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Short-term and Long-term Outcomes Regarding Laparoscopic Versus Open Surgery for Low Rectal Cancer: A Systematic Review and Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2016; 25:286-96. [PMID: 26241295 DOI: 10.1097/sle.0000000000000178] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE It is to disclose whether the laparoscopic technique is feasible or not in the treatment of low rectal cancer. MATERIALS AND METHODS We systematically searched PubMed, Embase, Ovid, Web of Science, Science Direct, SpringerLink, EBSCO, and the Cochrane Library databases for the eligible studies. Review Manager 5.2 was used to test the heterogeneity and to evaluate the overall test performance. RESULTS Twelve studies met the final inclusion criteria (total n=2973). The pooled analyses showed, despite longer operation times, that there were significantly less blood loss, fewer transfusions, shorter times to bowel function recovery, resumed diet and hospital durations, and lower overall complication and wound infection rates. The compared results of the lymph node harvest number, distal resection margin, circumferential resection margin involvement, local and distant recurrences, disease-free survival, and overall survival were similar between both the groups. CONCLUSION Laparoscopic surgery is safe and feasible for the treatment of low rectal cancer.
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Park JS, Sakai Y, Simon NSM, Law WL, Kim HR, Oh JH, Shan HCY, Kwak SG, Choi GS. Long-Term Survival and Local Relapse Following Surgery Without Radiotherapy for Locally Advanced Upper Rectal Cancer: An International Multi-Institutional Study. Medicine (Baltimore) 2016; 95:e2990. [PMID: 27258487 PMCID: PMC4900695 DOI: 10.1097/md.0000000000002990] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Controversy remains regarding whether preoperative chemoradiation protocol should be applied uniformly to all rectal cancer patients regardless of tumor height. This pooled analysis was designed to evaluate whether preoperative chemoradiation can be safely omitted in higher rectal cancer.An international consortium of 7 institutions was established. A review of the database that was collected from January 2004 to May 2008 identified a series of 2102 patients with stage II/III rectal or sigmoid cancer (control arm) without concurrent chemoradiation. Data regarding patient demographics, recurrence pattern, and oncological outcomes were analyzed. The primary end point was the 5-year local recurrence rate.The local relapse rate of the sigmoid colon cancer (SC) and upper rectal cancer (UR) cohorts was significantly lower than that of the mid/low rectal cancer group (M-LR), with 5-year estimates of 2.5% for the SC group, 3.5% for the UR group, and 11.1% for the M-LR group, respectively. A multivariate analysis showed that tumor depth, nodal metastasis, venous invasion, and lower tumor level were strongly associated with local recurrence. The cumulative incidence rate of local failure was 90.6%, 92.5%, and 94.4% for tumors located within 5, 7, and 9 cm from the anal verge, respectively.Routine use of preoperative chemoradiation for stage II/III rectal tumors located more than 8 to 9 cm above the anal verge would be excessive. The integration of a more individualized approach focused on systemic control is warranted to improve survival in patients with upper rectal cancer.
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Affiliation(s)
- Jun Seok Park
- From the Colorectal Cancer Center (JSP, G-SC), Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea; Department of Surgery (YS), Kyoto University Hospital, Kyoto, Japan; Department of Surgery (NGSMS), The Chinese University of Hong Kong, Sha Tin, Hong Kong; Division of Colorectal Surgery (WLL), The University of Hong Kong, Pok Fu Lam, Hong Kong; Department of Surgery (HRK), Chonnam National University Hwasun Hospital and Medical School, Gwangju, Korea; Center for Colorectal Cancer (JHO), National Cancer Center Hospital, Goyang city, Korea; Department of surgery (HCYS), Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong; and Department of Medical Statistics (SGK), School of Medicine, Catholic University of Daegu, Korea
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Topographic Anatomy of the Anal Sphincter Complex and Levator Ani Muscle as It Relates to Intersphincteric Resection for Very Low Rectal Disease. Dis Colon Rectum 2016; 59:426-33. [PMID: 27050605 DOI: 10.1097/dcr.0000000000000565] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intersphincteric resection has become a widely used treatment for patients with rectal cancer. However, the detailed anatomy of the anal canal related to this procedure has remained unclear. OBJECTIVE The purpose of this study was to clarify the detailed anatomy of the anal canal. DESIGN This is a descriptive study. SETTINGS Histologic evaluations of paraffin-embedded tissue specimens were conducted at a tertiary referral hospital. PATIENTS Tissue specimens were obtained from cadavers of 5 adults and from 13 patients who underwent abdominoperineal resection for rectal cancer. MAIN OUTCOME MEASURES Sagittal sections from 9 circumferential portions of the cadaveric anal canal (histologic staining) and 3 circumferential portions from patients were studied (immunohistochemistry for smooth and skeletal muscle fibers). RESULTS Longitudinal fibers between the internal and external anal sphincters consisted primarily of smooth muscle fibers that continued from the longitudinal muscle of the rectum. The levator ani muscle attached directly to the lateral surface of the longitudinal smooth muscle of the rectum. The length of the attachment was longer in the anterolateral portion and shorter in the posterior portion of the anal canal. In the lateral and posterior portions, the levator ani muscle partially overlapped the external anal sphincter; however, there was less overlap in the anterolateral portion. In the posterior portion, thick smooth muscle was present on the surface of the levator ani muscle and it continued to the longitudinal muscle of the rectum. LIMITATIONS We observed only limited portions in some surgical specimens because of obstruction by tumors. CONCLUSIONS The levator ani muscle attaches directly to the longitudinal muscle of the rectum. The spatial relationship between the smooth and skeletal muscles differed in different portions of the anal canal. For intersphincteric resection, dissection must be performed between the longitudinal muscle of the rectum and the levator ani muscle/external anal sphincter, and the appropriate surgical lines must be selected based on the specific structural characteristics of each portion.
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Pontallier A, Denost Q, Van Geluwe B, Adam JP, Celerier B, Rullier E. Potential sexual function improvement by using transanal mesorectal approach for laparoscopic low rectal cancer excision. Surg Endosc 2016; 30:4924-4933. [PMID: 26944728 DOI: 10.1007/s00464-016-4833-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 02/15/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Preliminary results of the transanal approach for low rectal cancer suggest better oncological outcomes than the conventional laparoscopic approach. We currently report the functional results. METHODS From 2008 to 2012, 100 patients with low rectal cancer and suitable for sphincter-saving resection were randomized between transanal and laparoscopic low rectal dissection. Patients derived from this randomized trial were enrolled for functional assessment. End points were bowel function (LARS bowel and Wexner continence scores) and urogenital function (IPSS, IIEF-5 and FSFI-6 scores) obtained by questionnaires sent to patients with a follow-up more than 12 months. RESULTS Overall, 76 patients were eligible and 72 responded to the questionnaire: 38 in the transanal group and 34 in the laparoscopic group. The bowel function did not differ between the transanal and the laparoscopic groups: LARS 36 versus 37 (p = 0.941) and Wexner 9 versus 10 (p = 0.786). The urologic function was also similar between the two groups: IPSS 5.5 versus 3.5 (p = 0.821). Among sexually active patients before surgery, 20 of 28 (71 %) patients in the transanal group and 9 of 23 (39 %) in the laparoscopic group maintained an activity after surgery (p = 0.02). Erectile function was also better in men after transanal compared to laparoscopic low rectal dissection: IIEF 17 versus 7 (p = 0.119). CONCLUSION Transanal approach for low rectal cancer did not change bowel and urologic functions compared to the conventional laparoscopic approach. However, there was a trend to a better erectile function with a significantly higher rate of sexual activity in the transanal group.
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Affiliation(s)
- Arnaud Pontallier
- CHU Bordeaux, Department of Digestive Surgery, Saint André Hospital, University of Bordeaux, 1 rue Jean Burguet, 33075, Bordeaux Cedex, France
- Université Bordeaux Segalen, 33076, Bordeaux, France
| | - Quentin Denost
- CHU Bordeaux, Department of Digestive Surgery, Saint André Hospital, University of Bordeaux, 1 rue Jean Burguet, 33075, Bordeaux Cedex, France.
- Université Bordeaux Segalen, 33076, Bordeaux, France.
| | - Bart Van Geluwe
- CHU Bordeaux, Department of Digestive Surgery, Saint André Hospital, University of Bordeaux, 1 rue Jean Burguet, 33075, Bordeaux Cedex, France
- Université Bordeaux Segalen, 33076, Bordeaux, France
| | - Jean-Philippe Adam
- CHU Bordeaux, Department of Digestive Surgery, Saint André Hospital, University of Bordeaux, 1 rue Jean Burguet, 33075, Bordeaux Cedex, France
- Université Bordeaux Segalen, 33076, Bordeaux, France
| | - Bertrand Celerier
- CHU Bordeaux, Department of Digestive Surgery, Saint André Hospital, University of Bordeaux, 1 rue Jean Burguet, 33075, Bordeaux Cedex, France
- Université Bordeaux Segalen, 33076, Bordeaux, France
| | - Eric Rullier
- CHU Bordeaux, Department of Digestive Surgery, Saint André Hospital, University of Bordeaux, 1 rue Jean Burguet, 33075, Bordeaux Cedex, France
- Université Bordeaux Segalen, 33076, Bordeaux, France
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Yamada T, Okabayashi K, Hasegawa H, Tsuruta M, Yoo JH, Seishima R, Kitagawa Y. Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery. Br J Surg 2016; 103:493-503. [DOI: 10.1002/bjs.10105] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 12/13/2015] [Accepted: 12/14/2015] [Indexed: 12/17/2022]
Abstract
Abstract
Background
One of the potential advantages of laparoscopic compared with open colorectal surgery is a reduction in postoperative bowel obstruction events. Early reports support this proposal, but accumulated evidence is lacking.
Methods
A systematic review and meta-analysis was performed of randomized clinical trials and observational studies by searching the PubMed and Cochrane Library databases from 1990 to August 2015. The primary outcomes were early and late postoperative bowel obstruction following laparoscopic and open colorectal surgery. Both ileus and bowel obstruction were defined as a postoperative bowel obstruction. Subgroup and sensitivity analyses were performed, and a random-effects model was used to account for the heterogeneity among the studies.
Results
Twenty-four randomized clinical trials and 88 observational studies were included in the meta-analysis; 106 studies reported early outcome and 12 late outcome. Collectively, these studies reported on the outcomes of 148 392 patients, of whom 58 133 had laparoscopic surgery and 90 259 open surgery. Compared with open surgery, laparoscopic surgery was associated with reduced rates of early (odds ratio 0·62, 95 per cent c.i. 0·54 to 0·72; P < 0·001) and late (odds ratio 0·61, 0·41 to 0·92; P = 0·019) postoperative bowel obstruction. Weighted mean values for early postoperative bowel obstruction were 8 (95 per cent c.i. 6 to 10) and 5 (3 to 7) per cent for open and laparoscopic surgery respectively, and for late bowel obstruction were 4 (2 to 6) and 3 (1 to 5) per cent respectively.
Conclusion
The reduction in postoperative bowel obstruction demonstrates an advantage of laparoscopic surgery in patients with colorectal disease.
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Affiliation(s)
- T Yamada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - K Okabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - H Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - M Tsuruta
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - J-H Yoo
- Department of Surgery, National Hospital Organization Saitama National Hospital, 2–1 Suwa Wako, Saitama, Japan
| | - R Seishima
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Y Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Rodríguez-Sanjuán JC, Gómez-Ruiz M, Trugeda-Carrera S, Manuel-Palazuelos C, López-Useros A, Gómez-Fleitas M. Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions. World J Gastroenterol 2016; 22:1975-2004. [PMID: 26877605 PMCID: PMC4726673 DOI: 10.3748/wjg.v22.i6.1975] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/20/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.
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57
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Muratore A, Mellano A, Failla A, Marsanic P, De Luca R. Transanal total mesorectal excision in rectal cancer: why, how and when. COLORECTAL CANCER 2016. [DOI: 10.2217/crc.15.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Down-to-up total mesorectal excision (TME) or transanal TME (taTME) has gained worldwide popularity. taTME is one of the most promising innovations of the last years in the field of gastrointestinal surgery. Due to the better view of the dissection planes even in difficult patients (i.e., narrow pelvis or low rectal cancer), taTME seems to achieve both better TME quality reducing the rate of incomplete TME and lower rates of positive circumferential resection margins. taTME has overall morbidity and anastomotic leak rates comparable with the up-to-down TME. Mid-term results of taTME seems to be comparable with those of the up-to-down approach but definitive conclusions cannot be drawn since the short follow-up and small cohort of patients of the present studies.
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Affiliation(s)
- Andrea Muratore
- Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Alfredo Mellano
- Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Andrea Failla
- Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Patrizia Marsanic
- Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Raffaele De Luca
- Department Surgical Oncology, Istituto Tumori ‘G Paolo II’, Bari, Italy
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58
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Song SH, Park SY, Park JS, Kim HJ, Yang CS, Choi GS. Laparoscopic para-aortic lymph node dissection for patients with primary colorectal cancer and clinically suspected para-aortic lymph nodes. Ann Surg Treat Res 2015; 90:29-35. [PMID: 26793690 PMCID: PMC4717606 DOI: 10.4174/astr.2016.90.1.29] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/16/2015] [Accepted: 09/30/2015] [Indexed: 01/30/2023] Open
Abstract
PURPOSE Treatment of patients with para-aortic lymph node metastasis from colorectal cancer is controversial. The goal of this study was to investigate the technical feasibility of laparoscopic intrarenal para-aortic lymph node dissection in patients with colorectal cancer and clinically suspected para-aortic lymph node dissection. METHODS The inclusion criteria for the laparoscopic approach were patients with infrarenal para-aortic lymph node metastasis from colorectal cancer. Patients who had any other distant metastatic lesion or metachronous para-aortic lymph node metastasis were excluded from this study. Perioperative outcomes and survival outcomes were analyzed. RESULTS Between November 2004 and October 2013, 40 patients underwent laparoscopic para-aortic lymph node dissection. The mean operating time was 192.3 ± 68.8 minutes (range, 100-400 minutes) and the mean estimated blood loss was 65.6 ± 52.6 mL (range, 20-210 mL). No patient required open conversion. The postoperative complication rate was 15.0%. Sixteen patients (40.0%) had pathologically positive lymph nodes. In patients with metastatic para-aortic lymph nodes, the 3-year overall survival rate and disease-free survival rate were 65.7% and 40.2%, respectively. CONCLUSION The results of our study suggest that a laparoscopic approach for patients with colorectal cancer with metastatic para-aortic lymph nodes can be a reasonable option for selected patients.
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Affiliation(s)
- Sung Ho Song
- Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chun-Seok Yang
- Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University School of Medicine, Daegu, Korea
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Park JS, Kim NK, Kim SH, Lee KY, Lee KY, Shin JY, Kim CN, Choi GS. Multicentre study of robotic intersphincteric resection for low rectal cancer. Br J Surg 2015; 102:1567-73. [PMID: 26312601 DOI: 10.1002/bjs.9914] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/22/2015] [Accepted: 07/08/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is a lack of information regarding the oncological safety of robotic intersphincteric resection (ISR) with coloanal anastomosis. The objective of this study was to compare the long-term feasibility of robotic compared with laparoscopic ISR. METHODS Between January 2008 and May 2011, consecutive patients who underwent robotic or laparoscopic ISR with coloanal anastomosis from seven institutions were included. Propensity score analyses were performed to compare outcomes for groups in a 1 : 1 case-matched cohort. The primary endpoint was 3-year disease-free survival. RESULTS A total of 334 patients underwent ISR with coloanal anastomosis, of whom 212 matched patients (106 in each group) formed the cohort for analysis. The overall rate of conversion to open surgery was 0.9 per cent in the robotic ISR group and 1.9 per cent in the laparoscopic ISR group. Nine patients (8.5 per cent) in the laparoscopic group and three (2.8 per cent) in the robotic ISR group still had a stoma at last follow-up (P = 0.075). Total mean hospital costs were significantly higher for robotic ISR (€ 12,757 versus € 9223 for laparoscopic ISR; P = 0.037). Overall 3-year local recurrence rates were similar in the two groups (6.7 per cent for robotic and 5.7 per cent for laparoscopic resection; P = 0.935). The combined 3-year disease-free survival rates were 89.6 (95 per cent c.i. 84.1 to 95.9) and 90.5 (85.4 to 96.6) per cent respectively (P = 0.298). CONCLUSION Robotic ISR with coloanal anastomosis for rectal cancer has reasonable oncological outcomes, but is currently too expensive with no short-term advantages.
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Affiliation(s)
- J S Park
- Departments of Surgery, Kyungpook National University Medical Centre, Kyungpook National University School of Medicine, Daegu, Korea
| | - N K Kim
- Yonsei University College of Medicine, Seoul, Korea
| | - S H Kim
- Korea University Anam Hospital, Seoul, Korea
| | - K Y Lee
- Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - K Y Lee
- Kyung Hee University, Seoul, Korea
| | - J Y Shin
- Inje University Paik-Hospital, Pusan, Korea
| | - C N Kim
- Eulji University Hospital, Daejeon, Korea
| | - G-S Choi
- Departments of Surgery, Kyungpook National University Medical Centre, Kyungpook National University School of Medicine, Daegu, Korea
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Jiang JB, Jiang K, Dai Y, Wang RX, Wu WZ, Wang JJ, Xie FB, Li XM. Laparoscopic Versus Open Surgery for Mid-Low Rectal Cancer: a Systematic Review and Meta-Analysis on Short- and Long-Term Outcomes. J Gastrointest Surg 2015; 19:1497-512. [PMID: 26040854 DOI: 10.1007/s11605-015-2857-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 05/11/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The safety of laparoscopic surgery for mid-low rectal cancer treatment has remained controversial, especially regarding the long-term outcomes. The aim of this study was to demonstrate whether the laparoscopic technique is feasible. METHODS We searched all of studies that compared the short- or long-term outcomes regarding laparoscopic and open rectal cancer surgeries (the tumour distance from anal verge within 10 cm). The data sources included PubMed, EMBASE, OVID, Web of Science and the Cochrane Library databases. The combined outcome of the dichotomous variables was expressed as an estimation of the odds ratios and continuous variables were presented in the form of weighted mean differences with 95% credible intervals. Subgroup, publication bias and sensitivity analyses were performed. RESULTS Thirteen studies met the final inclusion criteria (total n = 3,678). The pooled analyses showed, despite longer operation times, that there were significantly less blood loss, fewer transfusions, shorter times to bowel function recovery, resumed diet and hospital durations, and lower overall complication and wound infection rates. The compared results of the lymph node harvest number, distal resection margin, circumferential resection margin involvement, local and distant recurrences, disease-free survival and overall survival were similar between both groups. CONCLUSIONS This study suggests that the safety and feasibility of laparoscopic surgery appear to be equivalent to open surgery for treatment of mid- low rectal cancer, with the more favourable short-term benefits, fewer complications, comparable pathological outcomes and long-term outcomes.
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Affiliation(s)
- Jin-bo Jiang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Lee SY, Jo JS, Kim HJ, Kim CH, Kim YJ, Kim HR. Prognostic factors for low rectal cancer patients undergoing intersphincteric resection after neoadjuvant chemoradiation. J Surg Oncol 2015; 111:1054-8. [DOI: 10.1002/jso.23932] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 04/18/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Soo Young Lee
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Jeong Seon Jo
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Hun Jin Kim
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Chang Hyun Kim
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Young Jin Kim
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Hyeong Rok Kim
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
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Pai VD, Desouza A, De Menezes JL, Saklani AP. Laparoscopic intersphincteric resection and hand-sewn coloanal anastomosis: a natural orifice specimen extraction technique. J Laparoendosc Adv Surg Tech A 2015; 25:396-400. [PMID: 25825997 DOI: 10.1089/lap.2015.0023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The incidence of rectal cancer in India is on the rise, and unlike in the West, predominantly younger individuals are affected. Surgery for rectal cancer has evolved over the years with the ultimate goals of sphincter preservation and better quality of life, besides oncological safety. With the routine use of magnetic resonance imaging for local staging, intersphincteric resection has become a viable alternative to abdominoperineal resection. Similarly, there is enough evidence to consider laparoscopic surgery as feasible and oncologically safe for rectal cancer. Thus laparoscopic intersphincteric resection fulfills all the objectives of modern-day rectal cancer surgery. Here we describe the technical points while performing the surgery as well as short-term results of our own series.
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Affiliation(s)
- Vishwas D Pai
- Department of Surgical Oncology, Tata Memorial Centre , Mumbai, India
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Abstract
OBJECTIVE Oncologic and functional outcomes were compared between transanal and transabdominal specimen extraction after laparoscopic coloanal anastomosis for rectal cancer. BACKGROUND Laparoscopic coloanal anastomosis is an attractive new surgical option in patients with low rectal cancer because laparotomy is not necessary due to transanal specimen extraction. Risks of tumor spillage and fecal incontinence induced by transanal extraction are not known. METHODS Between 2000 and 2010, 220 patients with low rectal cancer underwent laparoscopic rectal excision with hand-sewn coloanal anastomosis. The rectal specimen was extracted transanally in 122 patients and transabdominally in 98 patients. End points were circumferential resection margin, mesorectal grade, local recurrence, survival, and functional outcome. RESULTS The mortality rate was 0.5% and surgical morbidity rate was 17%. The rate of positive circumferential resection margin was 9% and the mesorectum was graded complete in 79%, subcomplete in 12%, and incomplete in 9%. After a follow-up of 51 months (range, 1-151), the local recurrence rate was 4% and overall survival and disease-free survival rates were 83% and 70% at 5 years, respectively. The continence score was 6 (range, 0-20). There was no difference of mortality rate, morbidity rate, circumferential resection margin, mesorectal grade, local recurrence (4% vs 5%, P = 0.98), and disease-free survival rate (72% vs 68%, P = 0.63) between transanal and transabdominal extraction groups. Continence score was also similar (6 vs 6, P = 0.92). CONCLUSIONS Transanal extraction of the rectal specimen did not compromise oncologic and functional outcome after laparoscopic surgery for low rectal cancer and seems as a safe option to preserve the abdominal wall.
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Chi P, Huang SH, Lin HM, Lu XR, Huang Y, Jiang WZ, Xu ZB, Chen ZF, Sun YW, Ye DX. Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome. Ann Surg Oncol 2015; 22:944-951. [PMID: 25245128 DOI: 10.1245/s10434-014-4085-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND Traditionally, conventional intersphincteric resection requires a combined abdominal and perineal approach and a handsewn coloanal anastomosis procedure, which is difficult to accomplish via the perineal approach. A completely abdominal approach partial intersphincteric resection (APISR) with laparoscopy can simplify the anastomosis procedure. This study evaluated the intermediate-term oncological and functional results of laparoscopic versus open APISR for low rectal cancer. METHODS A total of 137 consecutive patients with low rectal cancer who underwent APISR from January 2006 to August 2013 were retrospectively evaluated. Patient groups were classified into as open surgery (OP, n = 48) group and laparoscopy (LAP, n = 89). The primary endpoint was 3-year disease-free survival and the Wexner score for anal function. RESULTS The LAP group had longer operating time, less intraoperative blood loss, and shorter hospital stay after surgery compared with the OP group. Median follow-up was 32.3 months. The local recurrence rates were similar in the two groups (LAP 3.2% vs. OP 6.1%; P = 0.652). The combined 3-year disease-free survival rate was 83.2% in the LAP group and 83.8% in the OP group (P = 0.857). Wexner scores were similar in the two groups (LAP 2.9 ± 4.5 vs. OP 3.1 ± 5.0). In the LAP group, 89.7% of patients had good continence compared with 91.4% in the OP group (P = 0.311). CONCLUSIONS Laparoscopic APISR can be performed safely and offers similar intermediate-term oncological and functional outcome compared with the open procedure. The oncological adequacy requires long-term follow-up data.
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Affiliation(s)
- Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China,
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Muratore A, Mellano A, Marsanic P, De Simone M. Transanal total mesorectal excision (taTME) for cancer located in the lower rectum: short- and mid-term results. Eur J Surg Oncol 2015; 41:478-83. [PMID: 25633642 DOI: 10.1016/j.ejso.2015.01.009] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 12/22/2014] [Accepted: 01/13/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Laparoscopic trans-abdominal total mesorectal excision is technically demanding. Transanal Total Mesorectal Excision (taTME) is a new technique which seems to provide technical advantages. This study describes the results of taTME in a consecutive series of patients with low rectal cancer. METHODS From January 2012 to December 2013, a consecutive series of 26 patients with low rectal cancer underwent laparoscopic taTME with coloanal anastomosis. cT4 or Type II-III rectal cancer (according to Rullier's classification) were contraindications to taTME. After anal sleeve mucosectomy, the rectal wall was transected at the ano-rectal junction. A single-access multichannel port was inserted in the anal canal. taTME was performed from down to up until the sacral promontory posteriorly and the Pouch of Douglas anteriorly were reached. A laparoscopic trans-abdominal approach was used to complete the left colon mobilization. RESULTS Sixteen patients (61.5%) were male. The mean distance of the rectal cancer from the anal verge was 4.4 cm (range 3-6). Nineteen patients (73.1%) received long-course neoadjuvant radiotherapy. At final pathology, resection margins were negative in all the patients: the mean distal and radial resection margins were 19 mm and 11.2 mm, respectively. TME was complete in 23 patients (88.5%) and nearly complete in three. Postoperative mortality was 3.8%. The overall morbidity rate was 26.9% (7 patients): two patients (7.7%) had an anastomotic leakage (Dindo I-d). After a mean follow up of 23 months, no patients have developed a local recurrence. CONCLUSIONS laparoscopic taTME allow wide resection margins and good quality TME.
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Affiliation(s)
- A Muratore
- Department of Surgical Oncology, Candiolo Cancer Institute - FPO, IRCCS, Candiolo, TO, Italy.
| | - A Mellano
- Department of Surgical Oncology, Candiolo Cancer Institute - FPO, IRCCS, Candiolo, TO, Italy
| | - P Marsanic
- Department of Surgical Oncology, Candiolo Cancer Institute - FPO, IRCCS, Candiolo, TO, Italy
| | - M De Simone
- Department of Surgical Oncology, Candiolo Cancer Institute - FPO, IRCCS, Candiolo, TO, Italy
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Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial. Ann Surg 2015; 260:993-9. [PMID: 24950270 DOI: 10.1097/sla.0000000000000766] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic sphincter preservation for low rectal cancer is challenging because of the high risk of positive circumferential resection margin. We hypothesized that perineal dissection of the distal rectum may improve quality of surgery, compared with the conventional abdominal dissection. METHODS Between 2008 and 2012, 100 patients with low rectal cancer (< 6 cm from the anal verge) suitable for sphincter preservation were randomized between perineal and abdominal low rectal dissection. Surgery included laparoscopic mobilization of the left colon with high rectal dissection. Distal rectal dissection was performed laparoscopically in the abdominal group and transanally in the perineal group. The primary endpoint was quality of surgery (circumferential resection margin, mesorectum grade, and lymph nodes). Secondary end points were morbidity and conversion. RESULTS The rate of positive circumferential resection margin decreased significantly after perineal compared with abdominal low rectal dissection, 4% versus 18% (P = 0.025). The mesorectum grade and the number of lymph nodes analyzed did not differ between the 2 groups. There was no difference in surgical morbidity (12% vs 14%; P = 0.766) and conversion (4% vs 10%; P = 0.436) between perineal and abdominal rectal dissection. Multivariate analysis showed that abdominal rectal dissection was the only independent factor of positive circumferential resection margin (odds ratio = 5.25; 95% confidence interval: 1.03-26.70; P = 0.046). CONCLUSIONS Perineal rectal dissection reduces the risk of positive circumferential resection margin, as compared with the conventional abdominal dissection in low rectal cancer. This suggests the perineal rectal dissection as a new standard in laparoscopic sphincter-saving resection for low rectal cancer.
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Devaraj B, Kaiser AM. Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms. World J Surg Proced 2015; 5:1. [DOI: 10.5412/wjsp.v5.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/21/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
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Laparoscopic en bloc excision of gastrointestinal stromal tumors of the rectum after neoadjuvant imatinib therapy: anteriorly extended intersphincteric resection combined with partial resection of the prostate. Tech Coloproctol 2014; 19:247-51. [DOI: 10.1007/s10151-014-1261-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/05/2014] [Indexed: 10/24/2022]
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Ye F, Chen D, Wang D, Lin J, Zheng S. Use of Valtrac™-secured intracolonic bypass in laparoscopic rectal cancer resection. Medicine (Baltimore) 2014; 93:e224. [PMID: 25546660 PMCID: PMC4602602 DOI: 10.1097/md.0000000000000224] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The occurrence of anastomotic leakage (AL) remains a major concern in the early postoperative stage. Because of the relatively high morbidity and mortality of AL in patients with laparoscopic low rectal cancer who receive an anterior resection, a fecal diverting method is usually introduced. The Valtrac™-secured intracolonic bypass (VIB) was used in open rectal resection, and played a role of protecting the anastomotic site. This study was designed to assess the efficacy and safety of the VIB in protecting laparoscopic low rectal anastomosis and to compare the efficacy and complications of VIB with those of loop ileostomy (LI). Medical records of the 43 patients with rectal cancer who underwent elective laparoscopic low anterior resection and received VIB procedure or LI between May 2011 and May 2013 were retrospectively analyzed, including the patients' demographics, clinical features, and operative data. Twenty-four patients received a VIB and 19 patients a LI procedure. Most of the demographics and clinical features of the groups, including Dukes stages, were similar. However, the median distance of the tumor edge from the anus verge in the VIB group was significantly longer (7.5 cm; inter-quartile range [IQR] 7.0-9.5 cm) than that of the L1 group (6.0 cm; IQR 6.0-7.0 cm). None of the patients developed clinical AL. The comparisons between the LI and the VIB groups were adjusted for the significant differences in the tumor level of the groups. After adjustment, the LI group experienced longer overall postoperative hospital stay (14.0 days, IQR: 12.0, 16.0 days; P < 0.001) and incurred higher costs ($6300 (IQR: $5900, $6600)) than the VIB group (7.0 days, $4800; P < 0.05). Stoma-related complications in the ileostomy group included dermatitis (n = 2), stoma bleeding (n = 1), and wound infection after closure (n = 2). No BAR-related complications occurred. The mean time to Valtrac™ ring loosening was 14.1 ± 3.2 days. The VIB procedure, as a good partner with the laparoscopic rectal cancer resection, appears to be a safe and effective, but time-limited, diverting technique to protect an elective low colorectal anastomosis.
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Affiliation(s)
- Feng Ye
- From the Department of Colorectal Surgery (FY, DC, DW, JL); and Department of General Surgery, the First Affiliated Hospital, Zhejiang University, No. 79, Qinchun Road, Hangzhou, China (SZ)
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Shussman N, Wexner SD. Current status of laparoscopy for the treatment of rectal cancer. World J Gastroenterol 2014; 20:15125-15134. [PMID: 25386061 PMCID: PMC4223246 DOI: 10.3748/wjg.v20.i41.15125] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/23/2014] [Accepted: 06/21/2014] [Indexed: 02/07/2023] Open
Abstract
Surgery for rectal cancer in complex and entails many challenges. While the laparoscopic approach in general and specific to colon cancer has been long proven to have short term benefits and to be oncologically safe, it is still a debatable topic for rectal cancer. The attempt to benefit rectal cancer patients with the known advantages of the laparoscopic approach while not compromising their oncologic outcome has led to the conduction of many studies during the past decade. Herein we describe our technique for laparoscopic proctectomy and assess the current literature dealing with short term outcomes, immediate oncologic measures (such as lymph node yield and specimen quality) and long term oncologic outcomes of laparoscopic rectal cancer surgery. We also briefly evaluate the evolving issues of robotic assisted rectal cancer surgery and the current innovations and trends in the minimally invasive approach to rectal cancer surgery.
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Sakamoto K, Okazawa Y, Takahashi R, Sugimoto K, Komiyama H, Takahashi M, Kojima Y, Goto M, Okuzawa A, Tomiki Y. Laparoscopic intersphincteric resection using needlescopic instruments. J Minim Access Surg 2014; 10:221-4. [PMID: 25336828 PMCID: PMC4204271 DOI: 10.4103/0972-9941.141535] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 07/31/2014] [Indexed: 12/02/2022] Open
Abstract
Intersphincteric resection (ISR) is a procedure designed to preserve anal function in cases with very low rectal cancer. We report our clinical experience with laparoscopic ISR (Lap ISR) performed using needlescopic instruments. First, a camera port is created at the umbilicus. Two 5-mm ports are then inserted at the right upper and lower quadrants. Two needlescopic forceps (Endo-Relief™ Hope Denshi Co., Chiba, Japan) are inserted at the left upper and lower quadrants. We then perform the following procedures; ligation of the inferior mesenteric artery and vein, total mesorectal excision and dissection of the intersphincteric space. After the transanal intersphincteric dissection, the specimen is extracted through the anus and a hand —sewn coloanal anastomosis is performed. The covering ileostomy is finally created at the right upper port. We performed Lap ISR using needlescopic forceps in two patients with very low rectal cancer. In both cases, we were able to perform this procedure without insertion of an additional port or to change the needlescopic forceps to conventional 5-mm forceps. Lap ISR with needlescopic instruments is a feasible procedure for minimally invasive surgery.
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Affiliation(s)
- Kazuhiro Sakamoto
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Yu Okazawa
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Rina Takahashi
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Kiichi Sugimoto
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Hiromitsu Komiyama
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Makoto Takahashi
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Yutaka Kojima
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Michitoshi Goto
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Atsushi Okuzawa
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Yuichi Tomiki
- Department of Coloproctological Surgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
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Yoo BE, Cho JS, Shin JW, Lee DW, Kwak JM, Kim J, Kim SH. Robotic versus laparoscopic intersphincteric resection for low rectal cancer: comparison of the operative, oncological, and functional outcomes. Ann Surg Oncol 2014; 22:1219-25. [PMID: 25326398 DOI: 10.1245/s10434-014-4177-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Robotic surgery was developed to overcome the limitations of laparoscopic surgery and is increasingly used to treat low rectal cancer. In this study, we compared the operative, oncological, and functional outcomes of low rectal cancer patients who underwent robotic or laparoscopic intersphincteric resection (ISR). METHODS Prospectively collected data from low rectal cancer patients who underwent laparoscopic or robotic ISR between September 2006 and August 2011 were retrospectively compared. The functional outcomes of patients followed up for ≥ 12 months after ileostomy closure were evaluated via questionnaire. RESULTS Forty-four and 26 patients underwent robotic and laparoscopic ISR, respectively. The robotic group patients had a higher body mass index (BMI; 21.42 ± 3.13 vs. 24.13 ± 3.33 kg/m(2); p = 0.001), more advanced clinical N stage (p = 0.029), lower cancer location (3.71 ± 0.89 vs. 3.24 ± 0.78 cm; p = 0.023), more frequent chemoradiotherapy (26.9 vs. 54.5 %; p = 0.025), and longer operation time (286.77 ± 51.46 vs. 316.43 ± 65.11 min; p = 0.038). However, no intergroup differences were observed in the pathological details (except the number of retrieved lymph nodes), postoperative morbidity, 3-year overall survival, recurrence-free survival (RFS), local RFS, and functional outcomes. CONCLUSIONS Robotic and laparoscopic ISR yielded similar operative, oncological, and functional outcomes in patients with low rectal cancer, despite differences in unfavorable outcome-affecting factors, including BMI, clinical N stage, cancer location, and chemoradiotherapy frequency. A randomized trial will provide more solid methodology for investigating the potential benefits of robotic ISR.
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Affiliation(s)
- Byung-Eun Yoo
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 126-1 Anam-dong, Seongbuk-gu, Seoul, 136-705, Republic of Korea
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Huh JW. Minimally invasive techniques for an intersphincteric resection and lateral pelvic lymph node dissection in rectal cancer. Ann Coloproctol 2014; 30:163-4. [PMID: 25210684 PMCID: PMC4155134 DOI: 10.3393/ac.2014.30.4.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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74
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No advantages of laparoscopy for left-sided malignant colonic obstruction compared with open colorectal resection in both short-term and long-term outcomes. Med Oncol 2014; 31:213. [DOI: 10.1007/s12032-014-0213-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
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Kim JC, Lim SB, Yoon YS, Park IJ, Kim CW, Kim CN. Completely abdominal intersphincteric resection for lower rectal cancer: feasibility and comparison of robot-assisted and open surgery. Surg Endosc 2014; 28:2734-2744. [PMID: 24687417 DOI: 10.1007/s00464-014-3509-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 03/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most previous studies of intersphincteric resection (ISR) adopted a two-stage procedure involving abdominal and transanal approaches. We performed completely abdominal ISR via open and a robot-assisted (RA) approaches as treatments for lower rectal cancer (LRC). The RA approach might enable deep dissection and facilitate ISR in patients with restrictive pelvic anatomy. METHODS A consecutive cohort of 222 LRC patients who underwent completely abdominal ISR (RA ISR, n = 108; open ISR, n = 114) was enrolled prospectively, and their short-term outcomes were evaluated. RESULTS In a multivariate analysis, ISR was performed more frequently in the RA than in the open group (82.6 vs. 67.9 %, p = 0.008). The number of harvested lymph nodes was >12 in both groups. A positive distal resection margin was not observed in either group, and a positive circumferential resection margin was found in one patient in the RA group. Overall morbidity did not differ between the groups. Moderate to severe sexual dysfunction occurred 2.7-fold more frequently in the open group (p = 0.023) among male patients ≤65 years. Mean Wexner's fecal incontinence scores at postoperative months 6 and 12 were greater in the open group than in the RA group (p < 0.05). CONCLUSIONS Completely abdominal ISR may be feasible in the treatment of LRC, based on a short-term study. Furthermore, RA ISR had equivalent oncological outcomes and slightly improved functional recovery relative to open ISR.
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Affiliation(s)
- Jin C Kim
- Colorectal Division, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 138-736, Korea,
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Kim HJ, Choi GS, Park JS, Park S, Kawai K, Watanabe T. Clinical significance of thrombocytosis before preoperative chemoradiotherapy in rectal cancer: predicting pathologic tumor response and oncologic outcome. Ann Surg Oncol 2014; 22:513-9. [PMID: 25145505 DOI: 10.1245/s10434-014-3988-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thrombocytosis is considered an adverse prognostic factor in various malignancies. However, the clinical significance of thrombocytosis in rectal cancer patients is unknown. We investigated the predictive value of thrombocytosis for pathologic tumor response to preoperative chemoradiotherapy (CRT) and oncologic outcomes in patients with rectal cancer. METHODS A total of 314 patients who underwent preoperative CRT and subsequent rectal resection for rectal cancer were retrospectively evaluated at two tertiary institutions. Univariate and multivariate analyses of the clinical parameters were performed to identify markers predictive of a pathologic complete response (pCR). The Kaplan-Meier method was used to estimate 3-year disease-free and overall survival rates. RESULTS Sixty-nine patients (22 %) had thrombocytosis before CRT, which significantly correlated with a large tumor size and advanced tumor depth. Thirty-nine patients (12.4 %) achieved a pCR. In the multivariate analyses, a platelet count of <370,000/μl (odds ratio 5.483; 95 % confidence interval, 1.271-23.653; P = 0.023) and a carcinoembryonic antigen (CEA) level of <5 ng/dl (odds ratio, 3.084; 95 % confidence interval, 1.291-7.368; P = 0.011) were identified as independent predictive factors for a pCR. Patients with pretreatment thrombocytosis had lower 3-year disease-free (P = 0.037) and overall survival (P = 0.001) rates than patients with normal pretreatment platelet counts. CONCLUSIONS Thrombocytosis is a negative predictive factor for a pCR and has an adverse impact on survival in rectal cancer. The predictive value of this easily available clinical factor should not be underestimated, and better therapeutic strategies for these tumors are required.
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Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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What should we intend for minimally invasive treatment of colorectal cancer? Surg Oncol 2014; 23:147-54. [PMID: 24957303 DOI: 10.1016/j.suronc.2014.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 05/19/2014] [Accepted: 06/01/2014] [Indexed: 01/06/2023]
Abstract
Non-inferiority of laparoscopic treatment of colorectal cancer (CRC) has been demonstrated in randomized controlled trials although operative and perioperative management varies widely among centers. Literature data in English language published up to April 15, 2014 were analyzed in order to give an up to date analysis that would highlights the key aspects of a modern and factual minimally invasive treatment of CRC. Laparoscopic resection is the first choice treatment of colon cancer. Laparoscopic resection of rectal cancer should be considered an investigational procedure to be performed in high volume centers with special interest in laparoscopy and colorectal surgery. Less invasive approaches should be taken into account with the aim of reducing surgical stress. The adoption of ERAS programs has demonstrated to optimize short-term results. Future research should be directed to prove possible long-term advantages, in terms of overall and disease-free survival, of minimally invasive treatment of CRC.
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Kim SJ, Choi BJ, Lee SC. Successful total shift from multiport to single-port laparoscopic surgery in low anterior resection of colorectal cancer. Surg Endosc 2014; 28:2920-30. [PMID: 24853846 DOI: 10.1007/s00464-014-3554-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 04/12/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the possibility of using single-port low anterior resection (LAR) in place of conventional laparoscopic LAR. BACKGROUND Though single-port LS is gradually evolving, the application of single-port LS techniques in LAR have been viewed with skepticism due to technical difficulties. METHODS Data from patients who had undergone either conventional laparoscopic LAR (n = 49) or single-port LAR (n = 67) for colorectal cancers between March 2006 and March 2013 were analyzed retrospectively. RESULTS In single-port LAR group, oncologic outcomes were satisfactory with respect to attainment of lymph nodes (23.4 ± 15.3) and surgical margins (proximal cut margin: 7.1 ± 4.6 cm, distal cut margin: 7.7 ± 5.7 cm). Single-port LAR showed acceptable clinical outcomes manifested by comparable outcomes of post-operative analgesics requirement and length of hospital stay, and by low incidence of post-operative complications (conventional laparoscopic LAR group: 30.6% vs. single-port LAR group: 14.9%; P < 0.01). Operative time was comparable between groups (conventional laparoscopic LAR group: 309 ± 93 min vs. single-port LAR group: 277 ± 106 min; P = 0.097). Throughout a series of 67 consecutive single-port LARs, no conversion to multiport or open surgery was occurred. CONCLUSION This study shows that single-port LAR is both safe and feasible for use in resection of colorectal cancer when performed by surgeons who are trained in conventional laparoscopic technique. If further and more extensive studies support our results, then single-port LAR can be an acceptable alternative to conventional laparoscopic LAR for treatment of colorectal cancer.
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Affiliation(s)
- Say-June Kim
- Department of Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-dong 520-2, Jung-gu, Daejeon, Republic of Korea
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Safe transanal tumor resection using a harmonic scalpel. Int Surg 2014; 99:17-22. [PMID: 24444263 DOI: 10.9738/intsurg-d-13-00137.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We performed a safe and simple transanal tumor resection involving total layer resection using a harmonic scalpel as a resecting device. Here we report the results of our experience with this technique between 2005 and 2011. This study involved 32 patients who underwent transanal tumor resection using a harmonic scalpel. The subjects comprised 18 men and 14 women ranging in age from 34 to 87 years (mean: 64.5 years). The tumors measured 8 to 70 mm (mean: 31 mm) in diameter. The operation took 7 to 86 minutes (mean: 29 minutes), and the amount of bleeding was 0 to 165 mL (mean: 16.2 mL). There was no intraoperative blood loss that necessitated hemostatic procedures. Histopathologically, the lesions included hyperplastic polyp in 1 case, adenoma in 9, carcinoma in situ in 7, submucosal invasive cancer in 6, muscularis propria cancer in 4, carcinoid in 1, malignant lymphoma in 1, gastrointestinal stromal tumor in 1, mucosal prolapsed syndrome in 1, and mucosa-associated lymphoid tissue lymphoma in 1. With our technique, en bloc resection was achieved in all patients, and the use of a harmonic scalpel enabled us to complete the operation within 30 minutes, on average, without intraoperative bleeding.
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Accuracy of preoperative MRI in predicting pathology stage in rectal cancers: node-for-node matched histopathology validation of MRI features. Dis Colon Rectum 2014; 57:32-8. [PMID: 24316943 DOI: 10.1097/dcr.0000000000000004] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies that meticulously match individual lymph nodes seen on MRI with their precise histologic counterparts after total mesorectal excision have been reported. OBJECTIVE The objective of this study was to determine whether preoperative MRI could detect lymph node metastases accurately in the node-by-node analysis. DESIGN This was a prospective, observational cohort study. SETTINGS The study was conducted at a tertiary-care hospital. PATIENTS Forty patients with rectal cancer were enrolled. MAIN OUTCOME MEASURES Specimens were assessed using MRI for clinical staging. After surgical resection of the tumor, the specimens were again imaged with ex vivo ultrasound scan to localize the perirectal node. The locations of each lymph node were precisely matched with its corresponding magnetic resonance image to enable a node-for-node comparison of magnetic resonance images and histologic findings. RESULTS Agreement between MRI and histologic assessment of T stage was 82.5%. Of the 341 nodes harvested, 120 were too small (<3 mm) to be depicted on magnetic resonance images, and 18 of these contained metastasis (15%). A correlation between the results of MRI and histopathology was feasible for 205 lymph nodes, and the overall success rate of matching between the 2 techniques was 91.1% (205 of 221). Preoperative MRI revealed a node-by-node sensitivity and positive predictive value of 58.0%, and 61.7%. There was no difference in the diagnostic accuracy between the primary surgery subgroup and preoperative radiation subgroups. LIMITATIONS The study is limited by its heterogeneity of cohorts including the subgroup with preoperative chemoradiation and the lack of preoperative ultrasound assessment. CONCLUSIONS Preoperative MRI was moderately accurate for the prediction of mesorectal lymph node metastasis. Moreover, preoperative MRI was insufficient for detecting small lymph nodes (<3 mm) with metastasis.
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Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy for patients with colorectal cancer peritoneal carcinomatosis: initial results from a single center. Surg Endosc 2013; 28:1555-62. [PMID: 24368743 DOI: 10.1007/s00464-013-3351-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 11/20/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND In recent decades, a combination of cytoreductive surgery and intraperitoneal chemotherapy has yielded improvements in the survival of patients with peritoneal carcinomatosis. Laparoscopic cytoreductive surgery and intraperitoneal chemotherapy comprise a challenging and rarely reported surgical procedure. METHODS Between November 2004 and February 2010, 29 patients underwent cytoreductive surgery and early postoperative intraperitoneal chemotherapy for peritoneal carcinomatosis secondary to colorectal cancer. Of the 29 patients, 15 underwent laparoscopic surgery and 14 underwent open surgery. RESULTS The patient characteristics did not differ significantly between the two groups. Synchronous peritoneal carcinomatosis with a primary tumor was more common in the laparoscopic group, and the Gilly stage of peritoneal carcinomatosis was found more frequently in the open group. Complication rate and hospital stay were less in the laparoscopic group. However, the outcomes for the patients undergoing the combined treatment were similar between the two groups with respect to completeness of cytoreduction, operation morbidity, and overall survival. The laparoscopic group had a cytoreduction completeness of 86.7 % and an operative morbidity of 13.3 %. Operative mortality occurred for one patient after open surgery. CONCLUSIONS Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy can be performed safely for selected patients with peritoneal carcinomatosis from colorectal cancer to a limited extent. Further studies with longer follow-up periods and larger numbers of patients are warranted to confirm the study findings.
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Shiomi A, Kinugasa Y, Yamaguchi T, Tsukamoto S, Tomioka H, Kagawa H. Feasibility of laparoscopic intersphincteric resection for patients with cT1-T2 low rectal cancer. Dig Surg 2013; 30:272-7. [PMID: 23970304 DOI: 10.1159/000354034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 06/24/2013] [Indexed: 01/19/2023]
Abstract
AIMS The purpose of this study was to assess the feasibility of laparoscopic intersphincteric resection (LAP-ISR) for rectal cancer in terms of morbidity, oncological outcomes, and functional results. METHODS Thirty-seven patients with primary low rectal cancer cT1-T2 underwent LAP-ISR. Surgical outcomes, pathological results, postoperative complications, oncological outcomes, and functional results were analyzed retrospectively. RESULTS Three patients (8.1%) had carcinoma in situ, 22 (59.5%) had pT1 tumor, and 11 (29.7%) had pT2 tumor. Eleven patients (29.7%) were diagnosed as being node positive, while 26 (70.3%) had node-negative disease. The median operative time was 315 min (range: 195-502). The median blood loss was 37 ml (range: 0-745). One case was converted to open surgery. Pathological complete resection was achieved in all cases. There was no surgical mortality. Postoperative complications of grade III-IV on the Clavien-Dindo classification were observed in 16.2% of the patients. The median follow-up period was 2.8 years (range: 187-2,241 days), and 3-year disease-free survival was 93.1%. No patient developed local recurrence. The functional result was objectively good. CONCLUSION LAP-ISR can be recommended as a feasible, ultimate sphincter-preserving procedure with acceptable functional and intermediate-term oncological outcomes in patients with cT1-T2 very low rectal cancer.
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Affiliation(s)
- Akio Shiomi
- Division of Colorectal Surgery, Shizuoka Cancer Center Hospital, Nagaizumi-cho, Japan
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83
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Dumont F, Ayadi M, Goéré D, Honoré C, Elias D. Comparison of fecal continence and quality of life between intersphincteric resection and abdominoperineal resection plus perineal colostomy for ultra-low rectal cancer. J Surg Oncol 2013; 108:225-9. [PMID: 23868337 DOI: 10.1002/jso.23379] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 06/21/2013] [Indexed: 01/08/2023]
Abstract
AIMS The only two procedures for surgical treatment of ultra-low rectal cancer without a permanent abdominal stoma are the intersphincteric resection (ISR) and the abdominoperineal resection (APR) plus a perineal pseudocontinent colostomy (PCC). This study compared functional results and quality of life following these two techniques. METHODS Between January 1995 and December 2011, 36 patients had undergone an ISR (n = 14) or a PPC (n = 22) for very low rectal cancer. The Cleveland Clinica Florida (Wexner) fecal incontinence questionnaire and the EORTC Quality of Life questionnaire QLQ-C30 and CR38 had been administered. RESULTS There were no differences in gender, age, the interval between surgery and questionnaire responses, preoperative TNM staging, perioperative treatment, the laparoscopic approach and circumferential margin involvement rate between the groups. The ISR and PPC led to no difference in quality of life (Qol) and continence with a median Wexner score of respectively 11 and 10 (P = 0.403) and a fecal incontinence rate of 58.2% and 41% (P = 0.221). The incontinent patients had experienced worse social functioning and tended to have worse overall health. The patients who had undergone ISR had more defecation problems and evacuation difficulties. CONCLUSION Qol and continence are similar between ISR and PPC.
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Affiliation(s)
- F Dumont
- Department of Surgical Oncology, Institut Gustave Roussy, Villejuif, France.
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Araki J, Nishizawa Y, Sato T, Naito M, Akita K, Tashiro K, Iida T, Koshima I. Anorectal transplantation in human cadavers: mock anorectal allotransplantation. PLoS One 2013; 8:e68977. [PMID: 23874833 PMCID: PMC3708922 DOI: 10.1371/journal.pone.0068977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 06/03/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anorectal transplantation is a method for patients who have lost their anorectal function or suffer from congenital anorectal dysfunction to recover this function, and this has been investigated in experimental animal models using pigs, dogs, and rats. In this study, we performed an examination of anorectal transplantation in human cadavers to investigate whether this procedure could be performed in patients. METHODS A 77-year-old woman cadaver 1 was used as the donor and a 98-year-old woman cadaver 2 was used as the recipient. Initially, abdominoperineal excision of the anus and rectum (the Miles' operation) was performed on the recipient. Next, an anorectal graft containing the pudendal nerve (PN), pudendal artery (PA), pudendal vein (PV), inferior mesenteric artery (IMA), and inferior mesenteric vein (IMV) was harvested from the donor. The donor graft was transplanted into the recipient by intestinal anastomosis and microneurovascular anastomoses orthotopically. RESULTS The diameters of the PN (right/left), IMA, and IMV were 2.5 mm/2.5 mm, 2.0 mm, and 1.5 mm, respectively, in cadaver 1, and 2.0 mm/2.0 mm, 2.0 mm, and 2.0 mm, respectively, in cadaver 2. The length of the PN, PA, PV, IMA, and IMV in the graft was sufficient to allow proper anastomosis. CONCLUSION This preliminary study indicated that human anorectal transplantation was possible anatomically and technically. We anticipate our study will aid in the potential future application of this procedure to human patients.
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Affiliation(s)
- Jun Araki
- Department of Plastic Surgery, University of Tokyo, Tokyo, Japan.
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85
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Baek SJ, Al-Asari S, Jeong DH, Hur H, Min BS, Baik SH, Kim NK. Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer. Surg Endosc 2013. [PMID: 23708725 DOI: 10.1007/s00464‐013‐3014‐4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Robotic surgery is increasingly used in the field of rectal cancer surgery. This study aimed to compare the short- and long-term outcomes between robotic and laparoscopic ultralow anterior resection (uLAR) and coloanal anastomosis (CAA). Between January 2007 and December 2010, a retrospective chart review was performed for all patients with low rectal cancer who underwent curative uLAR and CAA with or without intersphincteric resection using either a robotic or a laparoscopic approach. The study excluded patients with tumors invading the levator ani or external sphincter, patients with T4 cancers invading the prostate or vagina, and patients for whom an open approach was used. Patients' short- and long-term outcomes were evaluated. This study enrolled 84 consecutive patients (47 in the robotic group and 37 in the laparoscopic group). The patient characteristics and operative data did not differ significantly between the groups except for the rate of conversion to open surgery (robot, 2.1 % vs laparoscopy, 16.2 %; p = 0.02). The postoperative outcomes also were similar in the two groups, but the hospital stay was shorter in the robotic group than in the laparoscopic group (robot, 9 days vs laparoscopy, 11 days; p = 0.011). No postoperative mortality occurred. The median follow-up period was 31.5 months. No difference was shown in local recurrence, 3-year overall survival, or disease-free survival between the two groups. Robotic uLAR and CAA with or without ISR is a safe and feasible surgical approach with a lower conversion rate, a shorter hospital stay, and similar oncologic outcomes compared with a laparoscopic approach. Further prospective and case-control cohort studies with longer follow-up periods are required.
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Affiliation(s)
- Se Jin Baek
- Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul, 120-527, South Korea
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86
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Park JS, Choi GS, Jun SH, Park SY, Kim HJ. Long-term outcomes after laparoscopic surgery versus open surgery for rectal cancer: a propensity score analysis. Ann Surg Oncol 2013; 20:2633-40. [PMID: 23709099 DOI: 10.1245/s10434-013-2981-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND The aim of this study was to compare the long-term outcomes of laparoscopy-assisted surgery (LAP) with those for open surgery (OS) when excising nonmetastatic rectal cancers. METHODS We reviewed the prospectively collected records of all patients (n = 1,009) undergoing OS or LAP from January 2000 to November 2008 at Kyungpook National University Hospital. We undertook propensity score analyses and compared outcomes for the OS and LAC groups in a 1:1 matched cohort. Covariates in the model for propensity scores included age, gender, preoperative tumor marker level, preoperative chemoradiation status, tumor height from the anal verge, and clinical tumor stage. Subgroup analysis was conducted to evaluate the oncologic safety of LAP in patients with extraperitoneal rectal cancers. RESULTS There were no significant differences in mortality, morbidity, and pathological quality in the propensity-matched cohort (n = 812). The combined 3-year local recurrence rate for all tumor stages was 3.8 % (95 % confidence intervals [95 % CI], 1.9-5.7 %) in the LAP group and 5.9 % (95 % CI, 3.9-8.3 %) in the OS group (P = .089 by log-rank test). The combined 3-year disease-free survival for all stages was 80.5 % (95 % CI, 76.6-84.4 %) in the LAP group and 82.9 % (95 % CI 79.2-86.6 %) in the OS group (P = .516 by log-rank test). Similar results were confirmed for the subgroup of patients with extraperitoneal rectal cancers. CONCLUSIONS Laparoscopic rectal excision for rectal cancer is feasible and safe with acceptable oncologic outcomes. Further prospective multicenter trials are warranted before incorporating this technology into routine surgical care.
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Affiliation(s)
- Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, South Korea
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87
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Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer. Surg Endosc 2013; 27:4157-63. [PMID: 23708725 DOI: 10.1007/s00464-013-3014-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 05/09/2013] [Indexed: 01/01/2023]
Abstract
Robotic surgery is increasingly used in the field of rectal cancer surgery. This study aimed to compare the short- and long-term outcomes between robotic and laparoscopic ultralow anterior resection (uLAR) and coloanal anastomosis (CAA). Between January 2007 and December 2010, a retrospective chart review was performed for all patients with low rectal cancer who underwent curative uLAR and CAA with or without intersphincteric resection using either a robotic or a laparoscopic approach. The study excluded patients with tumors invading the levator ani or external sphincter, patients with T4 cancers invading the prostate or vagina, and patients for whom an open approach was used. Patients' short- and long-term outcomes were evaluated. This study enrolled 84 consecutive patients (47 in the robotic group and 37 in the laparoscopic group). The patient characteristics and operative data did not differ significantly between the groups except for the rate of conversion to open surgery (robot, 2.1 % vs laparoscopy, 16.2 %; p = 0.02). The postoperative outcomes also were similar in the two groups, but the hospital stay was shorter in the robotic group than in the laparoscopic group (robot, 9 days vs laparoscopy, 11 days; p = 0.011). No postoperative mortality occurred. The median follow-up period was 31.5 months. No difference was shown in local recurrence, 3-year overall survival, or disease-free survival between the two groups. Robotic uLAR and CAA with or without ISR is a safe and feasible surgical approach with a lower conversion rate, a shorter hospital stay, and similar oncologic outcomes compared with a laparoscopic approach. Further prospective and case-control cohort studies with longer follow-up periods are required.
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88
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Kuo LJ, Hung CS, Wang W, Tam KW, Lee HC, Liang HH, Chang YJ, Huang MT, Wei PL. Intersphincteric resection for very low rectal cancer: clinical outcomes of open versus laparoscopic approach and multidimensional analysis of the learning curve for laparoscopic surgery. J Surg Res 2013; 183:524-30. [PMID: 23465434 DOI: 10.1016/j.jss.2013.01.049] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 01/17/2013] [Accepted: 01/24/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND Laparoscopic rectal cancer surgery is regarded as more complex because of its technical difficulties in pelvic exposure, dissection, and sphincter preservation. This study therefore aimed to investigate the feasibility of laparoscopic resection for low rectal cancer using intersphincteric resection (ISR) and to assess its short-term oncological outcomes. Further, we intended to analyze the learning curve for laparoscopic surgery and identify the factors influencing the learning curve. METHODS Patients with low rectal cancer who received open or laparoscopic ISR were retrospectively chart reviewed. The surgical and oncological outcomes were evaluated. Comparisons of operating time, estimated blood loss, surgical outcomes, and histopathologic status were analyzed. Also, operating time was used as a technical indicator for learning curve analysis. RESULTS The mean estimated blood loss was 265 mL (range, 100-800 mL) in the open group and 104 mL (range, 30-250 mL) in the laparoscopic group. There was a significant difference between these two groups (P < 0.001). Operative experience analysis showed that the mean operating time was 402.1 min (range, 210-570 min) in the first stage and 331.4 min (range, 210-450 min) in the second stage, and on pathologic examination the mean number of lymph nodes harvested was 11.1 (range, 5-21) in the first stage and 18.3 (range, 11-31) in the second stage, with statistical differences between these two stages (P = 0.034 and P = 0.004, respectively). Multifactorial analysis showed that operating time was associated with surgeons' experience (<18 or ≥18 cases) (odds ratio = 2.918, 95% CI 1.078-7.902). Protective stoma creation was also associated with surgeons' experience (odds ratio = 3.999, 95% CI 1.153-13.86). CONCLUSIONS Our data show that laparoscopic ISR for low rectal cancer is feasible and safe. Surgeons' experience improved operating time and postoperative complications.
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Affiliation(s)
- Li-Jen Kuo
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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90
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Wang XD, Huang MJ, Yang CH, Li K, Li L. Minilaparotomy to rectal cancer has higher overall survival rate and earlier short-term recovery. World J Gastroenterol 2012; 18:5289-94. [PMID: 23066325 PMCID: PMC3468863 DOI: 10.3748/wjg.v18.i37.5289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 05/10/2012] [Accepted: 05/13/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To report our experience using mini-laparotomy for the resection of rectal cancer using the total mesorectal excision (TME) technique.
METHODS: Consecutive patients with rectal cancer who underwent anal-colorectal surgery at the authors’ hospital between March 2001 and June 2009 were included. In total, 1415 patients were included in the study. The cases were divided into two surgical procedure groups (traditional open laparotomy or mini-laparotomy). The mini-laparotomy group was defined as having an incision length ≤ 12 cm. Every patient underwent the TME technique with a standard operation performed by the same clinical team. The multimodal preoperative evaluation system and postoperative fast track were used. To assess the short-term outcomes, data on the postoperative complications and recovery functions of these cases were collected and analysed. The study included a plan for patient follow-up, to obtain the long-term outcomes related to 5-year survival and local recurrence.
RESULTS: The mini-laparotomy group had 410 patients, and 1015 cases underwent traditional laparotomy. There were no differences in baseline characteristics between the two surgical procedure groups. The overall 5-year survival rate was not different between the mini-laparotomy and traditional laparotomy groups (80.6% vs 79.4%, P = 0.333), nor was the 5-year local recurrence (1.4% vs 1.5%, P = 0.544). However, 1-year mortality was decreased in the mini-laparotomy group compared with the traditional laparotomy group (0% vs 4.2%, P < 0.0001). Overall 1-year survival rates were 100% for Stage I, 98.4% for Stage II, 97.1% for Stage III, and 86.6% for Stage IV. Local recurrence did not differ between the surgical groups at 1 or 5 years. Local recurrence at 1 year was 0.5% (2 cases) for mini-laparotomy and 0.5% (5 cases) for traditional laparotomy (P = 0.670). Local recurrence at 5 years was 1.5% (6 cases) for mini-laparotomy and 1.4% (14 cases) for traditional laparotomy (P = 0.544). Days to first ambulation (3.2 ± 0.8 d vs 3.9 ± 2.3 d, P = 0.000) and passing of gas (3.5 ± 1.1 d vs 4.3 ± 1.8 d, P = 0.000), length of hospital stay (6.4 ± 1.5 d vs 9.7 ± 2.2 d, P = 0.000), anastomotic leakage (0.5% vs 4.8%, P = 0.000), and intestinal obstruction (2.2% vs 7.3%, P = 0.000) were decreased in the mini-laparotomy group compared with the traditional laparotomy group. The results for other postoperative recovery function indicators, such as days to oral feeding and defecation, were similar, as were the results for immediate postoperative complications, including the physiologic and operative severity score for the enumeration of mortality and morbidity score.
CONCLUSION: Mini-laparotomy, as conducted in a single-centre series with experienced TME surgeons, is a safe and effective new approach for minimally invasive rectal cancer surgery. Further evaluation is required to evaluate the use of this approach in a larger patient sample and by other surgical teams.
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91
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Lázár G. [Intestinal surgery]. Magy Seb 2012; 65:116-28. [PMID: 22717966 DOI: 10.1556/maseb.65.2012.3.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- György Lázár
- Szegedi Tudományegyetem, Általános Orvostudományi Kar Sebészeti Klinika Szeged
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Intersphincteric resection and coloanal anastomosis in treatment of distal rectal cancer. Int J Surg Oncol 2012; 2012:581258. [PMID: 22690335 PMCID: PMC3368590 DOI: 10.1155/2012/581258] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 03/30/2012] [Indexed: 12/19/2022] Open
Abstract
In the treatment of distal rectal cancer, abdominoperineal resection is traditionally performed. However, the recognition of shorter safe distal resection line, intersphincteric resection technique has given a chance of sphincter-saving surgery for patients with distal rectal cancer during last two decades and still is being performed as an alternative choice of abdominoperineal resection. The first aim of this study is to assess the morbidity, mortality, oncological, and functional outcomes of intersphincteric resection. The second aim is to compare outcomes of patients who underwent intersphincteric resection with the outcomes of patients who underwent abdominoperineal resection.
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93
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Alimoglu O, Atak I, Kilic A, Caliskan M. Robot-assisted laparoscopic abdominoperineal resection for low rectal cancer. Int J Med Robot 2012; 8:371-4. [PMID: 22473676 DOI: 10.1002/rcs.1432] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND This article reports on patients with low rectal cancer treated with robot-assisted laparoscopic abdominoperineal resection. METHODS Robot-assisted laparoscopic abdominoperineal resection was performed on seven patients in the General Surgery Clinic of Umraniye Training and Research Hospital between 2010 and 2011 by performing abdominal and perineal skin incisions using the same technique. Gender, age of the patients, intraoperative and postoperative complications, morbidity and mortality were evaluated. RESULTS Five of the patients were male and two of them were female. Mean age was 59.2 years. All of the procedures were completed robotically. No intraoperative complication occurred, whereas urinary bladder dysfunction (n = 1) and chylous ascites (n = 1), treated conservatively, developed in the postoperative period. On histopathological examination, surgical and circumferential margins were found to be negative in all specimens. Early recurrence was not found on postoperative follow-up. CONCLUSION Robot-assisted laparoscopic surgery can be performed safely in narrow and deep anatomical areas, such as the pelvis.
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Affiliation(s)
- O Alimoglu
- Umraniye Training and Research Hospital, Istanbul, Turkey.
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