propensity score matching. The following data were collected: sex, age, BMI, ASA-PS, comorbidity, presence or absence of colonic stent insertion, tumor location, clinical T/N/M status, surgical approach, and presence or absence of multivisceral resection. The surgical and pathological data collected included operation time, blood loss, pathological T/N status, postoperative complications, and postoperative hospital stay. Postoperative complications were defined as complications that occurred within 30 days of the primary surgery. Patients with Clavien–Dindo (CD) grade ≥2 were included in the complication group. Statistical analysis was performed using JMP software (SAS Institute Inc., Cary, NC, USA). Data are presented as median and range. Differences in categorical variables were compared using the chi-squared test or Fisher’s exact test. Differences in continuous variables were analyzed using the Mann–Whitney U-test. All values of p < 0.05 were considered significant. Results Table 1 shows the details of postoperative complications. Postoperative complications of CD grade ≥2 were identified in 215 patients (17.3%) in F group and 8 patients (11.1%) in D group. In F group, 114 patients (11.6%) experienced complications of CD grade 2, including ileus (n = 40, 3.2%), surgical site infection (n = 34, 2.7%), and anastomotic leakage (n = 13, 1.0%). In D group, 4 patients (5.6%) experienced CD grade 2 complications, including anastomotic leakage (n = 2, 2.8%), ileus (n = 1, 1.4%), and surgical site infection (n = 1, 1.4%). In F group, 71 patients (5.7%) experienced CD grade ≥3 complications, including anastomotic leakage (n = 26, 2.1%), surgical site infection (n = 12, 1.0%), and ileus (n = 10, 0.8%). In D group, 4 patients (5.6%) experienced CD grade ≥3 complications, including anastomotic leakage (n = 2, 2.8%) and ileus (n = 2, 2.8%). Table 1 Details of postoperative complications Site F group ( n = 1242) (%) D group ( n = 72) (%) All complications (CD ≥2), n 215 (17.3) 8 (11.1) CD = 2, n 144 (11.6) 4 (5.6) Ileus 40 (3.2) 1 (1.4) Surgical site infection 34 (2.7) 1 (1.4) Anastomotic leakage 13 (1.0) 2 (2.8) Pneumonia 8 (0.6) 0 (0) Delirium 8 (0.6) 0 (0) Abscess 5 (0.4) 0 (0) Urinary tract infection 5 (0.4) 0 (0) Clostridium difficile colitis 4 (0.3) 0 (0) Chylous ascites 4 (0.3) 0 (0) Thrombosis 4 (0.3) 0 (0) Bleeding 4 (0.3) 0 (0) Diarrhea 1 (0.1) 0 (0) Other 14 (1.1) 0 (0) CD ≥3 71 (5.7) 4 (5.6) Anastomotic leakage 26 (2.1) 2 (2.8) Surgical site infection 12 (1.0) 0 (0) Ileus 10 (0.8) 2 (2.8) Bleeding 4 (0.3) 0 (0) Pneumonia 3 (0.2) 0 (0) Stenosis 2 (0.2) 0 (0) Thrombosis 1 (0.1) 0 (0) Hernia 1 (0.1) 0 (0) Diarrhea 1 (0.1) 0 (0) Other 11 (0.9) 0 (0) CD , Clavien–Dindo classification Table 2 compares clinical characteristics between F and D groups before and after matching. Before matching, transverse colon cancer was more common (p = 0.002), clinical N-positive status (44.1% vs 16.7%, p < 0.001) and distant metastases were less common (11.7% vs 1.4%, p = 0.003), and laparoscopic approach was more common (87.8% vs 100%, p < 0.001) in D group. Other factors, including sex, age, BMI, ASA-PS, comorbidity, presence or absence of colonic stent insertion, clinical T status, and presence or absence of multivisceral resection were similar between groups. After matching, no difference in any clinical factor was seen between groups. Table 2 Clinical characteristics in the FEEA and delta reconstruction before and after matching Before matching After matching FEEA ( n = 1242) (%) Delta ( n = 72) (%) p value FEEA ( n = 72) (%) Delta ( n = 72) (%) p value Sex 0.808 0.867 Male 581 (46.8) 35 (48.6) 33 (45.8) 35 (48.6) Female 661 (53.2) 37 (51.4) 39 (54.2) 37 (51.4) Age, y 74 (13–98) 73 (49–93) 0.499 74 (34–92) 73 (49–93) 0.964 BMI, kg/m 2 22 (13–40) 23 (14–35) 0.748 23 (15–32) 23 (14–35) 0.763 ASA performance status 0.461 0.771 1 285 (16.7) 12 (16.7) 12 (16.7) 12 (16.7) 2 818 (70.8) 51 (70.8) 48 (66.7) 51 (70.8) 3 139 (12.5) 9 (12.5) 12 (16.7) 9 (12.5) Comorbidity 0.307 1.000 No 421 (33.9) 20 (27.8) 21 (29.2) 20 (27.8) Yes 821 (66.1) 52 (72.2) 51 (70.8) 52 (72.2) Colonic stent insertion 0.618 0.619 No 1164 (93.7) 69 (95.8) 71 (98.6) 69 (95.8) Yes 78 (6.3) 3 (4.2) 1 (1.4) 3 (4.2) Tumor location 0.002 0.866 Cecum 273 (22.0) 15 (20.8) 11 (15.3) 15 (20.8) Ascending colon 599 (48.2) 33 (45.8) 36 (50.0) 33 (45.8) Transverse colon 275 (22.1) 19 (26.4) 18 (25.0) 19 (26.4) Descending colon 93 (7.5) 3 (4.2) 5 (6.9) 3 (4.2) Other 2 (0.2) 2 (2.8) 2 (2.8) 2 (2.8) Clinical T status 0.074 0.810 1–3 973 (78.3) 63 (87.5) 61 (84.7) 63 (87.5) 4 269 (21.7) 9 (12.5) 11 (15.3) 9 (12.5) Clinical N status < 0.001 1.000 Negative 694 (55.9) 60 (83.3) 60 (83.3) 60 (83.3) Positive 548 (44.1) 12 (16.7) 12 (16.7) 12 (16.7) Distant metastasis 0.003 1.000 No 1097 (88.3) 71 (98.6) 71 (98.6) 71 (98.6) Yes 145 (11.7) 1 (1.4) 1 (1.4) 1 (1.4) Surgical approach < 0.001 1.000 Laparoscopic 1091 (87.8) 72 (100) 72 (100) 72 (100) Open 151 (12.2) 0 (0) 0 (0) 0 (0) Multivisceral resection 0.070 1.000 No 1184 (95.3) 72 (100) 72 (100) 72 (100) Yes 58 (4.7) 0 (0) 0 (0) 0 (0) Data are presented as the number of patients (percentage) or the median (range). ASA , American Society of Anesthesiologists; BMI , body mass index. Differences in categorical variables were compared using Fisher’s exact test or the chi-squared test, as appropriate. Differences in continuous variables were analyzed using the Mann–Whitney U -test. Table 3 compares perioperative characteristics between F and D groups after matching. After matching, volume of blood loss was less (28 mL vs 10 mL, p = 0.002) in D group. No differences in any other clinical factors were evident between groups, including operation time and postoperative complications. Table 3 Perioperative characteristics in FEEA and delta reconstruction after matching FEEA ( n = 72) (%) Delta ( n = 72) (%) p value Operation time, min (range) 199 (60–646) 197 (138–561) 0.972 Blood loss, mL (range) 28 (0–560) 10 (0–300) 0.002 Pathological T status 1.000 1–3 63 (87.5) 63 (87.5) 4 9 (12.5) 9 (12.5) Pathological N status 0.649 Negative 59 (81.9) 62 (86.1) Positive 13 (18.1) 10 (13.9) Postoperative complications, CD ≥2 13 (18.1) 8 (11.1) 0.345 Anastomotic leakage 3 (4.2) 4 (5.6) Hospital stay, days (range) 12 (1–155) 11 (7–43) 0.051 Data are presented as the number of patients (percentage) or the median (range). T , tumor; N ; node; CD , Clavien–Dindo classification. Differences in categorical variables were compared using Fisher’s exact test or the chi-squared test, as appropriate. Differences in continuous variables were analyzed with the Mann–Whitney U -test. Discussion The present multicenter study examined short-term outcomes of FEEA and Delta in colorectal cancer surgery using propensity score matching. Postoperative complication rates were 17.3% in F group and 11.1% in D group. Before matching, transverse colon cancer was more frequent, clinical N-positive status and distant metastases were less common, and use of a laparoscopic approach were more common in D group. After matching, volume of blood loss was less in D group. However, operation time and postoperative complication rates were similar between groups. Several studies have reported on instrumented anastomosis for colorectal cancer [ 9 , 11 – 13 ]. The overall complication rate was 25.7% for FEEA and 35.4% for triangular anastomosis [ 9 ]. In the present study, complication rates were 17.3% for FEEA and 11.1% for Delta, comparable to previous reports, and both anastomoses were performed safely. In colorectal cancer surgery, suture failure is a serious complication that not only increases the risk of reoperation due to peritonitis and mortality, but also affects long-term outcomes such as risk of recurrence [ 14 – 16 ]. In a meta-analysis comparing hand-sewn and instrumented anastomoses for colorectal cancer surgery, stapled anastomosis was reported to be significantly safer with fewer suture failures compared to hand-sewn anastomosis (failure rate: 1.4% vs 5.8%, respectively; p = 0.02) [ 5 ]. In recent reports, the anastomotic leakage rate for FEEA has been reported as 1.6–4.8% [ 9 , 10 ], with limited data available for Delta anastomosis. Su et al. reported no anastomotic complications, including suture failure, in a study of 86 cases treated using Delta methods, the number of cases remains small and accumulation of more data is needed [ 12 ]. In the present study, FEEA and Delta anastomosis were used in 3.1% and 5.5% of cases, respectively, with no significant differences observed between either method. Ileus was one of the most frequent complications in this study. The diameter of the anastomotic hole at the time of anastomosis is often a problem, and long-term anastomotic stenosis is said to occur in 6.8–8.4% of cases [ 17 ]. In the present case of ileus, no direct evidence of anastomotic stenosis was observed. Some patients who developed ileus may have had relatively temporary stenosis due to postoperative edema. Further, no cases showed long-term complete stenosis requiring surgery or other treatment, and long-term function in patients who showed ileus was excellent. In a comparison of clinical and periodic backgrounds of F and D groups, a tendency was seen toward more frequent transverse colon cancer in D group. The transverse colon varies greatly in length from person to person, and obese patients may show a shortened mesentery, making adequate mesenteric transfer difficult. If the tension during anastomosis is too high, FEEA may cause anastomotic stricture and postoperative bleeding due to mesenteric engorgement [ 9 ]. In fact, a report examining the choice of instrumented anastomosis limited to the transverse colon found that FEEA was mainly selected for ileocolic anastomosis after extensive dissection and hemicolectomy rather than for colocolic anastomosis, which is less mobile and prone to tension in the intestinal tract. Delta anastomosis is less problematic than FEEA in terms of bowel tension during anastomosis and can be performed with relatively little bowel movement. This may be why transverse colon cancer was more common in the Delta group. In addition, significantly fewer Lap cases were seen in the FEEA group among pre-PSM cases in this study. This may be due to the fact that cancers were more advanced in the FEEA group. In this study, we were able to adjust for these covariates using PSM To the best of our knowledge, no previous studies have compared FEEA and delta anastomoses. In the present study, we compared the short-term outcomes of the two anastomosis methods under conditions of comparable patient backgrounds using PSM, and found no significant differences in operative time or postoperative complications (including anastomotic leakage) between groups. Based on this, we considered Delta anastomosis to be as safe as FEEA. In addition, Delta anastomosis tended to result in less blood loss than FEEA. This may be due to the fact that Delta anastomosis requires a smaller area for dissection than FEEA, resulting in relatively less bleeding. Several limitations to this study should be kept in mind. First, this was a retrospective study and the number of delta-shaped anastomosis was relatively small. Second, this was a rural multicenter study and the background characteristics of patients may have been biased. Third, the present multicenter database lacked information on intra- or extracorporeal anastomosis. A prospective study of a larger cohort is therefore needed. Despite these limitations, Delta and FEEA were considered to both represent safe reconstruction methods, including in terms of complication rates and operation time. Delta anastomosis was considered useful for reconstruction in patients with transverse colon cancer and other cases in which the extent of transfusion should be minimized Declarations Disclosures Drs. Rika Ono, Tetsuro Tominaga, Mitsutoshi Ishii, Makoto Hisanaga, Masato Araki, Yorihisa Sumida, Takashi Nonaka, Shintaro Hashimoto, Toshio Shiraishi, Keisuke Noda, Hiroaki Takeshita, Hidetoshi Fukuoka, Shosaburo Oyama, Kazuhide Ishimaru, Terumitsu Sawai, Keitaro Matsumoto have no conflicts of interest or financial ties to disclose. Funding: None Author Contribution Rika Ono and Tetsuro Tominaga mainly designed this study. Mitsutoshi Ishii, Makoto Hisanaga, Masato Araki, Yorihisa Sumida, Takashi Nonaka, Shintaro Hashimoto, Toshio Shiraishi, Keisuke Noda, Hiroaki Takeshita, Hidetoshi Fukuoka, Shosaburo Oyama, and Kazuhide Ishimaru performed surgery. Terumitsu Sawai and Keitaro Matsumoto supervised this study. References Ritchey ML, Lally KP, Ostericher R. Comparison of different techniques of stapled bowel anastomoses in a canine model. Arch Surg. 1993;128(12):1365–7. Meagher AP, Wolff BG. Right hemicolectomy with a linear cutting stapler. Dis Colon Rectum. 1994;37(10):1043–5. Yamamoto T, Keighley MR. Stapled functional end-to-end anastomosis in Crohn's disease. Surg Today. 1999;29(7):679–81. Steichen FM. The use of staplers in anatomical side-to-side and functional end-to-end enteroanastomoses. Surgery. 1968;64(5):948–53. Choy PY, Bissett IP, Docherty JG, Parry BR, Merrie A, Fitzgerald A. Stapled versus handsewn methods for ileocolic anastomoses. The Cochrane database of systematic reviews. 2011(9):Cd004320. Kanaya S, Gomi T, Momoi H, Tamaki N, Isobe H, Katayama T, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy: new technique of intraabdominal gastroduodenostomy. J Am Coll Surg. 2002;195(2):284–7. Zhang B, Tu JC, Fang J, Zhou L, Liu YL. Comparison of early-term effects between totally laparoscopic distal gastrectomy with delta-shaped anastomosis and conventional laparoscopic-assisted distal gastrectomy: a retrospective study. International journal of clinical and experimental medicine. 2015;8(6):9967–72. Kanaya S, Kawamura Y, Kawada H, Iwasaki H, Gomi T, Satoh S, et al. The delta-shaped anastomosis in laparoscopic distal gastrectomy: analysis of the initial 100 consecutive procedures of intracorporeal gastroduodenostomy. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4438895","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":303867474,"identity":"ccff1053-1f34-417b-924f-498d0f1095ba","order_by":0,"name":"Rika Ono","email":"","orcid":"","institution":"Sasebo City General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rika","middleName":"","lastName":"Ono","suffix":""},{"id":303867475,"identity":"4bba9c17-dc8b-484a-97ed-885edac74600","order_by":1,"name":"Tetsuro 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School of Biomedical Science","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Toshio","middleName":"","lastName":"Shiraishi","suffix":""},{"id":303867488,"identity":"5d3873e1-67a2-4fe5-9668-3b8af8d454be","order_by":9,"name":"Keisuke Noda","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Science","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Keisuke","middleName":"","lastName":"Noda","suffix":""},{"id":303867489,"identity":"93efa20d-f41f-4413-8b71-79c46eb4d1c0","order_by":10,"name":"Hiroaki Takeshita","email":"","orcid":"","institution":"National Hospital Organization Nagasaki Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hiroaki","middleName":"","lastName":"Takeshita","suffix":""},{"id":303867490,"identity":"8b76e62e-4ae3-4033-9703-1dffac29b3a7","order_by":11,"name":"Hidetoshi Fukuoka","email":"","orcid":"","institution":"Isahaya General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hidetoshi","middleName":"","lastName":"Fukuoka","suffix":""},{"id":303867491,"identity":"44db632a-20c4-42df-a9c5-45506b69f705","order_by":12,"name":"Shosaburo Oyama","email":"","orcid":"","institution":"Ureshino Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shosaburo","middleName":"","lastName":"Oyama","suffix":""},{"id":303867492,"identity":"eac08e4a-84d0-4f1f-bf54-c8f1fce9d3bb","order_by":13,"name":"Kazuhide Ishimaru","email":"","orcid":"","institution":"Saiseikai Nagasaki Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kazuhide","middleName":"","lastName":"Ishimaru","suffix":""},{"id":303867493,"identity":"84b5db92-9200-407c-be9a-2c76c4099001","order_by":14,"name":"Terumitsu Sawai","email":"","orcid":"","institution":"Sasebo City General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Terumitsu","middleName":"","lastName":"Sawai","suffix":""},{"id":303867494,"identity":"0619b125-7f61-4930-9b6d-057a60787b71","order_by":15,"name":"Keitaro Matsumoto","email":"","orcid":"","institution":"Sasebo City General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Keitaro","middleName":"","lastName":"Matsumoto","suffix":""}],"badges":[],"createdAt":"2024-05-18 00:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4438895/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4438895/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10151-024-03006-1","type":"published","date":"2024-09-23T15:57:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":65627210,"identity":"390451fb-210a-4bb3-a41a-20a0e4f0c3ad","added_by":"auto","created_at":"2024-09-30 16:13:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":573441,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4438895/v1/40e5312a-3614-4fd6-8d84-9c7c5f01d6bc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short-term outcomes of delta-shaped anastomosis versus functional end-to-end anastomosis using linear staplers for colon cancer","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBowel reconstruction in the treatment of colorectal cancer, particularly right-sided colon cancer, used to be performed by hand-sewn anastomosis, but recent improvements in devices and standardization of techniques have led to the use of mechanical anastomosis. Compared to hand-sewn anastomosis, instrumented anastomosis is considered to offer the advantages of a simpler technique, shorter time requirements, and wider caliber [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFunctional end-to-end anastomosis (FEEA) is a type of instrumented anastomosis first reported by Steichen [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As one of the most popular reconstruction methods, FEEA is reported to maintain the same intestinal function as manual anastomosis with a lower rate of anastomotic leakage compared to hand-sewn anastomosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother method is delta-shaped anastomosis (Delta), reported by Kanaya et al. in 2002 as a reconstruction method following laparoscopic distal gastrectomy for gastric cancer [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Various clinical experiences and instrumentation improvements have improved the safety of this anastomosis, mainly in the field of gastric cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a paucity of publications comparing short-term prognosis between methods of bowel reconstruction in cases of colorectal cancer [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Further, most previous reports have been single-center studies that could have had several sources of bias. The present study therefore compared short-term outcomes between FEEA and Delta using a multicenter database.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e We retrospectively reviewed 1314 consecutive patients who underwent colorectal surgery with FEEA/Delta in seven participating hospitals (Nagasaki University Hospital, Sasebo City General Hospital, Nagasaki Medical Center, and Isahaya General Hospital, Ureshino Medical Center, Saiseikai Nagasaki Hospital, and Sasebo Chuo Hospital) between January 2016 and December 2023. Patients with hand-sewn anastomosis were excluded. The study protocol was reviewed and approved by the clinical research review boards of the participating hospitals (approval no. 16062715-5).\u003c/p\u003e \u003cp\u003eFEEA is performed by making a small hole with an electrocautery scalpel in the contralateral mesentery, well away from the tumor. A stapler is inserted to create a common hole, which is then closed with a thread. The intestine is resected with another stapler so that the common hole is on the tumor side, completing tumor resection and intestinal reconstruction at the same time.\u003c/p\u003e \u003cp\u003eFor Delta, a stapler is first used to remove the intestinal tract on the oral and anal sides of the tumor. The stapler is inserted through a small hole made with an electrocautery scalpel at each mesenteric side of the dissected segment, and a common hole is created. The common hole is then closed with another stapler to complete the reconstruction.\u003c/p\u003e \u003cp\u003ePatients were divided into two groups: patients who underwent reconstruction by FEEA (F group; n\u0026thinsp;=\u0026thinsp;1242) and by Delta (D group; n\u0026thinsp;=\u0026thinsp;72). Propensity score matching (PSM) was applied to minimize the possibility of selection bias and balance covariates that could affect postoperative complications. The following covariates were included in score matching: sex, age, body mass index, American Society of Anesthesiologists (ASA) performance status (PS), comorbidity, presence or absence of colonic stent insertion, tumor location, clinical tumor/node/metastasis (T/N/M) status, surgical approach, and presence or absence of multivisceral resection. Nearest neighbor matching was performed in a 1:1 ratio, with the caliper set at 0.2. Finally, 72 patients in each group were matched.\u003c/p\u003e \u003cp\u003eClinical features were compared between groups before and after propensity score matching. The following data were collected: sex, age, BMI, ASA-PS, comorbidity, presence or absence of colonic stent insertion, tumor location, clinical T/N/M status, surgical approach, and presence or absence of multivisceral resection. The surgical and pathological data collected included operation time, blood loss, pathological T/N status, postoperative complications, and postoperative hospital stay. Postoperative complications were defined as complications that occurred within 30 days of the primary surgery. Patients with Clavien\u0026ndash;Dindo (CD) grade \u0026ge;2 were included in the complication group.\u003c/p\u003e \u003cp\u003eStatistical analysis was performed using JMP software (SAS Institute Inc., Cary, NC, USA). Data are presented as median and range. Differences in categorical variables were compared using the chi-squared test or Fisher\u0026rsquo;s exact test. Differences in continuous variables were analyzed using the Mann\u0026ndash;Whitney U-test. All values of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the details of postoperative complications. Postoperative complications of CD grade \u0026ge;2 were identified in 215 patients (17.3%) in F group and 8 patients (11.1%) in D group. In F group, 114 patients (11.6%) experienced complications of CD grade 2, including ileus (n\u0026thinsp;=\u0026thinsp;40, 3.2%), surgical site infection (n\u0026thinsp;=\u0026thinsp;34, 2.7%), and anastomotic leakage (n\u0026thinsp;=\u0026thinsp;13, 1.0%). In D group, 4 patients (5.6%) experienced CD grade 2 complications, including anastomotic leakage (n\u0026thinsp;=\u0026thinsp;2, 2.8%), ileus (n\u0026thinsp;=\u0026thinsp;1, 1.4%), and surgical site infection (n\u0026thinsp;=\u0026thinsp;1, 1.4%). In F group, 71 patients (5.7%) experienced CD grade \u0026ge;3 complications, including anastomotic leakage (n\u0026thinsp;=\u0026thinsp;26, 2.1%), surgical site infection (n\u0026thinsp;=\u0026thinsp;12, 1.0%), and ileus (n\u0026thinsp;=\u0026thinsp;10, 0.8%). In D group, 4 patients (5.6%) experienced CD grade \u0026ge;3 complications, including anastomotic leakage (n\u0026thinsp;=\u0026thinsp;2, 2.8%) and ileus (n\u0026thinsp;=\u0026thinsp;2, 2.8%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDetails of postoperative complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF group\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1242) (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD group\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72) (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll complications (CD \u0026ge;2), n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e215 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD\u0026thinsp;=\u0026thinsp;2, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e144 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelirium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eClostridium difficile\u003c/em\u003e colitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChylous ascites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD \u0026ge;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eCD\u003c/em\u003e, Clavien\u0026ndash;Dindo classification\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e compares clinical characteristics between F and D groups before and after matching. Before matching, transverse colon cancer was more common (p\u0026thinsp;=\u0026thinsp;0.002), clinical N-positive status (44.1% vs 16.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and distant metastases were less common (11.7% vs 1.4%, p\u0026thinsp;=\u0026thinsp;0.003), and laparoscopic approach was more common (87.8% vs 100%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in D group. Other factors, including sex, age, BMI, ASA-PS, comorbidity, presence or absence of colonic stent insertion, clinical T status, and presence or absence of multivisceral resection were similar between groups. After matching, no difference in any clinical factor was seen between groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics in the FEEA and delta reconstruction before and after matching\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eBefore matching\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003eAfter matching\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFEEA\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1242) (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelta\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72) (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFEEA\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72) (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDelta\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72) (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.808\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e581 (46.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e35 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e661 (53.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (13\u0026ndash;98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (49\u0026ndash;93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74 (34\u0026ndash;92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e73 (49\u0026ndash;93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.964\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (13\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (14\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.748\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23 (15\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23 (14\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA performance status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.461\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.771\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e285 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e818 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e51 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e421 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e821 (66.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e52 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColonic stent insertion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.619\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1164 (93.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71 (98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e69 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.866\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCecum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e273 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscending colon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e599 (48.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransverse colon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e275 (22.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescending colon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical T status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e973 (78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e61 (84.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e63 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e269 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical N status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e694 (55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e60 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e548 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistant metastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1097 (88.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71 (98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71 (98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1091 (87.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e72 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultivisceral resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1184 (95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e72 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eData are presented as the number of patients (percentage) or the median (range).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eASA\u003c/em\u003e, American Society of Anesthesiologists; \u003cem\u003eBMI\u003c/em\u003e, body mass index. Differences in categorical variables were compared using Fisher\u0026rsquo;s exact test or the chi-squared test, as appropriate. Differences in continuous variables were analyzed using the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e-test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e compares perioperative characteristics between F and D groups after matching. After matching, volume of blood loss was less (28 mL vs 10 mL, p\u0026thinsp;=\u0026thinsp;0.002) in D group. No differences in any other clinical factors were evident between groups, including operation time and postoperative complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative characteristics in FEEA and delta reconstruction after matching\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFEEA\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72) (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelta\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72) (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time, min (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199 (60\u0026ndash;646)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e197 (138\u0026ndash;561)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.972\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss, mL (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (0\u0026ndash;560)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (0\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological T status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological N status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.649\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (81.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (86.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications, CD \u0026ge;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay, days (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (1\u0026ndash;155)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (7\u0026ndash;43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as the number of patients (percentage) or the median (range).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eT\u003c/em\u003e, tumor; \u003cem\u003eN\u003c/em\u003e; node; \u003cem\u003eCD\u003c/em\u003e, Clavien\u0026ndash;Dindo classification.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDifferences in categorical variables were compared using Fisher\u0026rsquo;s exact test or the chi-squared test, as appropriate. Differences in continuous variables were analyzed with the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e-test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present multicenter study examined short-term outcomes of FEEA and Delta in colorectal cancer surgery using propensity score matching. Postoperative complication rates were 17.3% in F group and 11.1% in D group. Before matching, transverse colon cancer was more frequent, clinical N-positive status and distant metastases were less common, and use of a laparoscopic approach were more common in D group. After matching, volume of blood loss was less in D group. However, operation time and postoperative complication rates were similar between groups.\u003c/p\u003e \u003cp\u003eSeveral studies have reported on instrumented anastomosis for colorectal cancer [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The overall complication rate was 25.7% for FEEA and 35.4% for triangular anastomosis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the present study, complication rates were 17.3% for FEEA and 11.1% for Delta, comparable to previous reports, and both anastomoses were performed safely.\u003c/p\u003e \u003cp\u003eIn colorectal cancer surgery, suture failure is a serious complication that not only increases the risk of reoperation due to peritonitis and mortality, but also affects long-term outcomes such as risk of recurrence [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In a meta-analysis comparing hand-sewn and instrumented anastomoses for colorectal cancer surgery, stapled anastomosis was reported to be significantly safer with fewer suture failures compared to hand-sewn anastomosis (failure rate: 1.4% vs 5.8%, respectively; p\u0026thinsp;=\u0026thinsp;0.02) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In recent reports, the anastomotic leakage rate for FEEA has been reported as 1.6\u0026ndash;4.8% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], with limited data available for Delta anastomosis. Su et al. reported no anastomotic complications, including suture failure, in a study of 86 cases treated using Delta methods, the number of cases remains small and accumulation of more data is needed [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In the present study, FEEA and Delta anastomosis were used in 3.1% and 5.5% of cases, respectively, with no significant differences observed between either method.\u003c/p\u003e \u003cp\u003eIleus was one of the most frequent complications in this study. The diameter of the anastomotic hole at the time of anastomosis is often a problem, and long-term anastomotic stenosis is said to occur in 6.8\u0026ndash;8.4% of cases [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the present case of ileus, no direct evidence of anastomotic stenosis was observed. Some patients who developed ileus may have had relatively temporary stenosis due to postoperative edema. Further, no cases showed long-term complete stenosis requiring surgery or other treatment, and long-term function in patients who showed ileus was excellent.\u003c/p\u003e \u003cp\u003eIn a comparison of clinical and periodic backgrounds of F and D groups, a tendency was seen toward more frequent transverse colon cancer in D group. The transverse colon varies greatly in length from person to person, and obese patients may show a shortened mesentery, making adequate mesenteric transfer difficult. If the tension during anastomosis is too high, FEEA may cause anastomotic stricture and postoperative bleeding due to mesenteric engorgement [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In fact, a report examining the choice of instrumented anastomosis limited to the transverse colon found that FEEA was mainly selected for ileocolic anastomosis after extensive dissection and hemicolectomy rather than for colocolic anastomosis, which is less mobile and prone to tension in the intestinal tract. Delta anastomosis is less problematic than FEEA in terms of bowel tension during anastomosis and can be performed with relatively little bowel movement. This may be why transverse colon cancer was more common in the Delta group.\u003c/p\u003e \u003cp\u003eIn addition, significantly fewer Lap cases were seen in the FEEA group among pre-PSM cases in this study. This may be due to the fact that cancers were more advanced in the FEEA group. In this study, we were able to adjust for these covariates using PSM\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, no previous studies have compared FEEA and delta anastomoses. In the present study, we compared the short-term outcomes of the two anastomosis methods under conditions of comparable patient backgrounds using PSM, and found no significant differences in operative time or postoperative complications (including anastomotic leakage) between groups. Based on this, we considered Delta anastomosis to be as safe as FEEA. In addition, Delta anastomosis tended to result in less blood loss than FEEA. This may be due to the fact that Delta anastomosis requires a smaller area for dissection than FEEA, resulting in relatively less bleeding.\u003c/p\u003e \u003cp\u003eSeveral limitations to this study should be kept in mind. First, this was a retrospective study and the number of delta-shaped anastomosis was relatively small. Second, this was a rural multicenter study and the background characteristics of patients may have been biased. Third, the present multicenter database lacked information on intra- or extracorporeal anastomosis. A prospective study of a larger cohort is therefore needed.\u003c/p\u003e \u003cp\u003eDespite these limitations, Delta and FEEA were considered to both represent safe reconstruction methods, including in terms of complication rates and operation time. Delta anastomosis was considered useful for reconstruction in patients with transverse colon cancer and other cases in which the extent of transfusion should be minimized\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDisclosures\u003c/h2\u003e \u003cp\u003eDrs. Rika Ono, Tetsuro Tominaga, Mitsutoshi Ishii, Makoto Hisanaga, Masato Araki, Yorihisa Sumida, Takashi Nonaka, Shintaro Hashimoto, Toshio Shiraishi, Keisuke Noda, Hiroaki Takeshita, Hidetoshi Fukuoka, Shosaburo Oyama, Kazuhide Ishimaru, Terumitsu Sawai, Keitaro Matsumoto have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRika Ono and Tetsuro Tominaga mainly designed this study. Mitsutoshi Ishii, Makoto Hisanaga, Masato Araki, Yorihisa Sumida, Takashi Nonaka, Shintaro Hashimoto, Toshio Shiraishi, Keisuke Noda, Hiroaki Takeshita, Hidetoshi Fukuoka, Shosaburo Oyama, and Kazuhide Ishimaru performed surgery. Terumitsu Sawai and Keitaro Matsumoto supervised this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRitchey ML, Lally KP, Ostericher R. Comparison of different techniques of stapled bowel anastomoses in a canine model. Arch Surg. 1993;128(12):1365\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeagher AP, Wolff BG. Right hemicolectomy with a linear cutting stapler. Dis Colon Rectum. 1994;37(10):1043\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamamoto T, Keighley MR. Stapled functional end-to-end anastomosis in Crohn's disease. Surg Today. 1999;29(7):679\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteichen FM. The use of staplers in anatomical side-to-side and functional end-to-end enteroanastomoses. Surgery. 1968;64(5):948\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoy PY, Bissett IP, Docherty JG, Parry BR, Merrie A, Fitzgerald A. Stapled versus handsewn methods for ileocolic anastomoses. The Cochrane database of systematic reviews. 2011(9):Cd004320.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanaya S, Gomi T, Momoi H, Tamaki N, Isobe H, Katayama T, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy: new technique of intraabdominal gastroduodenostomy. J Am Coll Surg. 2002;195(2):284\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang B, Tu JC, Fang J, Zhou L, Liu YL. Comparison of early-term effects between totally laparoscopic distal gastrectomy with delta-shaped anastomosis and conventional laparoscopic-assisted distal gastrectomy: a retrospective study. International journal of clinical and experimental medicine. 2015;8(6):9967\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanaya S, Kawamura Y, Kawada H, Iwasaki H, Gomi T, Satoh S, et al. The delta-shaped anastomosis in laparoscopic distal gastrectomy: analysis of the initial 100 consecutive procedures of intracorporeal gastroduodenostomy. Gastric cancer: official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association. 2011;14(4):365\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmoto S, Fukunaga Y, Nakanishi R, Hirayama K, Nagaoka T, Matsui S, et al. Short- and long-term outcomes of laparoscopic surgery with extracorporeal anastomosis for transverse colon cancer: comparison of triangulating anastomosis with functional end-to-end anastomosis. Surg Endosc. 2022;36(5):3261\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSato K, Imaizumi K, Kasajima H, Kurushima M, Umehara M, Tsuruga Y, et al. Short-term outcomes of extracorporeal colo-colonic triangular anastomosis versus functional end-to-end anastomosis in laparoscopic-assisted surgery for left-sided colon cancer: a propensity score matching analysis. Langenbecks Arch Surg. 2022;407(2):747\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTajima JY, Nagayama S, Hiyoshi Y, Mukai T, Nagasaki T, Yamaguchi T, et al. Colonic delta-shaped anastomosis using linear staplers in laparoscopic colectomy. Tech Coloproctol. 2021;25(4):473\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSu H, Jin WS, Wang P, Bao M, Wang XW, Liu Q, et al. Intra-corporeal delta-shaped anastomosis in laparoscopic right hemicolectomy for right colon cancer: a safe and effective technique. Gastroenterology report. 2019;7(4):272\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOjima H, Sohda M, Ando H, Sano A, Fukai Y, Ogawa A, et al. Relationship between functional end-to-end anastomosis for colon cancer and surgical site infections. Surg Today. 2015;45(12):1489\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoto S, Hasegawa S, Hida K, Uozumi R, Kanemitsu Y, Watanabe T, et al. Multicenter analysis of impact of anastomotic leakage on long-term oncologic outcomes after curative resection of colon cancer. Surgery. 2017;162(2):317\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHa GW, Kim JH, Lee MR. Oncologic Impact of Anastomotic Leakage Following Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis. Ann Surg Oncol. 2017;24(11):3289\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePredictors for Anastomotic Leak, Postoperative Complications, and Mortality After Right Colectomy for Cancer: Results From an International Snapshot Audit. Dis Colon Rectum. 2020;63(5):606\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao L, Wang Y, Liu H, Chen H, Deng H, Yu J, et al. Long-term outcomes of laparoscopic surgery for advanced transverse colon cancer. J Gastrointest Surg. 2014;18(5):1003\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"colon cancer, functional end-to-end anastomosis, delta-shaped anastomosis, postoperative complication","lastPublishedDoi":"10.21203/rs.3.rs-4438895/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4438895/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSeveral methods are used for reconstruction in colon cancer surgery, including hand-sewn or stapled anastomosis. However, few reports have compared short-term outcomes among reconstruction methods. This study compared short-term outcomes between delta-shaped anastomosis (Delta) and functional end-to-end anastomosis (FEEA).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We retrospectively reviewed 1314 consecutive patients who underwent colorectal surgery with FEEA or Delta reconstruction between January 2016 and December 2023. Patients were divided into two groups according to reconstruction by FEEA (F group; n\u0026thinsp;=\u0026thinsp;1242) or Delta (D group; n\u0026thinsp;=\u0026thinsp;72). Propensity score matching was applied to minimize the possibility of selection bias and to balance covariates that could affect postoperative complications. Short-term outcomes were compared between groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePostoperative complications occurred in 215 patients (17.3%) in F group and 8 patients (11.1%) in D group. Before matching, transverse colon cancer was more frequent (p\u0026thinsp;=\u0026thinsp;0.002), clinical N-positive status was less frequent (44.1% vs 16.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), distant metastasis was less frequent (11.7% vs 1.4%, p\u0026thinsp;=\u0026thinsp;0.003), and laparoscopic approach was more frequent (87.8% vs 100%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in D group. After matching, no differences in any clinical factor were evident between groups. Blood loss was lower (28 mL vs 10 mL, p\u0026thinsp;=\u0026thinsp;0.002) in D group. However, operation time and postoperative complication rates were similar between groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDelta and FEEA were both considered safe as reconstruction methods. Delta anastomosis may be more useful for patients with transverse colon cancer for whom transfusion should be minimized.\u003c/p\u003e","manuscriptTitle":"Short-term outcomes of delta-shaped anastomosis versus functional end-to-end anastomosis using linear staplers for colon cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-29 09:34:25","doi":"10.21203/rs.3.rs-4438895/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-12T18:29:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-24T10:47:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-11T13:02:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14097263999895069973012534849623305461","date":"2024-06-11T12:39:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35152108049992323139728859030355749562","date":"2024-06-10T06:27:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-09T19:14:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-09T19:13:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-18T01:50:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2024-05-18T00:17:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ce575dae-7860-4db8-baa7-f40604ed57c9","owner":[],"postedDate":"May 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T16:01:58+00:00","versionOfRecord":{"articleIdentity":"rs-4438895","link":"https://doi.org/10.1007/s10151-024-03006-1","journal":{"identity":"techniques-in-coloproctology","isVorOnly":false,"title":"Techniques in Coloproctology"},"publishedOn":"2024-09-23 15:57:19","publishedOnDateReadable":"September 23rd, 2024"},"versionCreatedAt":"2024-05-29 09:34:25","video":"","vorDoi":"10.1007/s10151-024-03006-1","vorDoiUrl":"https://doi.org/10.1007/s10151-024-03006-1","workflowStages":[]},"version":"v1","identity":"rs-4438895","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4438895","identity":"rs-4438895","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}