Britishwww.147qqq

CORRESPONDENCEOpenAccessHightieversuslowtieoftheinferiormesentericartery:aprotocolforasystematicreviewRobertoCirocchi1*,EribertoFarinella1,StefanoTrastulli1,JacopoDesiderio1,GiorgioDiRocco2,PieroCovarelli3,AlbertoSantoro2,GiammarioGiustozzi1,AdrianoRedler2,NicolaAvenia3,AntonioRulli3,GiuseppeNoya3andCarloBoselli3AbstractInanteriorresectionofrectum,thesectionlevelofinferiormesentericarteryisstillsubjectofcontroversybetweentheadvocatesofhighandlowtie.
Thelowtieisthedivisionandligationtothebranchingoftheleftcolicarteryandthehightieisthedivisionandligationatitsoriginattheaorta.
Weintendtoassesscurrentscientificevidenceinliteratureandtoestablishthedifferencescomparingtechnique,anatomyandphysiology.
Theaimofthisprotocolistoachieveameta-analysisthattestssafetyandfeasibilityofthetwoprocedureswithseveraltypesofoutcomemeasures.
BackgroundNowadayssurgeryforrectalcancer(anteriorresectionorabdomino-perinealamputation)hasbeenwellstandar-dizedbothwaysinopenandlaparoscopicapproach[1].
Inpointofthefact,therearestilldisputesregardingthelevelhowtoexecutethesectionoftheinferiormesentericartery(IMA):theoriginfromtheaorta(hightie,Figure1and2)orbelowtheoriginoftheleftcolicartery(lowtie,Figure3and4)[2].
ThealternativetothesectionoftheIMAisitspreservation,adducedbyVal-doni[3];thistechniquehasbeenabdicatedbymostsur-geonsbecauseitdoesnotseemtoassurearadicalsurgeryforcancer.
In1959Dunphysuggestedamodifiedprocedureinsteadofhighligation,inwhichfattytissuesandnodesweredissectedfreeandexcisedintheanglebetweentheIMAandaorta,andthearterywasligatedbelowtheleftcolicartery;thistechniquerepresentedacompromisebetweenthehighandlowligation[4].
Overtheyears,wehaveseenaceaselessdebatebetweensurgeonsfavorabletothelow[5,6]orthehightie(Figure5)[7,8].
Nowadaysthespreadoflaparoscopyhasencouragedmorefrequentexecutionofthehightie,whichappearseasiertoachievethanthelowtie[9-13].
Thehightiealsohastheadvantageofaloweranasto-mosistraction[14,15]andthedisadvantageoftheworstvascularizationofthestumps[16-18].
Neitherofthesetechniquesassurestobesuperiortoanother,thisistheopinionoftwoexpertsandoftwoliteraturereviews[19,20].
Recentlyasystematicreviewoftheliteraturehasdisplayedasignificantadvantagetoaccomplishthehightie[21].
ObjectivesTheaimofoursystematicreviewistoappraisetherealadvantagesofthehighandlowtieoftheIMA.
MaterialsandmethodsAllaspectsofthePreferredReportingItemsforSys-tematicReviewsandMeta-analyses(PRISMA)statementwillbefollowed.
EligibilityCriteriaInclusioncriteriaWewillconsiderbothways,randomizedandnon-rando-mizedstudieswhichcomparehightie(ligationattheaor-ticorigin)versuslowtie(ligationbelowtheoriginoftheleftcolicartery)oftheIMAforsigmoidorrectalresectionforcancer.
Furthermore,inordertobeconsideredforinclusion,studieshavetoreportoutcomesforsigmoid(leftcolectomy)orrectalcancersurgery(anteriorresec-tion/sphincter-sparingsurgeryorabdomino-perineal*Correspondence:cirocchiroberto@yahoo.
itContributedequally1DepartmentofGeneralSurgery,UniversityofPerugia,St.
MariaHospital,Terni,05100,ItalyFulllistofauthorinformationisavailableattheendofthearticleCirocchietal.
WorldJournalofSurgicalOncology2011,9:147http://www.
wjso.
com/content/9/1/147WORLDJOURNALOFSURGICALONCOLOGY2011Cirocchietal;licenseeBioMedCentralLtd.
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.
org/licenses/by/2.
0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
resection)andtocomparehightieversuslowtie.
Wewillnotimposeanylanguageorpublicationstatusrestrictions.
ExclusioncriteriaforstudyThestudieswillbeexcludedfromanalysisiftheout-comesofinterestwillnotreportthetwotechniquesorwhetheritwillbenotpossibletoextrapolatethemfromthepublishedresults,alsostudieswillbeaboutbenignlesionsorinflammatoryboweldiseasewithoutadistinctgroupofpatientswithcancer.
TypesofparticipantsPatientsofanyageandsexwithsigmoidorrectalcan-cerwillbeconsidered.
TypesofsurgeryBothsigmoidorrectalresectionwithhighandlowIMAtie.
TypesofoutcomemeasuresThefollowingoutcomeswillbeobserved:PrimaryoutcomesPostoperativemorbidityOverallcoloniccancerat5yearsurvivalrateOverallrectalcancerat5yearsurvivalrateSecondaryoutcomesPostoperativemortalityAnastomoticleakageDiseasefreesurvivalcoloniccancerat5yearsurvivalrateDiseasefreesurvivalrectalcancerat5yearsurvivalrateInformationsourcesandsearchAsystematicsearchwillbeconductedin:Medline,Embase,CochraneCentralRegisterofControlledTrials,CINAHL,BioMedCentral,ScienceCitationIndexandperformedonallstudiesforpotentiallyrelevanttrialscomparinghighwithlowIMAtie.
Asecondarysearchwillbeconductedreviewingunpublishedliteraturedata-basesincluding:Greynet,SIGLE,NationalTechnologicalInformationService,BritishLibraryIntegratedcatalogue,CurrentControlledTrialsandtheCochraneCentralRegisterofControlledTrialsCombinationsofthefollowingsearchtermswillbeused:inferiormesentericartery';'lymphnode'or'lymphnodes';'colon'or'rectum';'cancer','neoplasia','tumour',or'tumor'.
Figure1evaluationofcolonandbloodsupplybeforehightieoftheinferiormesentericarteryinanteriorresectionoftherectum.
Theimageshowsthelevelandtypeofvascularligationtoperform.
Figure2colonandbloodsupplyafterhightieoftheinferiormesentericartery.
Cirocchietal.
WorldJournalofSurgicalOncology2011,9:147http://www.
wjso.
com/content/9/1/147Page2of5WewillsearchtherelatedarticleofPubMedandallreferences.
TominimizeretrievalbiaswewillperformanewmanualsearchmethodthatutilizetheGoogleScholardatabaseandmanuallysearchedsevenhigh-impactjour-nals,chosenonthebasisofthefrequencyofarticlesandonexpertopinion.
Thereferencelistsofallpotentiallyeligiblestudieswillbereviewed.
Researcherswhomayhavecarriedoutrelevantstudieswillbecontacted.
Animaltrialswillbeexcluded.
StudySelectionTwoauthors(RCandCB)willassesstitlesorabstractsofallidentifiedstudiesindependentlyandexcludealltheirrelevantones.
Fulltextarticlesofpotentiallyrele-vantstudieswillbeobtained.
Thesestudieswillbeassessindependentlyinanunblendedstandardizedman-nerbythetwoauthors(GDRandAS)astowhethertheymettheinclusioncriteriaforthisreview.
DatacollectionprocessWewilldevelopadataextractionsheet(basedontheCochraneConsumersandCommunicationReviewGroup'sdataextractiontemplate),pilottesteditontenrandomly-selectedincludedstudiesandrefineditaccordingly.
Oneauthor(ST)willextractthedatafromtheincludedstudyandthesecondauthor(GN)willchecktheextracteddata.
Disagreementswillbesolvedthroughdiscussion,ifnecessary,byinvolvinganinde-pendentthirdauthor(AR).
DataitemsThefollowinginformationwillbeextractedbyoneauthor(ST)foreachincludedtrial:-Yearandlanguageofpublication.
-Countryinwhichthetrialwasconducted.
-Yearofconductoftrial.
-Single-centerormulticentertrial.
-Characteristicsoftrialparticipants-Inclusionandexclusioncriteria.
-AlloutcomesStatisticalanalysisTwoauthors(STandEF)willperformthestatisticalana-lysisinlinewithrecommendationsfromthePRISMAFigure3colonandbloodsupplybeforelowtieoftheinferiormesentericarteryinanteriorresectionoftherectum.
It'sshownthemodetoperformthisprocedure.
Figure4colonandbloodsupplyafterlowtieoftheinferiormesentericartery.
Cirocchietal.
WorldJournalofSurgicalOncology2011,9:147http://www.
wjso.
com/content/9/1/147Page3of5statement[22]andtheCochraneHandbookforsystema-ticreviews[23].
Statisticalanalysisforcategoricalvari-ableswillbeperformedbyusingtheoddsratio(OR)assummarystatistic.
Thisratiorepresentstheoddsofanadverseeventoccurringinthehightiegroupcomparedwiththelowtie.
TheMantel-HaenszelmethodwillbeusedtocombinetheORSfortheoutcomesofinterest)[24,25].
Forcontinuousvariablesstatisticalanalysis,wewillusetheweightedmeandifference(WMD).
Anega-tiveWMDfavoredthehightiegroupandsubgroups,andtheestimatedpointoftheWMDwillbeconsideredsta-tisticallysignificantwithP70)[27].
Ifneitherrangenorothermeasureofdispersionwillbereported,itwillbeimpos-sibletoestimatethemeanandtheSDbasedonthepublisheddataandthecorrespondingcontinuousvari-ableswillbeexcludedfromthestatisticalpool.
Statisticalanalysiswillbeconductedbyusingthesta-tisticalsoftwareReviewManagerVersion5.
0.
AssessmentofqualityandbiasriskoftheincludedstudiesTwoauthorswillassesstheriskofbiasofthetrialsindependently(ST,JD)usingfortheRCTstheinstruc-tionsgivenintheCochraneHandbookforSystematicReviewsofInterventionsandforCCTsthemodifiedNewcastle-Ottawascale[28,29].
Graphicalexplorationwithfunnelplotswillbeusedtoevaluatepublicationbias[30].
StrategyfordatasynthesisAnarrativesynthesisoftheincludedstudies,riskofbiasandresultswillbeperformed.
Ifheterogeneitywillpre-sentaI2<50%willreportedtheoutcomeresultsusingarandomeffectsmeta-analysis.
Wewillconductsensi-tivityanalysesbasedonstudyquality.
DisseminationplansThearticlewillbesubmittedtoapeer-reviewedjournal.
OrganizationalaffiliationofthereviewUniversityofPerugiaAnticipatedoractualstartdate1September2011Anticipatedcompletiondate1December2011Authordetails1DepartmentofGeneralSurgery,UniversityofPerugia,St.
MariaHospital,Terni,05100,Italy.
2DepartmentofSurgicalSciences,SapienzaUniversityofRome,Rome,Italy.
3DepartmentofGeneralandOncologicSurgery,UniversityofPerugia,Perugia,Italy.
Authors'contributionsEachauthorhasparticipatedsufficientlytotakepublicresponsibilityforappropriateportionsofthecontent.
Allauthorscontributedequallytothiswork,readandapprovedthefinalmanuscript.
Figure5theimageshowsthedirectionoflymphaticdrainageoflower,middleandupperrectumandallowstoidentifythelocationofhighandlowtieareasalongtheinferiormesentericartery.
Cirocchietal.
WorldJournalofSurgicalOncology2011,9:147http://www.
wjso.
com/content/9/1/147Page4of5CompetinginterestsTheAuthorsstatethatnoneoftheauthorsinvolvedinthemanuscriptpreparationhasanyconflictsofinteresttowardsthemanuscriptitself,neitherfinancialnormoralconflicts.
Besidesnoneoftheauthorsreceivedsupportintheformofgrants,equipment,and/orpharmaceuticalitems.
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doi:10.
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:Hightieversuslowtieoftheinferiormesentericartery:aprotocolforasystematicreview.
WorldJournalofSurgicalOncology20119:147.
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