Comparative Outcomes of Intracorporeal and Extracorporeal Anastomosis Following Laparoscopic Colectomy in Patients with Obesity with Colon Cancer

Comparative Outcomes of Intracorporeal and Extracorporeal Anastomosis Following Laparoscopic Colectomy in Patients with Obesity with 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 Comparative Outcomes of Intracorporeal and Extracorporeal Anastomosis Following Laparoscopic Colectomy in Patients with Obesity with Colon Cancer Feng-Ching Tsai, Yih-Jong Chern, Yu-Jen Hsu, Chun-Kai Liao, Ching-Chung Cheng, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6582982/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Jul, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Laparoscopic surgery with intracorporeal anastomosis (IA) is a well-established procedure in colorectal cancer surgery. Nonetheless, its feasibility in patients with obesity remains unclear. This study aimed to evaluate the short-term and medium-term outcomes of IA to extracorporeal anastomosis (EA) among a cohort of patients with general obesity treated at a single teaching hospital. Methods The study included patients with obesity who underwent laparoscopic radical colectomy with primary bowel anastomosis for colon cancer between September 2007 and December 2021. Patients were split into two groups according to the method of anastomosis used: EA or IA. We evaluated various surgical outcomes, namely postoperative complications, recovery metrics, pain intensity, and 3-year survival rates. Results A total of 355 patients with obesity with colorectal cancer were enrolled in the study. 150 and 205 patients were in the IA and EA groups, respectively. The IA group demonstrated faster bowel recovery, faster resumption of diet, and shorter hospital stays compared with the EA group. Additionally, IA yielded specimens with longer lengths and larger safety margins relative to the tumor. The EA group exhibited a significantly higher overall rate of postoperative complications, most notably postoperative ileus. However, the 3-year oncological outcomes were similar between the IA and EA groups. Conclusion The study revealed that in patients with obesity, IA resulted in faster bowel function recovery, shorter hospital stays, and fewer complications. Furthermore, IA produced better pathological outcomes, characterized by longer specimen lengths and wider safety margins, without compromising 3-year overall and disease-free survival rates. Thus, IA is a safe and feasible anastomosis technique for patients with obesity undergoing laparoscopic colectomy for colorectal cancer. Laparoscopic surgery Obesity Intracorporeal anastomosis Colectomy Figures Figure 1 Figure 2 Introduction Obesity constitutes a growing public health concern, particularly in industrialized countries, and correlates with an increased incidence of colorectal cancer (CRC) ( 1 , 2 ). Obese individuals often present with additional comorbidities that can elevate the likelihood of complications following gastrointestinal tumor surgery ( 3 , 4 ). Compared with their nonobese counterparts, these individuals face an increased risk for postoperative complications, such as wound healing and cardiopulmonary functions. Additionally, reports indicate that the duration of surgical procedures tends to be significantly longer for patients with obesity, possibly due to the technical challenges inherent in operating on this population ( 5 , 6 ). Laparoscopic surgery for treating CRC has gained widespread acceptance to become a standard course of treatment since it was initially reported on in 1991; its safety and efficacy has been supported by numerous large-scale clinical trials over the past three decades ( 7 , 8 ). This surgical approach offers multiple advantages over traditional open surgery. It is minimally invasive and often leads to smaller incisions, less postoperative pain, shorter hospital stays, quicker recovery periods, improved cosmetic outcomes, and fewer complications. Laparoscopic surgery has been found to have equally effective long-term outcomes compared with open surgery ( 9 – 11 ). Laparoscopic colectomy is associated with shorter hospital stay, surgical site complications, and a quicker return to normal activities; this is so even for patients with obesity, who are generally more susceptible to surgical site infections and pulmonary embolism ( 12 ). Advances in medical technology and clinician skill have led to increased use of total laparoscopic surgery with intracorporeal anastomosis (IA), which requires only a small laparotomy for specimen extraction. This approach is thought to be less invasive and often results in faster recovery periods, shorter hospital stays, and reduced morbidity rates ( 13 – 15 ). Although IA has garnered attention for its benefits, studies have disagreed on the difference in surgical duration between IA and extracorporeal anastomosis (EA). Some studies have indicated that IA is associated with a significantly longer duration of surgery (DoS) ( 13 , 14 , 16 ). Most other studies have found no significant difference in duration of surgery between IA and EA ( 15 , 17 ). Furthermore, one study reported that clinicians face a learning curve in mastering the technique for IA ( 18 ). At present, no study has determined whether increased operative time contributes to surgical and anesthesia risk in patients with obesity. Moreover, whether IA is superior to EA in short-term and long-term outcomes in patients with obesity remains unknown. Despite the documented advantages of total laparoscopic surgery using IA, limited research exists on its feasibility and advantages in specific populations, such as those who are morbidly obese. This study, conducted in a single teaching hospital, aimed to address these gaps by evaluating both the short-term and medium-term outcomes of IA and EA in patients with general obesity. Material and methods Study Design and Population This retrospective study systematically collected data on clinicopathological variables from the Colorectal Section Tumor Registry of Chang Gung Memorial Hospital (CGMH). The Institutional Review Board of CGMH approved this study (IRB No. 202300507B0). This study enrolled patients who had a body mass index (BMI) greater than or equal to 27 kg/m 2 and underwent laparoscopic radical colectomy with primary bowel anastomosis for colon cancer. The tumors included in this study were in anatomical regions ranging from the cecum to the descending colon. The data spanned the September 2007 to December 2021 period. We excluded patients who underwent anterior resection with circular stapling anastomosis, patients whose procedure was converted to open surgery, and patients who had a diverting ostomy created. Variables and Outcome Measurement The study collected data on a variety of patient-related characteristics, namely age, gender, body weight, BMI, American Society of Anesthesiologists (ASA) classification, and underlying medical conditions—such as hypertension, heart disease, cerebrovascular accidents, asthma, diabetes mellitus, peptic ulcers, and hepatitis. Preoperative blood analyses included tests for carcinoembryonic antigen (CEA), hemoglobin (Hb), white blood cells, and albumin. Factors pertaining to the tumor were the depth of tumor invasion (T stage), the extent of lymph node involvement (N stage), the number of lymph nodes harvested, the location of the tumor, and the size of the tumor. Additionally, operation-related variables such as the technique of the surgery, the duration of the operation, the volume of blood loss, the type and technique of anastomosis, and the site of the extraction wound were evaluated. The definition of obesity for this study was based on guidelines from Taiwan's Ministry of Health and Welfare (BMI ≥ 27 kg/m 2 ) ( 19 ). The definition is according to the findings of local statistics to avoid underestimation of the health hazards associated with obesity in Asian populations. This deviates from the World Health Organization's definition of obesity (BMI ≥ 30 kg/m 2 ), which is primarily applicable to European-origin populations rather than East Asian–origin ones. The surgical procedures in the study encompassed right hemicolectomy, transverse colectomy, left hemicolectomy, and different segmental resections. Methods employed for bowel anastomosis included hand-sewing, entire stapling, and a combination of hand-sewing and stapling techniques. Specimens were extracted through mini-laparotomies at different sites including the umbilicus, McBurney point, Pfannenstiel, and natural orifice. Short-term outcomes included postoperative morbidity and mortality, pain scale assessment, postoperative recovery, and the length of the postoperative hospital stay. Pain intensity was quantified using a numeric rating scale (NRS) ranging from 0 to 10, where a score of 10 indicated the most severe pain. The mean postoperative pain scores were subsequently used for further evaluation. Midterm outcomes included the incidence of incisional hernia and overall survival rates. Both overall survival (OS) and disease-free survival (DFS) were used to assess survival. The endpoint for OS was defined as death from any cause, and the endpoints for DFS were death from any cause or recurrence. Surgical Techniques of Anastomosis: Extracorporeal anastomosis (EA) and Intracorporeal anastomosis (IA) Following complete division of the bowel designated for resection, anastomosis was achieved through either EA or IA, depending on the clinical judgement of the surgeon. For the EA group, a mini-laparotomy was conducted primarily along the midline. Surgeons extracted the specimen through this wound and performed the anastomosis using either hand-sewing or staplers. For the IA group, anastomosis was conducted inside the abdominal cavity, with the use of either a stapler, hand-sewing, or a combination of both methods. The specimen was subsequently extracted through a mini-laparotomy (using either a midline, Pfannenstiel incision, or right lower quadrant) or through a transrectal method for natural orifice specimen extraction. Statistical analysis All analyses were conducted using IBM SPSS Statistics software, Version 24.0 (Armonk, NY: IBM). Clinicopathological features with categorical variables were represented as frequencies and percentages and compared using the chi-square test. Analyses of continuous variables were given as means and standard deviations, with the Student t-test providing the statistical analysis. DFS and OS were assessed using Kaplan–Meier survival curves. Comparisons between different groups were made using the log-rank test. The statistical significance threshold was set at p < .05. Results Of the 377 patients with obesity with CRC who underwent minimally invasive radical resection, 22 were excluded due to the use of circular staples, conversion to open surgery, and the formation of a concomitant diverting ostomy. The remaining 355 patients were divided into two groups based on the anastomosis technique: 150 patients (43.7%) received IA, and 205 patients (57.7%) received EA. Table 1 presents the demographics and clinical characteristics of the patients with obesity. The IA and EA groups did not significantly differ in age, sex ratio, BMI, or the rate of patients with a BMI of 30 or greater. However, the IA group had a greater proportion of patients with higher ASA classifications compared with the EA group (84.0% in ASA III for IA compared with 63.9% for EA, p < .001). Preoperative laboratory data—including CEA, hemoglobin, white blood cell count, and albumin levels—and underlying medical conditions did not significantly differ between the two groups. Similarly, tumor characteristics such as location and cancer stage were comparable between both groups. Table 1 Demographics and clinical characteristics of patients with obesit undergoing intracorporeal and extracorporeal anastomosis IA a (n = 150) EA b (n = 205) P-value Age (years) 63.91 ± 12.74 64.78 ± 12.04 0.51 Age ≥ 65 77(51.3%) 105(51.2%) 0.983 BMI (kg/m 2 ) 29.86 ± 2.54 29.8 ± 3.12 0.836 BMI ≥ 30 57(38.0%) 76(37.1%) 0.859 Female, n(%) 68(45.3%) 85(54.7%) 0.515 ASA c Classification < 0.001 II 24(16%) 74 (36.1%) III 126(84%) 131(63.9%) Pre-op Lab CEA d ≥5 49(32.7%) 50(24.5%) 0.091 Hemoglobin (g/dL) 12.09 ± 2.72 12.10 ± 2.56 0.955 WBC e (/µL) 7308 ± 2220 7478 ± 2102 0.462 Albumin (g/dL) 4.15 ± 0.41 4.21 ± 0.39 0.144 Medical Illness, n(%) Hypertension 91 (60.7%) 130 (63.4%) 0.658 Heart disease 16(10.7%) 28(13.7%) 0.470 CVA f 6(4.0%) 11(5.4%) 0.622 Asthma 4 (2.7%) 6 (2.9%) 1 Diabetes 47(31.3%) 60(29.4%) 0.726 Peptic Ulcer 9(6.0%) 14(6.9%) 0.829 Hepatitis 7(2.7%) 10(4.9%) 0.410 Tumor Location, n(%) 0.128 Cecum 28(18.7%) 20(9.8%) Ascending Colon 53(35.3%) 88(42.9%) Hepatic Flexure 46(30.7%) 56(27.3%) Transverse Colon 3(2.0%) 9(4.4%) Splenic Flexure 6(4.0%) 11(5.4%) Descending Colon 14(9.3%) 21(10.2%) Cancer Stage 0.669 I 40(26.7%) 59(28.8%) II 45(30.0%) 60(30.7%) III 47(31.3%) 58(28.3%) IV 15(10.0%) 16(7.8%) a Intra-Corporeal Anastomosis b Extra-Corporeal Anastomosis c American Society of Anesthesiologist d Caricinoembryonic Antigen e White Blood Cell f Cerebrovascular Accident Table 2 lists the operative variables and pathological parameters. Right hemicolectomy was the most significant surgical procedure in both groups. The operation time was significantly longer in the IA group compared with the EA group (261.5 min for IA compared with 242.2 min for EA, p = .024). Anastomosis in the IA group was predominantly conducted using a hybrid of stapling and hand-sewing methods (88.7%). Conversely, hand-sewing (47.8%) and the exclusive use of staplers (52.2%) were the most prevalent methods in the EA group. Regarding the ​​extraction sites, the EA group predominantly had an umbilical midline wound (99.5%), whereas the IA group featured a diversity of approaches, namely umbilicus (42.7%), Pfannenstiel incision (41.3%), and natural orifice specimen extraction (15.3%). Both groups had similar tumor sizes and numbers of resected lymph nodes. However, the IA group had a significantly longer specimen length (27.3 cm for IA compared with 23.5 cm for EA, p < .001) and a greater nearest margin of tumor (8.0 cm for IA compared with 6.7 cm for EA, p < .001). Advanced T stages were more common in the IA group, whereas the N stages were similar in both groups. Table 2 Operative variables and pathological parameters of patients with obesity undergoing intracorporeal and extracorporeal anastomosis IA a (n = 150) EA b (n = 205) P-value Operation, n(%) 0.207 Right Hemicoletomy 120 (80%) 152 (74.1%) Other colectomy 30 (20%) 53(25.9) Operative Time (minutes) 261.51 ± 82.11 242.24 ± 76.70 0.024 Blood loss (mL) 42.63 ± 82.03 51.54 ± 53.43 0.217 Anastomosis < 0.001 Hand-sew 14 (9.3%) 98 (47.8%) Total stapled 3 (2%) 107 (52.2%) Staple + Suture 133 (88.7%) 0 Extraction Site, n(%) < 0.001 Umbilicus 64 (42.7%) 204 (99.5%) Pfannenstiel 62 (41.3%) 0(0.0%) NOSE c 23(15.3%) 0(0.0%) McBurney 1 (0.7%) 1 (0.5%) Harvested Lymph Node 32.72 ± 16.69 34.40 ± 17.208 0.359 Specimen Length (cm) 27.30 ± 9.44 23.53 ± 8.60 < 0.001 Nearest Margin (cm) 8.04 ± 3.61 6.72 ± 3.30 < 0.001 Tumor Size Tumor Width (cm) 3.79 ± 2.19 4.21 ± 6.99 0.475 Tumor Length (cm) 3.351 ± 1.87 3.63 ± 6.86 0.619 T stage, n(%) 0.020 T0 3(2.0%) 9(4.4%) T1 31(20.7%) 34(16.6%) T2 12(8.0%) 35(17.1%) T3 75(50.0%) 99(48.3%) T4a 23(15.3%) 27(13.2%) T4b 6(4.0%) 1(0.5%) N stage, n(%) 0.920 N0 93(62.0%) 135(65.9%) N1a 22(14.7%) 22(10.7%) N1b 12(8.0%) 17(8.3%) N1c 1(0.7%) 1(0.5%) N2a 9(6.0%) 11(5.4%) N2b 13(8.7%) 19(9.3%) a Intra-Corporeal Anastomosis b Extra-Corporeal Anastomosis c Natural Orifice specimen extraction Table 3 displays the postoperative outcomes of patients receiving IA as opposed to those receiving EA. NRS scores for pain severity and postoperative laboratory markers (white blood cell and C-reactive protein levels) did not significantly differ between the two groups. However, the IA group exhibited significantly shorter durations for the passage of flatus (2.3 days for IA compared with 2.8 days for EA, p = .012) and stool (3.6 days for IA compared with 4.7 days for EA, p < .001). Time to resume diet was also shorter in the IA group compared with the EA group. The average length of postoperative hospital stay was significantly shorter in the IA group (7.0 ± 4.9 days for IA compared with 9.5 ± 9.9 days in EA, p = .004), and a higher proportion of patients in the IA group had a hospital stay shorter than 5 days (42.7% for IA compared with 14.6% for EA, p < .001). In terms of postoperative complications, the overall rate was significantly higher in the EA group (4.0% for IA compared with 10.2% for EA, p = .028). Specifically, the incidence of postoperative ileus was significant higher in the EA group (0% for IA compared with 4.4% for EA, p = .028). Conversely, the rates of intraabdominal infection and anastomosis leakage showed no significant differences between the two groups. With regard to complications graded above Clavien–Dindo classification grade III, no significant differences were observed between the two groups. Rates of incisional hernia at the specimen extraction site were also similar. Table 3 Post-operative outcomes and complications of patients with obesity undergoing intracorporeal and extracorporeal anastomosis IA a EA b P-value POD c 1 NRS d 5.33 ± 1.85 5.36 ± 1.88 0.865 POD2 NRS 3.23 ± 1.33 3.24 ± 1.59 0.989 POD3 NRS 2.59 ± 0.85 2.55 ± 1.29 0.756 POD3 CRP e 93.76 ± 52.33 86.46 ± 62.82 0.322 POD3 WBC f 10.28 ± 2.86 10.06 ± 3.56 0.578 Flatus Passage (days) 2.29 ± 1.63 2.78 ± 1.90 0.012 Stool Passage (days) 3.55 ± 2.01 4.72 ± 2.13 < 0.001 Liquid Diet (days) 3.51 ± 3.29 5.16 ± 5.37 0.001 Soft Diet (days) 5.25 ± 3.90 6.91 ± 5.62 0.002 Hospital Stay (days) 6.95 ± 4.939 9.53 ± 9.928 0.004 Hospital Stay ≤ 5 days 64 (42.7%) 30 (14.6%) < 0.001 Complications 6(4%) 21(10.2%) 0.028 Complication type 0.174 Wound Infection 1(0.7%) 2(1.0%) 0.753 Pneumonia 1(0.7%) 1(0.5%) 0.824 Urine retention 0(0.0%) 1(0.5%) 0.392 Post-op Ileus 0(0.0%) 9(4.4%) 0.009 IAI g 2(1.3%) 1(0.5%) 0.390 Anastomosis leakage 2(1.3%) 6(2.9%) 0.318 Chylus Leakage 0(0.0%) 1(0.5%) 0.392 Clavian-Dindo ≥ 3 4(2.7%) 8(3.9%) 0.522 Incisional Hernia 7(6.5%) 14(8%) 0.425 a Intra-Corporeal Anastomosis b Extra-Corporeal Anastomosis c Post-Operative Day d Numerical Rating Scale e C-Reactive Protein f White Blood Cell g Intra-Abdominal Infection The median follow-up time was 27.2 months for the IA group and 62.6 months for the EA group. The 3-year OS rates were nearly identical—89.9% in the IA group and 90.5% in the EA group. Likewise, the 3-year DFS rates were comparable—82.7% in the IA group and 83.0% in the EA group. Survival curves for both overall ( p = .48, Fig. 2 A) and DFS curves ( p = .35, Fig. 2 B) demonstrated no differences. Discussion To our knowledge, this study is the largest cohort analysis exploring outcomes for patients with obesity with CRC who underwent minimally invasive radical resection, comparing outcomes of IA and EA. The study revealed that patients in the IA group experienced faster bowel recovery times, faster resumption of diet, and shorter hospital stays compared with their EA counterparts. Additionally, the IA group demonstrated longer specimen lengths and greater nearest margin of tumor. Notably, the EA group faced a higher overall rate of postoperative complications, particularly a higher incidence of postoperative ileus. Midterm oncological outcomes did not significantly differ between the IA and EA groups. Performing surgery on patients with obesity poses considerable challenges for surgeons, primarily due to the technical complexities and elevated risks associated with this population. Studies have demonstrated the safety of laparoscopic colectomy when used for patients with obesity ( 20 ). Concurrent advancements in surgical instruments have contributed to the growing adoption of total laparoscopic surgery with IA, particularly given its advantages of faster recovery and shorter hospital stays, in the general population. In line with these trends, our study revealed that the IA group experienced faster bowel recovery and faster resumption of diet. These findings align with several other studies that applied to general populations undergoing right and left hemi-colectomies ( 15 , 21 – 23 ). A case-matched study conducted in 2018, which focused on patients with obesity undergoing right hemicolectomy, also observed quicker recovery of bowel function ( 24 ). For patients in the EA group, the bowel containing the tumor must be maneuvered through the thick abdominal wall for transection and anastomosis. This additional manipulation of the bowel during externalization could account for the observed delays in bowel function recovery. Although the IA group exhibited similar levels of postoperative wound pain to the EA group according to our data, the IA group experienced shorter postoperative hospital stays. Specifically, 42.7% of patients in the IA group required inpatient care for no more than 5 days. This shortened stay may be attributed to the faster recovery of bowel function observed in the IA group. Nevertheless, a limited number of randomized controlled trials ( 17 , 25 ) have compared IA with EA in the general population undergoing right hemicolectomy and found no significant difference in the length of hospital stays, despite better bowel recovery in the IA group. However, these studies have not specifically focused on patients with obesity. Given that natural orifice specimen extraction (NOSE) is associated with significantly shorter hospital stays ( 8 ) and can be only performed in conjunction with IA, we conducted a subgroup analysis excluding patients who underwent NOSE. The data still indicated faster flatus passage ( p = .07), faster stool passage ( p < .001), shorter time to tolerate liquid diets ( p = .006), quicker acceptance of soft diets ( p = .015), and shorter hospital stays ( p = .021) in IA group compared with the EA group. In our patient series, the IA group exhibited fewer postoperative complications than the EA group. Notably, postoperative ileus was significantly more prevalent in the EA group, whereas no instances were observed in the IA group. A meta-analysis that compared IA to EA in a general population undergoing right hemicolectomy found no significant differences in surgical site complications and nonsurgical site complications, including ileus ( 26 ). Conversely, another meta-analysis raised questions about a greater incidence of prolonged postoperative ileus in the IA group compared with the EA group, although the findings were not statistically significant ( 27 ). From our perspective, the EA necessitates more dissection to mobilize the bowel, potentially increasing bowel manipulation and subsequently eliciting an intestinal muscularis inflammatory response that results in postsurgical ileus ( 28 ). Conversely, the IA group might also be at risk for postoperative ileus due to potential intraabdominal contamination during intracorporeal anastomosis and the prolonged anesthesia time resulting from longer surgical durations. Further study is warranted to address these concerns. The incidence of incisional hernia following laparoscopic colectomy varies widely in the literature, ranging from 1.4–15.9% ( 29 , 30 ). In our cohort, the overall incidence was 7.0%. The IA group had a slightly lower hernia rate (6.5%) compared with the EA group (8%), although the difference was not statistically significant. Obesity is known to elevate the risk of incisional hernia due to increased intraabdominal pressure ( 31 ). Visceral obesity has been found to be strongly associated with incisional hernia after colorectal surgery ( 32 ), and increased BMI was reported to be associated with incisional hernia after laparoscopic colorectal resection. Although our study did not demonstrate a risk reduction in the IA group, we still advocate for IA as a preferable surgical approach to minimize the risk of incisional hernia. Meta-analyses have indicated that midline incisions for specimen extraction are associated with a higher risk of incisional hernia compared with off-midline incisions ( 33 , 34 ). The anatomic structure of the mesentery often dictates the use of peri-umbilical midline wound for specimen extraction in the EA group. Conversely, the IA procedure offers greater flexibility in choosing the extraction site, which could potentially decrease the rate of incisional herniation if off-midline wounds are preferred. Regarding pathological outcomes, both groups had similar numbers of harvested lymph nodes. Few studies have investigated specimen length and safety margins between the IA and EA technique, and conflicting results have been presented in the literature. One trial examining right hemicolectomies in the general population found longer resected colon lengths in the IA group (25.3 ± 5.8 in the IA compared with 22.7 ± 7.8 in the EA, p = .026) ( 25 ). However, no significant differences were observed between the IA and EA groups in a study focusing on left colectomies for splenic flexure cancer (25.7 ± 12.9 in the IA compared with 29.0 ± 19.3 in the EA, p = .390) ( 35 ). In our cohort, the IA group had significantly longer specimen lengths and greater safety margins than the EA group. The thickness of the abdominal wall in patients with obesity may limit specimen length in the EA group because the procedure requires exteriorizing the specimen though a small laparotomy incision. Visceral fat can also obstruct a specimen as it is pulled through the laparotomy wound. Conversely, the IA technique, unencumbered by the abdominal wall and mesentery, allows for more accurate visualization of the specimen and precise resection, thereby enhancing surgical margins. The 3-year OS and 3-year DFS rates were similar between the IA and EA groups. Wang et al. ( 36 ) reported a similar 2-year OS (95.0% compared with 93.5%, p = .747) and DFS (97.5% compared with 90.9%, p = .182) between patients who underwent IA or EA for laparoscopic left colectomy. Another study employing propensity score matching analysis between the IA and EA groups for both right- and left-sided laparoscopic colectomy found no significant difference in estimated 3-year OS and estimated 3-year DFS ( 37 ). These studies generally analyzed outcomes in a general population, whereas our study focused on the midterm outcomes in patients with obesity, a subject not previously reported. To the best of our knowledge, only one other study compared IA with EA in patients with obesity, and that study exclusively examined right hemicolectomies. Our study is the first to investigate outcomes between IA and EA in patients with obesity who underwent laparoscopic radical colectomy and primary bowel anastomosis for either right- or left-sided colon cancer. Moreover, our study enrolled the largest cohort of patients with obesity who have undergone entirely minimally invasive colectomies. We are also the first to compare specimen length, margin distance, 3-year DFS, and 3-year OS between the two methods in patients with obesity. Our findings suggest that patients with obesity could derive greater benefits from the IA method without compromising oncological outcomes. This study has several limitations. First, the employment of a retrospective design introduces the potential for bias between the groups under investigation. Second, the preferences of surgeons for either EA or IA contribute to the variability in the study outcomes. Surgeons, in consultation with patients and their families, determine the final surgical approach. Some surgeons exhibit a predilection for EA over IA, or vice versa, which could influence the results. Third, the findings of the study could be affected by geographic variations in the definition of obesity. Specifically, the criteria for obesity differ between Asian and Western countries, which could affect the generalizability of the relationship between obesity and the chosen method of anastomosis. Conclusion In patients with obesity undergoing laparoscopic colectomy for CRC, the IA method is advantageous for its faster bowel function recovery, shorter duration of hospital stays, and reduced rate of postoperative complications. From a pathological standpoint, IA enables the extraction of longer specimens and achieves greater nearest margins, yet maintains comparable numbers of harvested lymph nodes. Patients who underwent IA procedures demonstrated outcomes compatible with those who underwent EA. These comparable outcomes spanned multiple dimensions, including 3-year OS rates, 3-year DFS rates, and the incidence rates of incisional hernias. In conclusion, IA emerges as a safe and feasible surgical procedure for treating colorectal malignancies in patients with obesity, irrespective of whether the malignancy is in the right or left of the colon. Declarations Authors' contributions All contributing authors participated equally in the completion of this study. Competing interests The authors declare that they have no competing interests Funding This study was supported by the Chang Gung Medical Research Fund (CMRPG3J1531). The funder had no role in study design and analysis. Ethics approval and consent to participate Chang Gung Medical Foundation Institutional Review Board approved this study (IRB No. 202300507B0). The need for consent to participate was waived by Chang Gung Medical Foundation Institutional Review Board. Consent for publication Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Acknowledgements Not applicable. References Ye P, Xi Y, Huang Z, Xu P (2020) Linking Obesity with Colorectal Cancer: Epidemiology and Mechanistic Insights. Cancers (Basel). ;12(6) Martinez-Useros J, Garcia-Foncillas J (2016) Obesity and colorectal cancer: molecular features of adipose tissue. J Transl Med 14:21 Ri M, Aikou S, Seto Y (2018) Obesity as a surgical risk factor. 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A prospective comparative assessment in our center. Surg Endosc 27(7):2613–2618 Allaix ME, Degiuli M, Bonino MA, Arezzo A, Mistrangelo M, Passera R et al (2019) Intracorporeal or Extracorporeal Ileocolic Anastomosis After Laparoscopic Right Colectomy: A Double-blinded Randomized Controlled Trial. Ann Surg 270(5):762–767 Marchesi F, Pinna F, Percalli L, Cecchini S, Ricco M, Costi R et al (2013) Totally laparoscopic right colectomy: theoretical and practical advantages over the laparo-assisted approach. J Laparoendosc Adv Surg Tech A 23(5):418–424 2022 Health Promotion Administration Annual Report Health Promotion Administration, Ministry of Health and Welfare, Taiwan: Chao-Chun Wu Vignali A, De Nardi P, Ghirardelli L, Di Palo S, Staudacher C (2013) Short and long-term outcomes of laparoscopic colectomy in obese patients. World J Gastroenterol 19(42):7405–7411 Scatizzi M, Kroning KC, Borrelli A, Andan G, Lenzi E, Feroci F (2010) Extracorporeal versus intracorporeal anastomosis after laparoscopic right colectomy for cancer: a case-control study. World J Surg 34(12):2902–2908 Arredondo Chaves J, Pastor Idoate C, Baixauli Fons J, Bellver Oliver M, Pedano Rodríguez N, Bueno Delgado Á et al (2011) A case-control study of extracorporeal versus intracorporeal anastomosis in patients subjected to right laparoscopic hemicolectomy. Cirugía Española (English Edition) 89(1):24–30 Milone M, Angelini P, Berardi G, Burati M, Corcione F, Delrio P et al (2018) Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients. Surg Endosc 32(8):3467–3473 Vignali A, Elmore U, Lemma M, Guarnieri G, Radaelli G, Rosati R (2018) Intracorporeal versus Extracorporeal Anastomoses Following Laparoscopic Right Colectomy in Obese Patients: A Case-Matched Study. Dig Surg 35(3):236–242 Bollo J, Turrado V, Rabal A, Carrillo E, Gich I, Martinez MC et al (2020) Randomized clinical trial of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy (IEA trial). Br J Surg 107(4):364–372 Feroci F, Lenzi E, Garzi A, Vannucchi A, Cantafio S, Scatizzi M (2013) Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis. Int J Colorectal Dis 28(9):1177–1186 Cirocchi R, Trastulli S, Farinella E, Guarino S, Desiderio J, Boselli C et al (2013) Intracorporeal versus extracorporeal anastomosis during laparoscopic right hemicolectomy - systematic review and meta-analysis. Surg Oncol 22(1):1–13 Kalff JC, Schraut WH, Simmons RL, Bauer AJ (1998) Surgical manipulation of the gut elicits an intestinal muscularis inflammatory response resulting in postsurgical ileus. Ann Surg 228(5):652–663 Mishra A, Keeler BD, Maxwell-Armstrong C, Simpson JA, Acheson AG (2014) The influence of laparoscopy on incisional hernia rates: a retrospective analysis of 1057 colorectal cancer resections. Colorectal Dis 16(10):815–821 Seo GH, Choe EK, Park KJ, Chai YJ (2018) Incidence of Clinically Relevant Incisional Hernia After Colon Cancer Surgery and Its Risk Factors: A Nationwide Claims Study. World J Surg 42(4):1192–1199 Park AE, Roth JS, Kavic SM (2006) Abdominal wall hernia. Curr Probl Surg 43(5):326–375 Aquina CT, Rickles AS, Probst CP, Kelly KN, Deeb AP, Monson JR et al (2015) Visceral obesity, not elevated BMI, is strongly associated with incisional hernia after colorectal surgery. Dis Colon Rectum 58(2):220–227 Benlice C, Stocchi L, Costedio MM, Gorgun E, Kessler H (2016) Impact of the Specific Extraction-Site Location on the Risk of Incisional Hernia After Laparoscopic Colorectal Resection. Dis Colon Rectum 59(8):743–750 Lee L, Abou-Khalil M, Liberman S, Boutros M, Fried GM, Feldman LS (2017) Incidence of incisional hernia in the specimen extraction site for laparoscopic colorectal surgery: systematic review and meta-analysis. Surg Endosc 31(12):5083–5093 Grieco M, Cassini D, Spoletini D, Soligo E, Grattarola E, Baldazzi G et al (2019) Intracorporeal Versus Extracorporeal Anastomosis for Laparoscopic Resection of the Splenic Flexure Colon Cancer: A Multicenter Propensity Score Analysis. Surg Laparoscopy Endoscopy Percutaneous Techniques 29(6):483–488 Wang LM, Jong BK, Liao CK, Kou YT, Chern YJ, Hsu YJ et al (2022) Comparison of short-term and medium-term outcomes between intracorporeal anastomosis and extracorporeal anastomosis for laparoscopic left hemicolectomy. World J Surg Oncol 20(1):270 Hamamoto H, Suzuki Y, Takano Y, Kuramoto T, Ishii M, Osumi W et al (2022) Medium-term oncological outcomes of totally laparoscopic colectomy with intracorporeal anastomosis for right-sided and left-sided colon cancer: propensity score matching analysis. BMC Surg 22(1):345 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Jul, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 10 Jun, 2025 Reviews received at journal 06 Jun, 2025 Reviews received at journal 31 May, 2025 Reviewers agreed at journal 31 May, 2025 Reviewers agreed at journal 18 May, 2025 Reviewers invited by journal 06 May, 2025 Editor assigned by journal 06 May, 2025 Submission checks completed at journal 06 May, 2025 First submitted to journal 03 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-6582982","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":452862076,"identity":"821e310a-fc81-497a-b51f-d5a208da4f20","order_by":0,"name":"Feng-Ching Tsai","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Feng-Ching","middleName":"","lastName":"Tsai","suffix":""},{"id":452862077,"identity":"c667b123-03e5-4d2b-ac67-1711f7934267","order_by":1,"name":"Yih-Jong Chern","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yih-Jong","middleName":"","lastName":"Chern","suffix":""},{"id":452862078,"identity":"a98c8f86-dc73-47e2-9d62-a3b2b0c5cf40","order_by":2,"name":"Yu-Jen Hsu","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yu-Jen","middleName":"","lastName":"Hsu","suffix":""},{"id":452862079,"identity":"08fc4269-f35c-4972-9016-81151ea5ae7f","order_by":3,"name":"Chun-Kai Liao","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Chun-Kai","middleName":"","lastName":"Liao","suffix":""},{"id":452862080,"identity":"96ef33aa-93f9-4077-8bc5-3f6139b96899","order_by":4,"name":"Ching-Chung Cheng","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ching-Chung","middleName":"","lastName":"Cheng","suffix":""},{"id":452862081,"identity":"bbd52311-7b91-43ec-87a6-56e191ae7a56","order_by":5,"name":"Wen-Sy Tsai","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Wen-Sy","middleName":"","lastName":"Tsai","suffix":""},{"id":452862082,"identity":"ba58fc3f-ff06-4acf-b0a9-80855d1bcc8e","order_by":6,"name":"Pao-Shiu Hsieh","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Pao-Shiu","middleName":"","lastName":"Hsieh","suffix":""},{"id":452862083,"identity":"2c27023b-7dad-4759-b9b7-71d2c2e1c779","order_by":7,"name":"Jeng-Fu You","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYBACxgYgwQNmMh8AEhIypGhhSwBp4SHOKogyHgMEGx9gbu89+OBtW509v0TO51c3aix4GNgPH92A12E955IN57YdTpw5I3ebdc4xoMN40tJu4NUyI8dMmrftQILBjdxtxjlsQC0SPGb4tcx/A9JSZ29/I+eZcc4/YrTM4AFpYWbcIJHD/Di3jRgtPTnGhnPOHU6cceaZGXNunwQPGyG/GLafMXzwpgwYYu3Jjz/nfKuT42c/fAy/lgaQVWxAQiCBTQIkwoZPOQjIg8k/QMx/gPkDIdWjYBSMglEwMgEAJKBG9sMFBK8AAAAASUVORK5CYII=","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Jeng-Fu","middleName":"","lastName":"You","suffix":""}],"badges":[],"createdAt":"2025-05-03 08:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6582982/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6582982/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-025-03805-6","type":"published","date":"2025-07-11T15:58:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82583087,"identity":"0393195e-4d2e-4d48-9f96-48a01763118a","added_by":"auto","created_at":"2025-05-13 06:48:14","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":205681,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Population Flowchart\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6582982/v1/8ad090ee01191d829266817d.jpeg"},{"id":82583085,"identity":"a85a4007-c5cd-4b1e-9a56-21d2e5bfe4d8","added_by":"auto","created_at":"2025-05-13 06:48:14","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":107515,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier analysis between patients with obesity undergoing intracorporeal and extracorporeal anastomosis. \u003cstrong\u003ea \u003c/strong\u003e3-Year overall survival;\u003cstrong\u003e b \u003c/strong\u003e3-Year disease-free survival.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6582982/v1/546bd18b27be338edec0310e.jpeg"},{"id":86700491,"identity":"79d1a154-e738-4a6a-84a5-e1acf219afc5","added_by":"auto","created_at":"2025-07-14 16:12:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1091667,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6582982/v1/9eba094c-41c5-416c-97c5-99e74435ce88.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Outcomes of Intracorporeal and Extracorporeal Anastomosis Following Laparoscopic Colectomy in Patients with Obesity with Colon Cancer","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObesity constitutes a growing public health concern, particularly in industrialized countries, and correlates with an increased incidence of colorectal cancer (CRC) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Obese individuals often present with additional comorbidities that can elevate the likelihood of complications following gastrointestinal tumor surgery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Compared with their nonobese counterparts, these individuals face an increased risk for postoperative complications, such as wound healing and cardiopulmonary functions. Additionally, reports indicate that the duration of surgical procedures tends to be significantly longer for patients with obesity, possibly due to the technical challenges inherent in operating on this population (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLaparoscopic surgery for treating CRC has gained widespread acceptance to become a standard course of treatment since it was initially reported on in 1991; its safety and efficacy has been supported by numerous large-scale clinical trials over the past three decades (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This surgical approach offers multiple advantages over traditional open surgery. It is minimally invasive and often leads to smaller incisions, less postoperative pain, shorter hospital stays, quicker recovery periods, improved cosmetic outcomes, and fewer complications. Laparoscopic surgery has been found to have equally effective long-term outcomes compared with open surgery (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Laparoscopic colectomy is associated with shorter hospital stay, surgical site complications, and a quicker return to normal activities; this is so even for patients with obesity, who are generally more susceptible to surgical site infections and pulmonary embolism (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdvances in medical technology and clinician skill have led to increased use of total laparoscopic surgery with intracorporeal anastomosis (IA), which requires only a small laparotomy for specimen extraction. This approach is thought to be less invasive and often results in faster recovery periods, shorter hospital stays, and reduced morbidity rates (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Although IA has garnered attention for its benefits, studies have disagreed on the difference in surgical duration between IA and extracorporeal anastomosis (EA). Some studies have indicated that IA is associated with a significantly longer duration of surgery (DoS) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Most other studies have found no significant difference in duration of surgery between IA and EA (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Furthermore, one study reported that clinicians face a learning curve in mastering the technique for IA (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). At present, no study has determined whether increased operative time contributes to surgical and anesthesia risk in patients with obesity. Moreover, whether IA is superior to EA in short-term and long-term outcomes in patients with obesity remains unknown.\u003c/p\u003e \u003cp\u003eDespite the documented advantages of total laparoscopic surgery using IA, limited research exists on its feasibility and advantages in specific populations, such as those who are morbidly obese. This study, conducted in a single teaching hospital, aimed to address these gaps by evaluating both the short-term and medium-term outcomes of IA and EA in patients with general obesity.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eStudy Design and Population\u003c/p\u003e \u003cp\u003eThis retrospective study systematically collected data on clinicopathological variables from the Colorectal Section Tumor Registry of Chang Gung Memorial Hospital (CGMH). The Institutional Review Board of CGMH approved this study (IRB No. 202300507B0). This study enrolled patients who had a body mass index (BMI) greater than or equal to 27 kg/m\u003csup\u003e2\u003c/sup\u003e and underwent laparoscopic radical colectomy with primary bowel anastomosis for colon cancer. The tumors included in this study were in anatomical regions ranging from the cecum to the descending colon. The data spanned the September 2007 to December 2021 period. We excluded patients who underwent anterior resection with circular stapling anastomosis, patients whose procedure was converted to open surgery, and patients who had a diverting ostomy created.\u003c/p\u003e \u003cp\u003eVariables and Outcome Measurement\u003c/p\u003e \u003cp\u003eThe study collected data on a variety of patient-related characteristics, namely age, gender, body weight, BMI, American Society of Anesthesiologists (ASA) classification, and underlying medical conditions\u0026mdash;such as hypertension, heart disease, cerebrovascular accidents, asthma, diabetes mellitus, peptic ulcers, and hepatitis. Preoperative blood analyses included tests for carcinoembryonic antigen (CEA), hemoglobin (Hb), white blood cells, and albumin. Factors pertaining to the tumor were the depth of tumor invasion (T stage), the extent of lymph node involvement (N stage), the number of lymph nodes harvested, the location of the tumor, and the size of the tumor. Additionally, operation-related variables such as the technique of the surgery, the duration of the operation, the volume of blood loss, the type and technique of anastomosis, and the site of the extraction wound were evaluated.\u003c/p\u003e \u003cp\u003eThe definition of obesity for this study was based on guidelines from Taiwan's Ministry of Health and Welfare (BMI\u0026thinsp;\u0026ge;\u0026thinsp;27 kg/m\u003csup\u003e2\u003c/sup\u003e) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The definition is according to the findings of local statistics to avoid underestimation of the health hazards associated with obesity in Asian populations. This deviates from the World Health Organization's definition of obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e), which is primarily applicable to European-origin populations rather than East Asian\u0026ndash;origin ones.\u003c/p\u003e \u003cp\u003eThe surgical procedures in the study encompassed right hemicolectomy, transverse colectomy, left hemicolectomy, and different segmental resections. Methods employed for bowel anastomosis included hand-sewing, entire stapling, and a combination of hand-sewing and stapling techniques. Specimens were extracted through mini-laparotomies at different sites including the umbilicus, McBurney point, Pfannenstiel, and natural orifice.\u003c/p\u003e \u003cp\u003eShort-term outcomes included postoperative morbidity and mortality, pain scale assessment, postoperative recovery, and the length of the postoperative hospital stay. Pain intensity was quantified using a numeric rating scale (NRS) ranging from 0 to 10, where a score of 10 indicated the most severe pain. The mean postoperative pain scores were subsequently used for further evaluation. Midterm outcomes included the incidence of incisional hernia and overall survival rates. Both overall survival (OS) and disease-free survival (DFS) were used to assess survival. The endpoint for OS was defined as death from any cause, and the endpoints for DFS were death from any cause or recurrence.\u003c/p\u003e \u003cp\u003eSurgical Techniques of Anastomosis: Extracorporeal anastomosis (EA) and Intracorporeal anastomosis (IA)\u003c/p\u003e \u003cp\u003eFollowing complete division of the bowel designated for resection, anastomosis was achieved through either EA or IA, depending on the clinical judgement of the surgeon. For the EA group, a mini-laparotomy was conducted primarily along the midline. Surgeons extracted the specimen through this wound and performed the anastomosis using either hand-sewing or staplers. For the IA group, anastomosis was conducted inside the abdominal cavity, with the use of either a stapler, hand-sewing, or a combination of both methods. The specimen was subsequently extracted through a mini-laparotomy (using either a midline, Pfannenstiel incision, or right lower quadrant) or through a transrectal method for natural orifice specimen extraction.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll analyses were conducted using IBM SPSS Statistics software, Version 24.0 (Armonk, NY: IBM). Clinicopathological features with categorical variables were represented as frequencies and percentages and compared using the chi-square test. Analyses of continuous variables were given as means and standard deviations, with the Student t-test providing the statistical analysis. DFS and OS were assessed using Kaplan\u0026ndash;Meier survival curves. Comparisons between different groups were made using the log-rank test. The statistical significance threshold was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 377 patients with obesity with CRC who underwent minimally invasive radical resection, 22 were excluded due to the use of circular staples, conversion to open surgery, and the formation of a concomitant diverting ostomy. The remaining 355 patients were divided into two groups based on the anastomosis technique: 150 patients (43.7%) received IA, and 205 patients (57.7%) received EA.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographics and clinical characteristics of the patients with obesity. The IA and EA groups did not significantly differ in age, sex ratio, BMI, or the rate of patients with a BMI of 30 or greater. However, the IA group had a greater proportion of patients with higher ASA classifications compared with the EA group (84.0% in ASA III for IA compared with 63.9% for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Preoperative laboratory data\u0026mdash;including CEA, hemoglobin, white blood cell count, and albumin levels\u0026mdash;and underlying medical conditions did not significantly differ between the two groups. Similarly, tumor characteristics such as location and cancer stage were comparable between both groups.\u003c/p\u003e \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographics and clinical characteristics of patients with obesit undergoing intracorporeal and extracorporeal anastomosis\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eIA\u003csup\u003ea\u003c/sup\u003e(n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eEA\u003csup\u003eb\u003c/sup\u003e(n\u0026thinsp;=\u0026thinsp;205)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e63.91\u0026thinsp;\u0026plusmn;\u0026thinsp;12.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e64.78\u0026thinsp;\u0026plusmn;\u0026thinsp;12.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e77(51.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e105(51.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.983\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e29.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e29.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.836\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e57(38.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e76(37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e68(45.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e85(54.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eASA\u003csup\u003ec\u003c/sup\u003e Classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e24(16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e74 (36.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e126(84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e131(63.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-op Lab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCEA\u003csup\u003ed\u003c/sup\u003e\u0026ge;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e49(32.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e50(24.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e12.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e12.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.955\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWBC\u003csup\u003ee\u003c/sup\u003e (/\u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e7308\u0026thinsp;\u0026plusmn;\u0026thinsp;2220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e7478\u0026thinsp;\u0026plusmn;\u0026thinsp;2102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.462\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlbumin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e4.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e4.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical Illness, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e91 (60.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e130 (63.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.658\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e16(10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e28(13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.470\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCVA\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e6(4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e11(5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.622\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsthma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e4 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e6 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e47(31.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e60(29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.726\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeptic Ulcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e9(6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e14(6.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.829\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHepatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e7(2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e10(4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.410\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eTumor Location, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eCecum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e28(18.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e20(9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eAscending Colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e53(35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e88(42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eHepatic Flexure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e46(30.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e56(27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eTransverse Colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e3(2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e9(4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eSplenic Flexure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e6(4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e11(5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eDescending Colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e14(9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e21(10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCancer Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e0.669\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e40(26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e59(28.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e45(30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e60(30.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e47(31.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e58(28.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e15(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e16(7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eIntra-Corporeal Anastomosis\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003eExtra-Corporeal Anastomosis\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ec\u003c/sup\u003eAmerican Society of Anesthesiologist\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ed\u003c/sup\u003eCaricinoembryonic Antigen\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ee\u003c/sup\u003eWhite Blood Cell\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ef\u003c/sup\u003eCerebrovascular Accident\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e lists the operative variables and pathological parameters. Right hemicolectomy was the most significant surgical procedure in both groups. The operation time was significantly longer in the IA group compared with the EA group (261.5 min for IA compared with 242.2 min for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.024). Anastomosis in the IA group was predominantly conducted using a hybrid of stapling and hand-sewing methods (88.7%). Conversely, hand-sewing (47.8%) and the exclusive use of staplers (52.2%) were the most prevalent methods in the EA group. Regarding the ​​extraction sites, the EA group predominantly had an umbilical midline wound (99.5%), whereas the IA group featured a diversity of approaches, namely umbilicus (42.7%), Pfannenstiel incision (41.3%), and natural orifice specimen extraction (15.3%). Both groups had similar tumor sizes and numbers of resected lymph nodes. However, the IA group had a significantly longer specimen length (27.3 cm for IA compared with 23.5 cm for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and a greater nearest margin of tumor (8.0 cm for IA compared with 6.7 cm for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Advanced T stages were more common in the IA group, whereas the N stages were similar in both 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\u003eOperative variables and pathological parameters of patients with obesity undergoing intracorporeal and extracorporeal anastomosis\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\u003eIA\u003csup\u003ea\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEA\u003csup\u003eb\u003c/sup\u003e (n\u0026thinsp;=\u0026thinsp;205)\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, n(%)\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\u003e0.207\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight Hemicoletomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e152 (74.1%)\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\u003eOther colectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53(25.9)\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\u003eOperative Time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e261.51\u0026thinsp;\u0026plusmn;\u0026thinsp;82.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e242.24\u0026thinsp;\u0026plusmn;\u0026thinsp;76.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.63\u0026thinsp;\u0026plusmn;\u0026thinsp;82.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.54\u0026thinsp;\u0026plusmn;\u0026thinsp;53.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.217\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomosis\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\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHand-sew\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98 (47.8%)\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\u003eTotal stapled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (52.2%)\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\u003eStaple\u0026thinsp;+\u0026thinsp;Suture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133 (88.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\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\u003eExtraction Site, n(%)\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\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUmbilicus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (42.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e204 (99.5%)\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\u003ePfannenstiel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (41.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0.0%)\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\u003eNOSE\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(15.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0.0%)\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\u003eMcBurney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.5%)\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\u003eHarvested Lymph Node\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.72\u0026thinsp;\u0026plusmn;\u0026thinsp;16.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.40\u0026thinsp;\u0026plusmn;\u0026thinsp;17.208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecimen Length (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.30\u0026thinsp;\u0026plusmn;\u0026thinsp;9.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.53\u0026thinsp;\u0026plusmn;\u0026thinsp;8.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNearest Margin (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.04\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Size\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\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Width (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.21\u0026thinsp;\u0026plusmn;\u0026thinsp;6.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Length (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.351\u0026thinsp;\u0026plusmn;\u0026thinsp;1.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.63\u0026thinsp;\u0026plusmn;\u0026thinsp;6.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.619\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT stage, n(%)\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\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(4.4%)\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\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31(20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(16.6%)\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\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35(17.1%)\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\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75(50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99(48.3%)\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\u003eT4a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(15.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(13.2%)\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\u003eT4b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.5%)\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\u003eN stage, n(%)\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\u003e0.920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93(62.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135(65.9%)\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\u003eN1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22(14.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(10.7%)\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\u003eN1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(8.3%)\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\u003eN1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.5%)\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\u003eN2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(5.4%)\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\u003eN2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eIntra-Corporeal Anastomosis \u003c/p\u003e \u003cp\u003e\u003csup\u003eb\u003c/sup\u003eExtra-Corporeal Anastomosis \u003c/p\u003e \u003cp\u003e\u003csup\u003ec\u003c/sup\u003eNatural Orifice specimen extraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e displays the postoperative outcomes of patients receiving IA as opposed to those receiving EA. NRS scores for pain severity and postoperative laboratory markers (white blood cell and C-reactive protein levels) did not significantly differ between the two groups. However, the IA group exhibited significantly shorter durations for the passage of flatus (2.3 days for IA compared with 2.8 days for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.012) and stool (3.6 days for IA compared with 4.7 days for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Time to resume diet was also shorter in the IA group compared with the EA group. The average length of postoperative hospital stay was significantly shorter in the IA group (7.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 days for IA compared with 9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9 days in EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.004), and a higher proportion of patients in the IA group had a hospital stay shorter than 5 days (42.7% for IA compared with 14.6% for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). In terms of postoperative complications, the overall rate was significantly higher in the EA group (4.0% for IA compared with 10.2% for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.028). Specifically, the incidence of postoperative ileus was significant higher in the EA group (0% for IA compared with 4.4% for EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.028). Conversely, the rates of intraabdominal infection and anastomosis leakage showed no significant differences between the two groups. With regard to complications graded above Clavien\u0026ndash;Dindo classification grade III, no significant differences were observed between the two groups. Rates of incisional hernia at the specimen extraction site were also similar.\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\u003ePost-operative outcomes and complications of patients with obesity undergoing intracorporeal and extracorporeal anastomosis\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\u003eIA\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEA\u003csup\u003eb\u003c/sup\u003e\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\u003ePOD\u003csup\u003ec\u003c/sup\u003e1 NRS\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.865\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOD2 NRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOD3 NRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOD3 CRP\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.76\u0026thinsp;\u0026plusmn;\u0026thinsp;52.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.46\u0026thinsp;\u0026plusmn;\u0026thinsp;62.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.322\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOD3 WBC\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.28\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlatus Passage (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStool Passage (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiquid Diet (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.16\u0026thinsp;\u0026plusmn;\u0026thinsp;5.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoft Diet (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.91\u0026thinsp;\u0026plusmn;\u0026thinsp;5.62\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\u003eHospital Stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.53\u0026thinsp;\u0026plusmn;\u0026thinsp;9.928\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital Stay\u0026thinsp;\u0026le;\u0026thinsp;5 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (42.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (14.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication type\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\u003e0.174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.753\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=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.824\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrine retention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.392\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-op Ileus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIAI\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.390\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomosis leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChylus Leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.392\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavian-Dindo\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisional Hernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.425\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eIntra-Corporeal Anastomosis \u003c/p\u003e \u003cp\u003e\u003csup\u003eb\u003c/sup\u003eExtra-Corporeal Anastomosis \u003c/p\u003e \u003cp\u003e\u003csup\u003ec\u003c/sup\u003ePost-Operative Day\u003c/p\u003e \u003cp\u003e\u003csup\u003ed\u003c/sup\u003eNumerical Rating Scale\u003c/p\u003e \u003cp\u003e\u003csup\u003ee\u003c/sup\u003eC-Reactive Protein \u003c/p\u003e \u003cp\u003e\u003csup\u003ef\u003c/sup\u003eWhite Blood Cell \u003c/p\u003e \u003cp\u003e\u003csup\u003eg\u003c/sup\u003eIntra-Abdominal Infection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe median follow-up time was 27.2 months for the IA group and 62.6 months for the EA group. The 3-year OS rates were nearly identical\u0026mdash;89.9% in the IA group and 90.5% in the EA group. Likewise, the 3-year DFS rates were comparable\u0026mdash;82.7% in the IA group and 83.0% in the EA group. Survival curves for both overall (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.48, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA) and DFS curves (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.35, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB) demonstrated no differences.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this study is the largest cohort analysis exploring outcomes for patients with obesity with CRC who underwent minimally invasive radical resection, comparing outcomes of IA and EA. The study revealed that patients in the IA group experienced faster bowel recovery times, faster resumption of diet, and shorter hospital stays compared with their EA counterparts. Additionally, the IA group demonstrated longer specimen lengths and greater nearest margin of tumor. Notably, the EA group faced a higher overall rate of postoperative complications, particularly a higher incidence of postoperative ileus. Midterm oncological outcomes did not significantly differ between the IA and EA groups.\u003c/p\u003e \u003cp\u003ePerforming surgery on patients with obesity poses considerable challenges for surgeons, primarily due to the technical complexities and elevated risks associated with this population. Studies have demonstrated the safety of laparoscopic colectomy when used for patients with obesity (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Concurrent advancements in surgical instruments have contributed to the growing adoption of total laparoscopic surgery with IA, particularly given its advantages of faster recovery and shorter hospital stays, in the general population. In line with these trends, our study revealed that the IA group experienced faster bowel recovery and faster resumption of diet. These findings align with several other studies that applied to general populations undergoing right and left hemi-colectomies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). A case-matched study conducted in 2018, which focused on patients with obesity undergoing right hemicolectomy, also observed quicker recovery of bowel function (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). For patients in the EA group, the bowel containing the tumor must be maneuvered through the thick abdominal wall for transection and anastomosis. This additional manipulation of the bowel during externalization could account for the observed delays in bowel function recovery.\u003c/p\u003e \u003cp\u003eAlthough the IA group exhibited similar levels of postoperative wound pain to the EA group according to our data, the IA group experienced shorter postoperative hospital stays. Specifically, 42.7% of patients in the IA group required inpatient care for no more than 5 days. This shortened stay may be attributed to the faster recovery of bowel function observed in the IA group. Nevertheless, a limited number of randomized controlled trials (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) have compared IA with EA in the general population undergoing right hemicolectomy and found no significant difference in the length of hospital stays, despite better bowel recovery in the IA group. However, these studies have not specifically focused on patients with obesity. Given that natural orifice specimen extraction (NOSE) is associated with significantly shorter hospital stays (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and can be only performed in conjunction with IA, we conducted a subgroup analysis excluding patients who underwent NOSE. The data still indicated faster flatus passage (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.07), faster stool passage (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), shorter time to tolerate liquid diets (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.006), quicker acceptance of soft diets (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.015), and shorter hospital stays (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.021) in IA group compared with the EA group.\u003c/p\u003e \u003cp\u003eIn our patient series, the IA group exhibited fewer postoperative complications than the EA group. Notably, postoperative ileus was significantly more prevalent in the EA group, whereas no instances were observed in the IA group. A meta-analysis that compared IA to EA in a general population undergoing right hemicolectomy found no significant differences in surgical site complications and nonsurgical site complications, including ileus (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Conversely, another meta-analysis raised questions about a greater incidence of prolonged postoperative ileus in the IA group compared with the EA group, although the findings were not statistically significant (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). From our perspective, the EA necessitates more dissection to mobilize the bowel, potentially increasing bowel manipulation and subsequently eliciting an intestinal muscularis inflammatory response that results in postsurgical ileus (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Conversely, the IA group might also be at risk for postoperative ileus due to potential intraabdominal contamination during intracorporeal anastomosis and the prolonged anesthesia time resulting from longer surgical durations. Further study is warranted to address these concerns.\u003c/p\u003e \u003cp\u003eThe incidence of incisional hernia following laparoscopic colectomy varies widely in the literature, ranging from 1.4\u0026ndash;15.9% (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In our cohort, the overall incidence was 7.0%. The IA group had a slightly lower hernia rate (6.5%) compared with the EA group (8%), although the difference was not statistically significant. Obesity is known to elevate the risk of incisional hernia due to increased intraabdominal pressure (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Visceral obesity has been found to be strongly associated with incisional hernia after colorectal surgery (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and increased BMI was reported to be associated with incisional hernia after laparoscopic colorectal resection. Although our study did not demonstrate a risk reduction in the IA group, we still advocate for IA as a preferable surgical approach to minimize the risk of incisional hernia. Meta-analyses have indicated that midline incisions for specimen extraction are associated with a higher risk of incisional hernia compared with off-midline incisions (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The anatomic structure of the mesentery often dictates the use of peri-umbilical midline wound for specimen extraction in the EA group. Conversely, the IA procedure offers greater flexibility in choosing the extraction site, which could potentially decrease the rate of incisional herniation if off-midline wounds are preferred.\u003c/p\u003e \u003cp\u003eRegarding pathological outcomes, both groups had similar numbers of harvested lymph nodes. Few studies have investigated specimen length and safety margins between the IA and EA technique, and conflicting results have been presented in the literature. One trial examining right hemicolectomies in the general population found longer resected colon lengths in the IA group (25.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 in the IA compared with 22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 in the EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.026) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). However, no significant differences were observed between the IA and EA groups in a study focusing on left colectomies for splenic flexure cancer (25.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9 in the IA compared with 29.0\u0026thinsp;\u0026plusmn;\u0026thinsp;19.3 in the EA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.390) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In our cohort, the IA group had significantly longer specimen lengths and greater safety margins than the EA group. The thickness of the abdominal wall in patients with obesity may limit specimen length in the EA group because the procedure requires exteriorizing the specimen though a small laparotomy incision. Visceral fat can also obstruct a specimen as it is pulled through the laparotomy wound. Conversely, the IA technique, unencumbered by the abdominal wall and mesentery, allows for more accurate visualization of the specimen and precise resection, thereby enhancing surgical margins.\u003c/p\u003e \u003cp\u003eThe 3-year OS and 3-year DFS rates were similar between the IA and EA groups. Wang et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) reported a similar 2-year OS (95.0% compared with 93.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.747) and DFS (97.5% compared with 90.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.182) between patients who underwent IA or EA for laparoscopic left colectomy. Another study employing propensity score matching analysis between the IA and EA groups for both right- and left-sided laparoscopic colectomy found no significant difference in estimated 3-year OS and estimated 3-year DFS (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). These studies generally analyzed outcomes in a general population, whereas our study focused on the midterm outcomes in patients with obesity, a subject not previously reported.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, only one other study compared IA with EA in patients with obesity, and that study exclusively examined right hemicolectomies. Our study is the first to investigate outcomes between IA and EA in patients with obesity who underwent laparoscopic radical colectomy and primary bowel anastomosis for either right- or left-sided colon cancer. Moreover, our study enrolled the largest cohort of patients with obesity who have undergone entirely minimally invasive colectomies. We are also the first to compare specimen length, margin distance, 3-year DFS, and 3-year OS between the two methods in patients with obesity. Our findings suggest that patients with obesity could derive greater benefits from the IA method without compromising oncological outcomes.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the employment of a retrospective design introduces the potential for bias between the groups under investigation. Second, the preferences of surgeons for either EA or IA contribute to the variability in the study outcomes. Surgeons, in consultation with patients and their families, determine the final surgical approach. Some surgeons exhibit a predilection for EA over IA, or vice versa, which could influence the results. Third, the findings of the study could be affected by geographic variations in the definition of obesity. Specifically, the criteria for obesity differ between Asian and Western countries, which could affect the generalizability of the relationship between obesity and the chosen method of anastomosis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn patients with obesity undergoing laparoscopic colectomy for CRC, the IA method is advantageous for its faster bowel function recovery, shorter duration of hospital stays, and reduced rate of postoperative complications. From a pathological standpoint, IA enables the extraction of longer specimens and achieves greater nearest margins, yet maintains comparable numbers of harvested lymph nodes. Patients who underwent IA procedures demonstrated outcomes compatible with those who underwent EA. These comparable outcomes spanned multiple dimensions, including 3-year OS rates, 3-year DFS rates, and the incidence rates of incisional hernias. In conclusion, IA emerges as a safe and feasible surgical procedure for treating colorectal malignancies in patients with obesity, irrespective of whether the malignancy is in the right or left of the colon.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll contributing authors participated equally in the completion of this study.\u0026nbsp;\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Chang Gung Medical Research Fund (CMRPG3J1531). The funder had no role in study design and analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChang Gung Medical Foundation Institutional Review Board approved this study (IRB No. 202300507B0). The need for consent to participate was waived by Chang Gung Medical Foundation Institutional Review Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYe P, Xi Y, Huang Z, Xu P (2020) Linking Obesity with Colorectal Cancer: Epidemiology and Mechanistic Insights. Cancers (Basel). ;12(6)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinez-Useros J, Garcia-Foncillas J (2016) Obesity and colorectal cancer: molecular features of adipose tissue. J Transl Med 14:21\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRi M, Aikou S, Seto Y (2018) Obesity as a surgical risk factor. Ann Gastroenterol Surg 2(1):13\u0026ndash;21\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTjeertes EK, Hoeks SE, Beks SB, Valentijn TM, Hoofwijk AG, Stolker RJ (2015) Obesity\u0026ndash;a risk factor for postoperative complications in general surgery? BMC Anesthesiol 15:112\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoban PS, Flancbaum L (1997) The impact of obesity on surgical outcomes: a review. 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Ann Surg 246(4):655\u0026ndash;662 discussion 62\u0026thinsp;\u0026ndash;\u0026thinsp;4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM et al (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365(9472):1718\u0026ndash;1726\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu YL, Hsu YJ, Liao CK, Lin YC, You JF, Tsai WS et al (2022) Advantage of laparoscopic surgery in patients with generalized obesity operated for colorectal malignancy: A retrospective cohort study. Front Surg 9:1062746\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiao CK, Chern YJ, Lin YC, Hsu YJ, Chiang JM, Tsai WS et al (2021) Short- and medium-term outcomes of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a propensity score-matched study. World J Surg Oncol 19(1):6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapiro R, Keler U, Segev L, Sarna S, Hatib K, Hazzan D (2016) Laparoscopic right hemicolectomy with intracorporeal anastomosis: short- and long-term benefits in comparison with extracorporeal anastomosis. Surg Endosc 30(9):3823\u0026ndash;3829\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmile SH, Elfeki H, Shalaby M, Sakr A, Bassuni M, Christensen P et al (2019) Intracorporeal versus extracorporeal anastomosis in minimally invasive right colectomy: an updated systematic review and meta-analysis. Tech Coloproctol 23(11):1023\u0026ndash;1035\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMagistro C, Lernia SD, Ferrari G, Zullino A, Mazzola M, De Martini P et al (2013) Totally laparoscopic versus laparoscopic-assisted right colectomy for colon cancer: is there any advantage in short-term outcomes? A prospective comparative assessment in our center. Surg Endosc 27(7):2613\u0026ndash;2618\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllaix ME, Degiuli M, Bonino MA, Arezzo A, Mistrangelo M, Passera R et al (2019) Intracorporeal or Extracorporeal Ileocolic Anastomosis After Laparoscopic Right Colectomy: A Double-blinded Randomized Controlled Trial. Ann Surg 270(5):762\u0026ndash;767\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarchesi F, Pinna F, Percalli L, Cecchini S, Ricco M, Costi R et al (2013) Totally laparoscopic right colectomy: theoretical and practical advantages over the laparo-assisted approach. J Laparoendosc Adv Surg Tech A 23(5):418\u0026ndash;424\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2022 Health Promotion Administration Annual Report Health Promotion Administration, Ministry of Health and Welfare, Taiwan: Chao-Chun Wu\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVignali A, De Nardi P, Ghirardelli L, Di Palo S, Staudacher C (2013) Short and long-term outcomes of laparoscopic colectomy in obese patients. World J Gastroenterol 19(42):7405\u0026ndash;7411\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScatizzi M, Kroning KC, Borrelli A, Andan G, Lenzi E, Feroci F (2010) Extracorporeal versus intracorporeal anastomosis after laparoscopic right colectomy for cancer: a case-control study. World J Surg 34(12):2902\u0026ndash;2908\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArredondo Chaves J, Pastor Idoate C, Baixauli Fons J, Bellver Oliver M, Pedano Rodr\u0026iacute;guez N, Bueno Delgado \u0026Aacute; et al (2011) A case-control study of extracorporeal versus intracorporeal anastomosis in patients subjected to right laparoscopic hemicolectomy. Cirug\u0026iacute;a Espa\u0026ntilde;ola (English Edition) 89(1):24\u0026ndash;30\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilone M, Angelini P, Berardi G, Burati M, Corcione F, Delrio P et al (2018) Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients. Surg Endosc 32(8):3467\u0026ndash;3473\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVignali A, Elmore U, Lemma M, Guarnieri G, Radaelli G, Rosati R (2018) Intracorporeal versus Extracorporeal Anastomoses Following Laparoscopic Right Colectomy in Obese Patients: A Case-Matched Study. Dig Surg 35(3):236\u0026ndash;242\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBollo J, Turrado V, Rabal A, Carrillo E, Gich I, Martinez MC et al (2020) Randomized clinical trial of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy (IEA trial). Br J Surg 107(4):364\u0026ndash;372\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeroci F, Lenzi E, Garzi A, Vannucchi A, Cantafio S, Scatizzi M (2013) Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis. 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Dis Colon Rectum 58(2):220\u0026ndash;227\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenlice C, Stocchi L, Costedio MM, Gorgun E, Kessler H (2016) Impact of the Specific Extraction-Site Location on the Risk of Incisional Hernia After Laparoscopic Colorectal Resection. Dis Colon Rectum 59(8):743\u0026ndash;750\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee L, Abou-Khalil M, Liberman S, Boutros M, Fried GM, Feldman LS (2017) Incidence of incisional hernia in the specimen extraction site for laparoscopic colorectal surgery: systematic review and meta-analysis. Surg Endosc 31(12):5083\u0026ndash;5093\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrieco M, Cassini D, Spoletini D, Soligo E, Grattarola E, Baldazzi G et al (2019) Intracorporeal Versus Extracorporeal Anastomosis for Laparoscopic Resection of the Splenic Flexure Colon Cancer: A Multicenter Propensity Score Analysis. Surg Laparoscopy Endoscopy Percutaneous Techniques 29(6):483\u0026ndash;488\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang LM, Jong BK, Liao CK, Kou YT, Chern YJ, Hsu YJ et al (2022) Comparison of short-term and medium-term outcomes between intracorporeal anastomosis and extracorporeal anastomosis for laparoscopic left hemicolectomy. World J Surg Oncol 20(1):270\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamamoto H, Suzuki Y, Takano Y, Kuramoto T, Ishii M, Osumi W et al (2022) Medium-term oncological outcomes of totally laparoscopic colectomy with intracorporeal anastomosis for right-sided and left-sided colon cancer: propensity score matching analysis. BMC Surg 22(1):345\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":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Laparoscopic surgery, Obesity, Intracorporeal anastomosis, Colectomy","lastPublishedDoi":"10.21203/rs.3.rs-6582982/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6582982/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eLaparoscopic surgery with intracorporeal anastomosis (IA) is a well-established procedure in colorectal cancer surgery. Nonetheless, its feasibility in patients with obesity remains unclear. This study aimed to evaluate the short-term and medium-term outcomes of IA to extracorporeal anastomosis (EA) among a cohort of patients with general obesity treated at a single teaching hospital.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study included patients with obesity who underwent laparoscopic radical colectomy with primary bowel anastomosis for colon cancer between September 2007 and December 2021. Patients were split into two groups according to the method of anastomosis used: EA or IA. We evaluated various surgical outcomes, namely postoperative complications, recovery metrics, pain intensity, and 3-year survival rates.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 355 patients with obesity with colorectal cancer were enrolled in the study. 150 and 205 patients were in the IA and EA groups, respectively. The IA group demonstrated faster bowel recovery, faster resumption of diet, and shorter hospital stays compared with the EA group. Additionally, IA yielded specimens with longer lengths and larger safety margins relative to the tumor. The EA group exhibited a significantly higher overall rate of postoperative complications, most notably postoperative ileus. However, the 3-year oncological outcomes were similar between the IA and EA groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study revealed that in patients with obesity, IA resulted in faster bowel function recovery, shorter hospital stays, and fewer complications. Furthermore, IA produced better pathological outcomes, characterized by longer specimen lengths and wider safety margins, without compromising 3-year overall and disease-free survival rates. Thus, IA is a safe and feasible anastomosis technique for patients with obesity undergoing laparoscopic colectomy for colorectal cancer.\u003c/p\u003e","manuscriptTitle":"Comparative Outcomes of Intracorporeal and Extracorporeal Anastomosis Following Laparoscopic Colectomy in Patients with Obesity with Colon Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 06:48:10","doi":"10.21203/rs.3.rs-6582982/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-10T19:43:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-07T01:50:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-01T01:08:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"278471866117648869621196628667350340624","date":"2025-05-31T20:28:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293169436052897131731788445101770631952","date":"2025-05-18T23:19:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-06T19:05:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-06T14:04:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-06T09:32:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2025-05-03T08:33:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"95e8642c-6732-4d77-bf2d-081aa935c781","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T16:11:32+00:00","versionOfRecord":{"articleIdentity":"rs-6582982","link":"https://doi.org/10.1007/s00423-025-03805-6","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2025-07-11 15:58:01","publishedOnDateReadable":"July 11th, 2025"},"versionCreatedAt":"2025-05-13 06:48:10","video":"","vorDoi":"10.1007/s00423-025-03805-6","vorDoiUrl":"https://doi.org/10.1007/s00423-025-03805-6","workflowStages":[]},"version":"v1","identity":"rs-6582982","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6582982","identity":"rs-6582982","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}