The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Ann Surg. 2008;248:1-7. [PMID: 18580199 DOI: 10.1097/sla.0b013e31816a9d65]

Operative technique in robotic rectal resection

A still too high percentage of the colorectal resections are currently performed by open technique. This in part because laparoscopy has some technical hurdles: not ideal ergonomics, poor control on the traction exerted by the Assistant, long/steep learning curve, confined dexterity, low tactile feedback, hand-tremor and 2D vision with a not completely stable camera. The robotic approach, given the increased surgical dexterity and the better surgical view, may be used to solve the laparoscopic downsides (in particular in the most complex cases). In the present work, after an extensive robotic experience and a robotic program started by Giulianotti et al. in October 2000, we show our operative steps for the robotic rectal resection. The aim is to propose a model to standardize the surgical technique and potentially pave the way for the acquisition of more reproducible data among different centers. This proposal may be also a technical guide to learn the robotic way and also for the expert surgeons as an adjunct in the teaching strategy.

Colonic stents for malignant bowel obstruction: current status and future prospects

Introduction: Although more than two decades are already passed from the first description of this technique, the debate remains open on the role of self-expanding metal stents (SEMS) placement in the management of malignant bowel obstruction (MBO). According to most recent data, SEMS placement is considered a safe and effective alternative treatment as a bridge to surgery(BTS). In addition, stent placement should be considered as primary option for palliative treatment of obstructing cancer.Areas covered: Current status, indication, technique, oncological outcomes, advantages, and risks of SEMS placement in MBO were reviewed.Expert commentary: The placement of colonic SEMS for palliation and for BTS in patients with MBO has been increasingly reported and it seems to have several advantages over emergency surgery. Substantial concerns of tumor seeding following SEMS placement, especially in case of perforation, have been raised in numerous studies. Actually, no significant differences are reported in oncologic long-term survival between patients undergoing stent placement as a BTS and those undergoing emergency surgery. Considering all the mentioned factors, indication for colorectal stenting should be evaluated only in highly specialized centers, in the context of multidisciplinary approach where risks and benefits of stenting are carefully weighed, especially in the BTS setting.

Long-term tumour outcomes of self-expanding metal stents as 'bridge to surgery' for the treatment of colorectal cancer with malignant obstruction: a systematic review and meta-analysis

PURPOSE

To explore the long-term oncological results of self-expanding metal stents (SEMS) as a surgical transition compared with those of simple emergency surgery.

METHODS

A systematic review of studies involving long-term tumour outcomes comparing SEMS with emergency surgery was conducted. All studies included information on 3-year and 5-year survival rates, 3-year and 5-year disease-free survival (DFS) rates, and local and overall recurrence rates; the results were expressed as odds ratios.

RESULTS

Overall, 24 articles and 2508 patients were included, including 5 randomised controlled trials, 3 prospective studies, and 16 retrospective studies. The 3-year survival rate (odds ratio (OR) = 0.88, 95% confidence interval (CI) 0.69-1.12, P = 0.05), 5-year survival rate (OR = 0.91, 95% CI 0.70-1.17, P = 0.67), 3-year DFS rate (OR = 1.14, 95% CI 0.91-1.42, P = 0.65), 5-year DFS rate (OR = 1.35, 95% CI 0.91-2.02, P = 0.17), overall recurrence rate (OR 1.04, 95% CI 0.77-1.41, P = 0.14), and local recurrence rate (OR 1.37, 95% CI 0.84-2.23, P = 0.92) were determined. There was no significant difference between the randomised and observational studies in the subgroup analysis, and the 5-year survival rate was higher in studies with a stent placement success rate of ≥ 95%.

CONCLUSION

SEMS implantation was a viable alternative in malignant left colon obstruction as a transition to surgery; its long-term survival results, including 5-year DFS and overall survival, were equivalent to those of emergent surgery.

"Caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the superior mesenteric artery for the treatment of right colon cancer: is it more in line with the principle of oncology?

OBJECTIVE

To explore the feasibility and application value of a "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the superior mesenteric artery (SMA) for the treatment of right colon cancer METHODS: Clinical data consisting of 168 right colon cancer cases under going laparoscopic D3 radical resection, including 84 cases of "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the SMA (CC + SMA group) and 84 cases of conventional medial approach plus dissection around the superior mesenteric vein (MA + SMV group), from January 2017 to March 2018 were retrospectively analyzed. For CC + SMA group, our surgical method was to isolate the mesocolon using a caudal-to-cranial pathway and ligate blood vessels along the midline of the SMA.

RESULTS

The baseline data was not significantly different between the two groups (all p > 0.05). The mean operation time and intraoperative blood loss in the CC + SMA and the MA + SMV groups were 170.04 ± 43.10 versus 172.33 ± 41.84 min and 91.07 ± 55.12 versus 77.38 ± 40.21 ml, respectively, which has no significant difference (p > 0.05). The mean number of total and positive harvested lymph nodes in the two groups were 29.44 ± 5.90 versus 26.21 ± 6.64 (p < 0.05) and 2.57 ± 1.93 versus 2.51 ± 1.05, respectively (p > 0.05). Compared with the MA + SMV group, there was no significant difference in total postoperative complication rate in the CC + SMA group. The time to pull out drainage tube in the CC + SMA group was longer than MA + SMV group (4.05 ± 1.79 versus 3.38 ± 1.99 day; p = 0.022).

CONCLUSION

It is safe and feasible for the "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the SMA in right colon cancer. It may have some advantages in the number of lymph nodes dissection, and the long-term prognosis remains to be expected.

Operative technique in robotic left colonic resection

Minimally invasive techniques have changed the clinical practice in general surgery and provided an improvement of outcomes. Laparoscopic and open surgery have similar oncological outcomes in the colorectal field. Those findings have been proven by prospective randomized multicenter trials and systematic reviews. However, some colorectal operations are still being performed by the open approach. This is partially related to the technical hurdles of the laparoscopic approach (particularly for more complex cases). Robotic surgery can be beneficial in overcoming the laparoscopic hurdles and limitations. Indeed, given the improved dexterity, the 3D stereotactic magnified view (with the camera controlled directly by the surgeon), the tremor filtering technology and the 7 degrees of liberty of the surgical instruments can guarantee a more accurate surgical dissection and tissue manipulation. Herein, after a large robotic experience in this field connected to a robotic program started by Giulianotti et al. in October 2000, we present our approach to robotic left colonic resection with routine splenic flexure mobilization. This approach may be helpful to get more reproducible results, it may be a technical guide and also an additional training tool for surgical residents.

Is follow-up still mandatory more than 5 years after surgery for colorectal cancer?

PURPOSE

The aim of this study was to assess if to prolong follow-up (FU) more than 5 years after surgery for colorectal cancer (CRC) is justified or not.

METHODS

Patients who underwent surgery for a CRC before 2013 and without any tumor recurrence (or synchronous metastases) during the first 5 years after surgery were identified from our database and included.

RESULTS

Between 1996 and 2012, 121 patients operated for rectal (RC) (median of FU of 84 months; range 60-211) and 97 with colonic cancer (CC) (median of FU of 78 months; range 60-139), without any tumor recurrence (or synchronous metastases) during the first 5 years after surgery, presented a late tumor recurrence: 13/121 RC (10.7%) versus 2/97 CC (2.1%) (p = 0.014); 8/13 recurrences in RC (61.5%) were observed after neoadjuvant radiochemotherapy, and 9/13 (69.2%) in pN0 tumors. Among the 13 recurrences, 3 had both local and metastatic recurrences (23%), 5 an isolated local recurrence (38.5%) and 5 an isolated metastatic recurrence (38.5%). After surgery for CC, the 2 recurrences were observed in patients with T3N0 tumors.

CONCLUSION

After surgery for a CRC, in patients without tumor recurrence during the first 5 years after surgery, follow-up after 5 years must be continued in rectal cancer patients because of a 10.7% rate of late recurrence. On the opposite, after surgery for colon cancer the 2% rate of late recurrence after 5 years suggested that only patients with pT3-T4 colonic cancer could probably be followed more than 5 years after surgery.

Short-term and midterm outcomes of single-incision laparoscopic surgery for right-sided colon cancer

INTRODUCTION

The purpose of this study was to clarify the usefulness of SILS for right-sided colon cancer by evaluating the short-term and midterm outcomes.

METHODS

Between 2012 and 2017, 65 selected patients with right-sided colon cancer underwent ileocecal resection, right hemicolectomy, or transverse colectomy; all were enrolled in the study. The same well-trained surgeon performed each procedure by using a multi-instrument access port with three channels, which was placed at the umbilicus via an approximately 3-cm skin incision.

RESULTS

The pathological disease stage distribution was stage 0, 4 cases; stage I, 23 cases; stage II, 19 cases; stage III, 17 cases; and stage IV, 2 cases. The surgical procedures performed were ileocecal resection, 23 cases; right hemicolectomy, 35 cases; and transverse colectomy, 7 cases. The median operative time and intraoperative blood loss were 216 min and 10 mL, respectively. Although 18 cases needed additional ports, none required conversion to open surgery. The median number of harvested lymph nodes was 24. No major perioperative morbidities occurred in this patient series. The median postoperative hospital stay was 7 days. The median follow-up period was 30 months, and the 3-year relapse-free and overall survival rates were 100% and 100%, respectively, in the stage 0-I cases and 89% and 96% in the stage II-III cases, respectively.

CONCLUSION

We concluded that SILS is as feasible as multiport laparoscopic surgery and a reliable surgical option in selected cases of right-sided colon cancer.

Comparison of Oncologic Outcomes in Laparoscopic versus Open Surgery for Non-Metastatic Colorectal Cancer: Personal Experience in a Single Institution

The oncologic merits of the laparoscopic technique for colorectal cancer surgery remain debatable. Eligible patients with non-metastatic colorectal cancer who were scheduled for an elective resection by one surgeon in a medical institution were randomized to either laparoscopic or open surgery. During this period, a total of 188 patients received laparoscopic surgery and the other 163 patients received the open approach. The primary endpoint was cancer-free five-year survival after operative treatment, and the secondary endpoint was the tumor recurrence incidence. Besides, surgical complications were also compared. There was no statistically significant difference between open and laparoscopic groups regarding the average number of lymph nodes dissected, ileus, anastomosis leakage, overall mortality rate, cancer recurrence rate, or cancer-free five-year survival. Even though performing a laparoscopic approach used a significantly longer operation time, this technique was more effective for colorectal cancer treatment in terms of shorter hospital stay and less blood loss. Meanwhile, fewer patients receiving the laparoscopic approach developed postoperative urinary tract infection, wound infection, or pneumonia, which reached statistical significance. For non-metastatic colorectal cancer patients, laparoscopic surgery resulted in better short-term outcomes, whether in several surgical complications and intra-operative blood loss. Though there was no significant statistical difference in terms of cancer-free five-year survival and tumor recurrence, it is strongly recommended that patients undergo laparoscopic surgery if not contraindicated.

Survival and outcomes after laparoscopic versus open curative resection for colon cancer

BACKGROUND

Many studies have shown that open and laparoscopicsurgery for resection of colonic cancers produce similar short- and long-term results, but no data have been reported from Saudi Arabia.

OBJECTIVE

Compare 3-year disease-free and overall survival after laparoscopic versus open curative resection for potentially curable colon cancer.

DESIGN

Multicenter retrospective cohort study.

SETTING

Tertiary academic hospital.

PATIENTS AND METHODS

We analyzed data of patients who underwent curative resection for potentially curable colon cancer using the laparoscopic or open approach at three tertiary care centers during the period 2000-2015.

MAIN OUTCOME MEASURES

Overall and disease-free 3-year survival were the primary endpoints. Secondary endpoints included conversion rate, duration of surgery, length of hospital stay, rate of wound infection, resumption of bowel function, number of lymph nodes retrieved, adequacy of resection and rate of recurrence. Risk factors for recurrence, including complete mesocolic excision, were assessed.

SAMPLE SIZE

721.

RESULTS

Patient and tumor characteristics were similar in the two groups except for ASA class ( P<.01), weight ( P<.05) and tumor stage ( P<.05). Over a median follow-up of 46 months, the 3-year overall survival was 76.7% for open resection and 90.3% for laparoscopic colon resection ( P<.05). The 3-year disease-free survival was 55.3% for open colon resection and 64.9% for laparoscopic colon resection ( P=.0714).

CONCLUSION

Overall and disease-free survival after the laparoscopic approach for curative resection of colon cancer is comparable to the open approach.

LIMITATIONS

Retrospective design and the possibility of selection bias.

CONFLICT OF INTEREST

None.

Short-term postoperative outcomes following robotic versus laparoscopic ileal pouch-anal anastomosis are equivalent

BACKGROUND

Minimally invasive approaches have become the standard of care for ileal pouch-anal anastomoses (IPAA). There are few reports comparing outcomes following a laparoscopic versus robotic approach. Our aim was to determine if there were any differences in the 30-day postoperative outcomes following IPAA performed laparoscopically versus robotically.

METHODS

A retrospective chart review of all laparoscopic and robotic IPAA performed between January 1, 2015 and June 30, 2018 was carried out. Patients included were adult patients who underwent a proctectomy and IPAA utilizing either a laparoscopic or robotic approach. Data collected included patient demographics, operative variables, and 30-day postoperative outcomes.

RESULTS

A total of 132 patients had a minimally invasive IPAA; 58 were performed laparoscopically and 74 robotically. Less than half the patients were female (n = 55; 41.7%) with a median age of 37 years (range 18-68 years). The majority of patients had a diagnosis of ulcerative colitis (n = 103; 78.0%) with medically refractory disease (n = 87; 65.9%). A greater proportion of patients in the laparoscopic cohort had a prolonged length of stay (n = 27; 46.6% versus n = 18; 24.3%; p < 0.001) and a two-stage approach (n = 56; 96.6% versus n = 37; 50%; p < 0.001), but there were no differences in the rates between the laparoscopic versus robotic cohorts of superficial surgical site infection (6.9% versus 6.8%; p = 0.99), peripouch abscess (15.5% versus 6.8%; p = 0.11), anastomotic leak (6.9% versus 2.7%; p = 0.21), pelvic abscess (15.5% versus 6.8%; p = 0.11), and pelvic sepsis (15.5% versus 6.8%; p = 0.11), readmission (24.1% versus 17.6%; p = 0.35) or reoperation (6.9% versus 5.4%; p = 0.72). On multivariable analysis, only male sex remained predictive of prolonged length of stay, and a robotic approach trended toward a decreased rate of prolonged length of stay.

CONCLUSIONS

Laparoscopic and robotic IPAA have equivalent postoperative morbidity underscoring the safety of the continued expansion of the robotic platform for pouch surgery.

Decentralized colorectal cancer care in Germany over the last decade is associated with high in-hospital morbidity and mortality

Purpose

Despite several national initiatives, centralization of cancer care in Germany remains insufficient for most malignancies. Currently, there is a plethora of centers, including 290 voluntary certified and audited colorectal cancer (CRC) centers by the end of 2017, in the nation with many patients still being treated outside of such centers. This study aimed to assess morbidity and mortality rates of surgical procedures for primary colorectal CRC in Germany over the last decade through a comprehensive unbiased analysis.

Patients and methods

We performed an analysis of the national diagnosis-related group inpatient statistics from 2005 to 2015 including all German hospitals. All patients who underwent surgeries for primary CRC during the study period were included.

Results

A total of 351,028 cases were analyzed (61.6% colonic and 38.4% rectal resections). The mortality rate of colonic resections remained high during the study period (4.9% in 2005 vs 4.5% in 2015; P=0.57). Reduced perioperative mortality after rectal surgery was observed only after 2012 compared to previous years (3.8% in 2005 vs 3.0% in 2015; P<0.001), with no further improvement. In-hospital morbidity such as anastomotic leak, wound infections, hemorrhage, pneumonia, deep vein thrombosis, and lung embolism did not improve for either rectal or for colonic surgery, but in contrast, most outcomes deteriorated over time.

Conclusion

The present study challenges the current national health policies aiming to improve outcomes of surgical patients. CRC care in Germany remains decentralized with high in-hospital morbidity and mortality rates. New national strategies focusing on the implementation of centralization and high-quality CRC care are urgently needed.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Risk factors affecting hospital stay among patients undergoing colon cancer surgery: a prospective cohort study

PURPOSE

To identify and validate risk factors that contribute to prolonged length of hospital stay (LOS) in patients undergoing resection for colorectal cancer.

METHODS

This prospective cohort study included 1955 patients admitted to 22 hospitals for primary resection of colorectal cancer. Multivariate analyses were used to identify and validate risk factors, randomizing patients into a derivation and a validation cohort. Multiple correspondence and cluster analysis were performed to identify clinical subtypes based on LOS.

RESULTS

The strongest independent predictors of prolonged LOS were postoperative reintervention, surgical site infection, open surgery, and distant metastasis. The multiple correspondence and cluster analysis provided three groups of patients in relation to prolonged LOS: patients with the longest LOS included the highest percentage of patients with open surgery, distant metastasis, deep surgical site infections, emergency admissions, additional diagnostic factors, and highly contaminated surgical sites. Patients with prolonged LOS (> 14 days) were more likely to develop adverse outcomes within 30 days after discharge.

CONCLUSIONS

Patients undergoing resection of colorectal cancer cluster into different groups based on LOS of the index admission. Those with prolonged LOS were more likely to develop adverse outcomes within 30 days after discharge. Some of the strongest independent predictors of prolonged LOS, such as surgical infections or open surgery, could be modified to reduce LOS and, in turn, other adverse outcomes.

TRIAL REGISTRATION

NCT02488161.

Oncologic Outcomes after Laparoscopic and Open Distal Gastrectomy for Advanced Gastric Cancer: Propensity Score Matching Analysis

Purpose

This study aimed to compare the oncologic and short-term outcomes of laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) for advanced gastric cancer (AGC).

Materials and Methods

From July 2006 to November 2016, 384 patients underwent distal gastrectomy for AGC. Data on short- and long-term outcomes were prospectively collected and reviewed. Propensity score matching was applied at a ratio of 1:1 to compare the LDG and ODG groups.

Results

The operative times were longer for the LDG group than for the ODG group. However, the time to resumption of diet and the length of hospital stay were shorter in the LDG group than in the ODG group (4.7 vs. 5.6 days, P=0.049 and 9.6 vs. 11.5 days, P=0.035, respectively). The extent of lymph node dissection in the LDG group was more limited than in the ODG group (P=0.002), although there was no difference in the number of retrieved lymph nodes between the 2 groups. The 3-year overall survival rates were 98% and 86.9% (P=0.018), and the 3-year recurrence-free survival rates were 86.3% and 75.3% (P=0.259), respectively, in the LDG and ODG groups.

Conclusions

LDG is safe and feasible for AGC, with earlier recovery after surgery and long-term oncologic outcomes comparable to those of ODG.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy - single center experience

Introduction

Nowadays laparoscopic right hemicolectomy is widely accepted as the standard of care for benign and malignant colon disease. There are wide variations among laparoscopic techniques. One of the most discussed topics is the ileocolic anastomosis. There are two different techniques: intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA).

Aim

To compare short-term outcomes of performing intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy.

Material and methods

A retrospective chart review was performed of 92 consecutive patients who underwent laparoscopic right hemicolectomy, with either an IA or EA, from January 2013 to December 2016.

Results

Eighty-five patients were included in the analysis. There were 53 males and 32 females with a mean age of 67.1 ±13.2 years. Mean body mass index (BMI) was 27.7 ±4.8 kg/m². An intracorporeal anastomosis was performed in 51 patients, while an extracorporeal anastomosis was performed in 34. The duration of operations was significantly longer when intracorporeal anastomosis was performed, taking 154 ±58 min compared to 95 ±34 min (p < 0.001), in the extracorporeal group. No mortality was observed in the IA group. The postoperative mortality in the EA group was 8.8% (p = 0.060). The rate of reoperation in the intracorporeal anastomosis group was 7.8%, whereas in the extracorporeal anastomosis group it was 14.7% (p = 0.474). Length of hospital stay in the IA group was shorter in comparison to the EA group (5.3 ±3.7 vs. 11.2 ±19.8 days, p = 0.022).

Conclusions

Our results are encouraging to consider the intracorporeal approach as the better way to fashion the anastomosis after laparoscopic right hemicolectomy.

[Short- and long-term outcomes of laparoscopic interventions in patients with colon cancer: single-centre experience]

OBJECTIVE

To compare short- and long-term outcomes of treatment in patients with colon cancer undergoing laparoscopic and open surgery.

MATERIAL AND METHODS

There were 281 patients with colon cancer. All patients underwent open (n=144, 51.2%) or laparoscopic (n=137, 48.8%) procedures. Short- and long-term outcomes of treatment were compared in both groups.

RESULTS

There were no significant differences in sex, age, body mass index, location of tumors and tumor differentiation grade in both groups. Conversion was required in 10 (7.2%) cases. The median of duration of surgery was greater for laparoscopic procedures (150 min vs. 130 min; p<0.001). Intraoperative blood loss was significantly less in laparoscopic surgery (100 ml vs. 300 ml; p=0.001). Postoperative mortality was similar (3.5% vs. 2.5%; p=0.5) while incidence of postoperative complications was significantly lower after laparoscopic interventions (13.1% vs. 22.2%; p=0.04). There was earlier recovery of the gastrointestinal tract after laparoscopic procedures (2.1±0.9 days vs. 3.6±1.5 days, respectively; p<0.001). The postoperative hospital-stay was significantly less in the 2^nd group (p<0.001). Two-year disease -free and overall survival was similar in both groups.

CONCLUSION

Laparoscopic interventions for colon cancer are followed by similar overall and disease-free 2-year survival and better early outcomes.

Comparison between conventional colectomy and complete mesocolic excision for colon cancer: a systematic review and pooled analysis : A review of CME versus conventional colectomies

BACKGROUND

Complete mesocolic excision (CME) is advocated based on oncologic superiority, but not commonly performed in North America. Many data are case series with few comparative studies. Our aim was to perform a systematic review comparing outcomes between CME and non-CME colectomy.

METHODS

A systematic review was performed according to PRISMA guidelines of MEDLINE, EMBASE, HealthStar, Web of Science, and Cochrane Library. Studies were included if they compared conventional resection (non-CME) to CME for colon cancer. Quality was assessed using methodological index for non-randomized studies (MINORS). The main outcome measures were short-term morbidity and oncologic outcomes. Weighted pooled means and proportions with 95% CI were calculated using a random-effects model when appropriate.

RESULTS

Out of 825 unique citations, 23 studies underwent full-text reviews and 14 met inclusion criteria. Mean MINORS score was 13.3 (range 11-15). The mean sample size in CME group was 1166 (range 45-3756) and 945 (range 40-3425) in non-CME. Four papers reported plane of dissection, with CME plane achieved in 85.8% (95% CI 79.8-91.7). Mean OR time in CME group was 167 min (163-171) and 138 min (135-142) in conventional group. Perioperative morbidity was reported in six studies, with pooled overall complications of 22.5% (95% CI 18.4-26.6) for CME and 19.6 (95% CI 13.6-25.5) for non-CME. Anastomotic leak occurred in 6.0% (95% CI 2.2-9.7) of CME resections versus 6.0% (95% CI 4.1-7.9) in non-CME. CME had more lymph nodes, longer distance to high tie, and specimen length in all studies. Nine studies compared long-term oncologic outcomes and only three reported statistically significant higher disease-free or overall survival in favor of CME. Local recurrence was lower after CME in two of four studies.

CONCLUSIONS

The quality of evidence is limited and does not consistently support the superiority of CME. Better data are needed before CME can be recommended as the standard of care for colon cancer resections.

Robotic colectomy with intracorporeal anastomosis is feasible with no operative conversions during the learning curve for an experienced laparoscopic surgeon developing a robotics program

The benefits of performing a colectomy robotically instead of laparoscopically have not conclusively been demonstrated. Evaluation of studies is limited by sample size, retrospective design, heterogeneity of operative techniques, sparse adjustment for learning curve, and mixed results. Consequently, adoption of robotic colectomy by surgeons has been expectedly slow. The objectives of the study were to compare the outcomes of robotic colectomy to laparoscopic colectomy for patients with right-sided tumors undergoing a standardized completely intracorporeal operation and to examine the impact of prior experience with laparoscopic right colectomies on the performance of robotic right colectomies. Retrospective review of outcomes of consecutive patients undergoing a robotic right colectomy (robot) compared to those undergoing laparoscopic colectomy (LAP). LAP patients were further subdivided into a group during the learning curve (LC) and after the learning curve (post-LC). Data collected included operative time (OT), conversion to laparotomy, lymph nodes harvested (LN), length of stay (LOS), 30-day morbidity, and mortality. Comparison of continuous and categorical variables was assessed with the independent samples t test and Chi-square test, respectively. Data are expressed as mean ± SD, and significance defined as p < 0.05. 122 patients underwent robot (n = 21), LAP (n = 101), LC (n = 51), or post-LC (n = 50). OT was decreased for post-LC compared to LC (198 vs. 228 min). There were no conversions in robot and five with LAP. Morbidity was similar for robot (14%) compared to LAP (22%), LC (24%), or post-LC cases (20%). Median LOS was similar for robot vs. LAP (3 vs. 5 days). Robot had greater mean LN yield vs. LAP (19 vs. 14, p = 0.02). The initial outcomes with completely intracorporeal colectomy achieved robotically were equivalent to results during or after LC for laparoscopic resection. Proficiency gained with LAP seems to positively impact the initial results with the robot.

Surgical techniques for advanced transverse colon cancer using the pincer approach of the transverse mesocolon

BACKGROUND

Laparoscopic surgery for colorectal cancer, not only early cancer but also advanced cancer, has become standardized by some randomized controlled studies. However, cases involving advanced transverse colon cancer were excluded from these studies due to the technical difficulty of the surgery. Hence, laparoscopic surgery for advanced transverse colon cancer is still a theme that we need to overcome. To solve these issues, it is necessary to establish a standardized approach and surgical technique.

SURGICAL TECHNIQUES

The advantage of our method, which approaches from both sides of the transverse mesocolon, is that it is easier to achieve hemostasis when active bleeding occurs because this approach provides space for ligating and sealing. This allows the surgeon to perform lymphadenectomy around the superior mesenteric artery and vein.

CONCLUSIONS

We introduced the usefulness of the "Pincer approach of the transverse mesocolon" to standardize laparoscopic surgery for advanced transverse colon cancer.

Minimally invasive surgery for colorectal cancer remains underutilized in Germany despite its nationwide application over the last decade

Minimally invasive surgery (MIS) has superior short-term outcomes than open surgery (OS) for colorectal cancer (CRC). However, a nationwide dataset has not been analysed to confirm these findings. We evaluated the distribution and outcomes of MIS for CRC from 2005 to 2015; all in-patients with CRC surgery procedure codes were identified from hospital data, which are entered into the nationwide diagnosis-related group database and forwarded anonymised to the Federal Bureau of Statistics. We determined absolute MIS, morbidity, and mortality rates for specific sub-categories, including procedure type. We identified 345,913 in-patient files. The MIS rate increased from 6.4% (n = 2366; 2005) to 28.5% (n = 8363; 2015), with the highest rates for sigmoid colon (38%) and rectal (39%) resections. The overall conversion rate was 14.4%, without noticeable improvement over time. International Classification of Disease codes related to postoperative complications were documented more frequently after OS than after MIS. OS was associated with a higher mortality rate (4.7%) than MIS (1.8%) (P < 0.001), even after stratifying patients according to the resection site. Use of MIS remains low in Germany compared with that in other European countries. Underutilization of MIS has to be addressed in the future by promoting structured training programs and standardization of laparoscopic surgery.

Three-Port Laparoscopic Right Colectomy Versus Conventional Five-Port Laparoscopy for Right-Sided Colon Cancer

BACKGROUND

The purpose of the study was to evaluate the safety and effectiveness of three-port laparoscopic right colectomy (3-LRC) for right-sided colon cancer compared with conventional five-port laparoscopic right colectomy (5-LRC).

MATERIALS AND METHODS

One hundred sixty-three patients diagnosed with right-sided colon adenocarcinoma underwent laparoscopic right colectomy (LRC) between April 2011 and December 2017. Seventy-four of these patients underwent 3-LRC procedure and 89 patients underwent 5-LRC. Clinical characteristics, perioperative short-term outcomes, and pathologic data were analyzed.

RESULTS

There were no differences in TNM stage, tumor location, estimated blood loss, complications, and open conversion rates. The operation time was shorter in the 3-LRC group than in 5-LRC group (140.9 ± 27.5 minutes versus 178.2 ± 38.2 minutes; P = .001). The number of harvested lymph nodes (28.5 ± 13.9 versus 22.6 ± 11.7; P = .004) was also higher in the 3-LRC group. The first passage of flatus and first oral diet were significantly faster in the 3-LRC group than in the 5-LRC group (2.8 ± 1.0 days versus 4.0 ± 1.2 days; P = .001, 3.6 ± 2.9 days versus 5.0 ± 1.5 days; P = .001). The number of patients who required analgesics is less in the 3-LRC group (32.4% versus 43.8%; P = .583).

CONCLUSION

3-LRC for right-sided colon cancer is technically feasible and is associated with a short operation time. We believe that 3-LRC effectively reduces the costs associated with equipment and manpower and represents a standard procedure.

Outcomes of open versus laparoscopic surgery in patients with colon cancer

OBJECTIVE

There is limited information on health service use or patient-reported outcomes when comparing the effectiveness of laparoscopic with that of open surgery. The aim was to compare the effectiveness of laparoscopic with that of open surgery up to 2 years after intervention in patients with colon cancer.

METHODS

Prospective cohort study of patients with colon cancer who underwent surgery (laparoscopic or open surgery) between June 2010 and December 2012, at 22 hospitals. Main outcomes of the study were mortality, complications, reoperation, readmission, and patient-reported outcome measures (PROMs), as measured using the Hospital Anxiety and Depression Scale, Duke-UNC, EuroQol-5D, and European Organisation for Research and Treatment of Cancer-Q30 and Q29 at baseline, and 30 days and 1 and 2 years after surgery. Multivariable multilevel logistic regression and generalized linear models were used in analyses after adjusting for specific propensity scores developed for each outcome and time point.

RESULTS

In the multivariable analysis, the complication rates up to 30 days (infectious, surgical, and medical) and 1 year (surgical), and readmission rate at 30 days and at 2 years were higher among patients who underwent open surgery than among those who underwent laparoscopic surgery. There were no differences between the two surgical approaches in all other parameters assessed and in changes of all PROMs.

CONCLUSIONS

Though in most outcomes both surgical approaches provide similar results up to 2 years after intervention, still the rates of some complications and readmission, mainly up to 30 days, are higher in open surgery. CLINICALTRIALS.

GOV IDENTIFIER

NCT02488161.

Mentor Tutoring: An Efficient Method for Teaching Laparoscopic Colorectal Surgical Skills in a General Hospital

OBJECTIVE

We retrospectively assessed the efficacy of our mentor tutoring system for teaching laparoscopic colorectal surgical skills in a general hospital.

MATERIALS AND METHODS

A series of 55 laparoscopic colectomies performed by 1 trainee were evaluated. Next, the learning curves for high anterior resection performed by the trainee (n=20) were compared with those of a self-trained surgeon (n=19).

RESULTS

Cumulative sum analysis and multivariate regression analyses showed that 38 completed cases were needed to reduce the operative time. In high anterior resection, the mean operative times were significantly shorter after the seventh average for the tutored surgeon compared with that for the self-trained surgeon. In cumulative sum charting, the curve reached a plateau by the seventh case for the tutored surgeon, but continued to increase for the self-trained surgeon.

CONCLUSIONS

Mentor tutoring effectively teaches laparoscopic colorectal surgical skills in a general hospital setting.

Comparison of robot-assisted surgery, laparoscopic-assisted surgery, and open surgery for the treatment of colorectal cancer: A network meta-analysis

BACKGROUND

The aim of this study was to find the better treatment for colorectal cancer (CRC) by comparing robot-assisted colorectal surgery (RACS), laparoscopic-assisted colorectal surgery (LACS), and open surgery using network meta-analysis.

METHODS

A literature search updated to August 15, 2017 was performed. All the included literatures were evaluated according to the quality evaluation criteria of bias risk recommended by the Cochrane Collaboration. All data were comprehensively analyzed by ADDIS. Odds ratio (OR), mean difference (MD), and 95% confidence interval (CI) were used to show the effect index of all data. The degree of convergence of the model was evaluated by the Brooks-Gelman-Rubin method with the potential scale reduction factor (PSRF) as the evaluation indicator.

RESULTS

The PSRF values of operation time, estimated blood loss, length of hospital stay, complication, mortality, and anastomotic leakage ranged from 1.00 to 1.01, and those of wound infection, bleeding, and ileus ranged from 1.00 to 1.02. Open surgery had the shortest operation time compared with LACS and RACS. Furthermore, compared with LACS, the amount of blood loss, complication, mortality, bleeding rate, and ileus rate for RACS were the least, and the length of hospital stay for RACS was the shortest. The anastomotic leakage rate for LACS was the least, but there was no significant difference compared with those of RACS and open surgery. The wound infection rate for LACS was the least, but there was no significant difference compared with that of RACS.

CONCLUSION

RACS might be a better treatment for patients with CRC.

Preventive effect of diverting stoma on anastomotic leakage after laparoscopic low anterior resection with double stapling technique reconstruction applied based on risk stratification

INTRODUCTION

During laparoscopic low anterior resection with double stapling technique reconstruction, it is necessary to securely implement rectal transection and anastomosis to prevent anastomotic leakage (AL). However, risk factors and preventive measures for AL are not known sufficiently. Therefore, this study aimed to elucidate risk factors associated with AL and to clarify strategies to prevent it.

METHODS

We analyzed a total of 296 cases with rectal cancer who had undergone laparoscopic low anterior resection with double stapling technique reconstruction at the National Cancer Center Hospital East. The relationship between AL and patient, tumor, and treatment characteristics were retrospectively investigated.

RESULTS

There were 186 male and 110 female patients with a median age of 62. Overall, AL occurred in 24 cases (8.1%). Being a man, having an anal verge distance ≤7 cm, and undergoing neoadjuvant chemotherapy were associated with an elevated risk for AL (P = 0.0005, 0.0034, and 0.0222, respectively). Neither an anal drainage tube nor diverting stoma creation correlated with incidence of AL. Multivariate analysis demonstrated that being a man (odds ratio = 18.0; 95% confidence interval: 2.4-138) and having an anal verge distance ≤7 cm (odds ratio = 3.8; 95% confidence interval: 1.5-9.4) were significant risk factors. These two factors were present in 61 cases, including 14 who developed AL (23.0%). In this high-risk group, diverting stoma creation significantly reduced the occurrence of AL (P = 0.0363), but an anal drainage tube had no effect on incidence of AL (P = 0.3399).

CONCLUSION

We identified the high-risk population for AL after laparoscopic low anterior resection with double stapling technique reconstruction based on two factors. This will enable surgeons to appropriately recommend diverting stoma creation.

Spillage of bacterial products during colon surgery increases the risk of liver metastases development in a rat colon carcinoma model

Surgical resection of the primary tumor provides the best chance of cure for patients with colorectal carcinoma (CRC). However, bacterial translocation during intestinal surgery has been correlated with poor long-term oncological outcome. Therefore, we investigated the influence of bacterial contamination during colon surgery on CRC liver metastases development. Blood and liver samples of patients undergoing resection of primary CRC or liver metastases were collected. Cell numbers, activation markers and inflammatory mediators were determined. Tumor cell adhesion and outgrowth after sham- or colectomy operations were determined in a rat model, in which tumor cells had been injected into the portal vein.

White blood cells and granulocytes were increased in per- and post-operative patient blood samples. IL-6 was also increased post-operatively compared to the preoperative level. Expression of NOX-2, NOX-4 and polymorphonuclear cells (PMNs) numbers were elevated in post-operative human liver samples. In vitro stimulation of macrophages with plasma of rats after colectomy resulted in production of reactive oxygen species (ROS). Colectomy in rats increased D-lactate levels in plasma, supporting bacterial translocation. Decreased expression of tight junction molecules and increased tumor cell adhesion and outgrowth was observed. Treatment with a selective decontamination of the digestive tract (SDD) cocktail decreased tumor cell adherence after colectomy.

In conclusion, postoperative bacterial translocation may activate liver macrophages and PMNs, resulting in ROS production. As we previously showed that ROS release led to liver vasculature damage, circulating tumor cells may adhere to exposed extracellular matrix and grow out into liver metastases. This knowledge is pivotal for development of therapeutic strategies to prevent surgery-induced liver metastases development.

Novel biomarkers for patient stratification in colorectal cancer: A review of definitions, emerging concepts, and data

Colorectal cancer (CRC) treatment has become more personalised, incorporating a combination of the individual patient risk assessment, gene testing, and chemotherapy with surgery for optimal care. The improvement of staging with high-resolution imaging has allowed more selective treatments, optimising survival outcomes. The next step is to identify biomarkers that can inform clinicians of expected prognosis and offer the most beneficial treatment, while reducing unnecessary morbidity for the patient. The search for biomarkers in CRC has been of significant interest, with questions remaining on their impact and applicability. The study of biomarkers can be broadly divided into metabolic, molecular, microRNA, epithelial-to-mesenchymal-transition (EMT), and imaging classes. Although numerous molecules have claimed to impact prognosis and treatment, their clinical application has been limited. Furthermore, routine testing of prognostic markers with no demonstrable influence on response to treatment is a questionable practice, as it increases cost and can adversely affect expectations of treatment. In this review we focus on recent developments and emerging biomarkers with potential utility for clinical translation in CRC. We examine and critically appraise novel imaging and molecular-based approaches; evaluate the promising array of microRNAs, analyze metabolic profiles, and highlight key findings for biomarker potential in the EMT pathway.

Laparoscopic right-sided colon resection for colon cancer-has the control group so far been chosen correctly?

Background

The treatment strategies for colorectal cancer located in the right side of the colon have changed dramatically during the last decade. Due to the introduction of complete mesocolic excision (CME) with central ligation of the vessels and systematic lymph node dissection, the long-term survival of affected patients has increased significantly. It has also been proposed that right-sided colon resection can be performed laparoscopically with the same extent of resection and equal long-term results.

Methods

A retrospective evaluation of a prospectively expanded database on right-sided colorectal cancer or adenoma treated at the University Hospital of Wuerzburg between 2009 and 2016 was performed. All patients underwent CME. This data was analyzed alone and in comparison to the published data describing laparoscopic right-sided colon resection for colon cancer.

Results

The database contains 279 patients, who underwent right-sided colon resection due to colorectal cancer or colorectal adenoma (255 open; 24 laparoscopic). Operation data (time, length of stay, time on ICU) was equal or superior to laparoscopy, which is comparable to the published results. Surprisingly, the surrogate parameter for correct CME (the number of removed lymph nodes) was significantly higher in the open group. In a subgroup analysis only including patients who were feasible for laparoscopic resection and had been operated with an open procedure by an experienced surgeon, operation time was significantly shorter and the number of removed lymph nodes is significantly higher in the open group.

Conclusion

So far, several studies demonstrate that laparoscopic right-sided colon resection is comparable to open resection. Our data suggests that a consequent CME during an open operation leads to significantly more removed lymph nodes than in laparoscopically resected patients and in several so far published data of open control groups from Europe. Further prospective randomized trials comparing the long-term outcome are urgently needed before laparoscopy for right-sided colon resection can be recommended ubiquitously.

Surgical technique in robotic right colonic resection. How we do it: operative steps and surgical video

Minimally invasive surgery (MIS) has produced an important improvement in terms of peri-operative outcomes. Laparoscopic colorectal surgery presents comparable outcomes vs. open approach from an oncological standpoint. However, there are some technical challenges/hurdles that laparoscopy may have. Worldwide there are still too many colonic/rectal operations carried out by the open approach. The robotic technology may be useful in solving some of the potential laparoscopic issues and potentially it may increase the number of procedures performed in a minimally invasive way. This is a description of our standardized operative technique for Robotic Right Colonic Resection. Conceivably, this manuscript may be useful to collect more repeatable data in the future. Moreover, it might be a guide to learn the robotic technique and also for the expert surgeons as an additional tool which they may find useful during their teaching activity. In this manuscript, taking advantage of the long and extensive expertise in minimally invasive colorectal resections, connected to a robotic experience started by Giulianotti in October 2000, we present our standardized technique for the robotic right colonic resection. The currently available literature data have proven that robotic colorectal surgery is safe/feasible. From the literature data, and from our experience as well, we think that these are the following main points: 1) the right colectomy is often an operation which can be performed in a relatively simple way even with traditional laparoscopy. However, the robotic approach is easier to standardize and this operation is very useful from a teaching standpoint in order to master multiple robotic surgical skills (that can be applied in more complex colorectal operations); 2) the robotic surgery may increase the MIS penetrance in this field. 3) the robotic third arm (R3) is an important technical advantage which can potentially increase the range of surgical options available; 4) the robotic technology is relatively recent. Most of the available data are retrospective and there is literature heterogenity (this affects also the conclusions of the currently available meta-analysis results, which sometimes are conflicting); 5) we need more data from prospective randomized well-powered studies (with standardized technique). Achieving a standardized technical approach will be essential in robotic colorectal surgery.

Laparoscopic treatment of rectal cancer and lateral pelvic lymph node dissection: are they obsolete?

Laparoscopic surgery for rectal cancer offers favorable short-term results without compromising long term oncological outcomes so far, according to the data from major trials. For this reason, it is currently considered as a standard option for rectal cancer surgery. The learning curve of laparoscopic rectal cancer surgery is generally longer compared to colon cancer. Appropriate standardization and training of laparoscopic rectal cancer surgery is required. Several RCTs suggested the potential negative effect on quality of resected specimen, which can increase local recurrence. The long-term outcomes - especially local recurrence rate - of these RCTs are awaited. Lateral pelvic lymph node dissection (LPLND) has a certain effect of reducing local recurrence of rectal cancer even after neoadjuvant radiotherapy. Since LPLND is associated with postoperative morbidity, we should carefully select the candidate to maximize the effect of LPLND and minimize the morbidity caused by LPLND. Recent advancements in imaging study such as CT and MRI enable us to find the suitable candidates for LPLND. The morbidity caused by LPLND could be reduced by minimally invasive surgeries such as laparoscopic surgery and robotic surgery. We have to improve oncological outcomes and reduce morbidity by the multidisciplinary strategy for rectal cancer including total mesorectal excision, neoadjuvant chemoradiotherapy and LPLND together with laparoscopic surgery.

Short- and long-term outcomes following laparoscopic palliative resection for patients with incurable, asymptomatic stage IV colorectal cancer: A multicenter study in Japan

OBJECTIVE

This retrospective multicenter study compared short- and long-term results between Japanese patients with asymptomatic stage IV colorectal cancer who underwent palliative laparoscopic surgery (LS) versus those who underwent conventional open surgery (OS).

METHODS

Among 968 patients treated for stage IV colorectal cancer from January 2006 to December 2007 in 41 surgical units that were participating in the Japan Society of Laparoscopic Colorectal Surgery group, we studied 398 patients who received palliative resection of their asymptomatic primary colorectal tumor.

RESULTS

We analyzed data from patients undergoing LS (LS group, n=106) and OS (OS group, n=292). Fourteen (13.2%) LS group patients were converted to OS. Although the differences between groups for postoperative complications were not significant, the mean time to solid food intake and postoperative length of hospital stay for the LS group were significantly shorter than those for the OS group (2 vs. 3 days, p<0.0001; 13 vs. 16 days, p<0.0001, respectively). The LS group patients experienced a longer median survival time than that of the OS group (24.5 vs. 23.9 months, p=0.0357).

CONCLUSIONS

Laparoscopic palliative resection (LS) offers advantages for short-term outcomes and no disadvantages for long-term outcomes. The use of laparoscopic procedures to treat asymptomatic, incurable stage IV colorectal cancer appears to be acceptable.

Long term outcomes of simultaneous laparoscopic versus open resection for colorectal cancer with synchronous liver metastases

BACKGROUND/OBJECTIVE

Because of the advancements in the surgical techniques of liver resection and improvements in anesthesia and postoperative critical care, the simultaneous resection of synchronous colorectal cancer with liver metastasis either by the laparoscopic procedure or by the open resection method has been considered as a safe and acceptable option. However, there is limited information on the comparison of postoperative outcomes between laparoscopic surgery and open surgery. This study investigated the clinical results and postoperative outcomes of laparoscopic simultaneous resection of synchronous colorectal cancer with liver metastasis in comparison with those of open surgery.

METHODS

Patients with synchronous colorectal cancer and liver metastasis who underwent simultaneous resection at Shuang Ho Hospital from 2009 to 2017 were identified. The patient demographics, perioperative morbidity, and survival rates were analyzed.

RESULTS

A total of 38 patients underwent simultaneous resection of synchronous colorectal cancer with liver metastasis. Laparoscopic procedure was performed for 16 patients, and the remaining 22 patients underwent open surgery. No significant differences were observed in the patient characteristics between the two groups. There was no perioperative mortality in both groups. The 1- and 3-year disease-free survival rates were 56% and 35% in the laparoscopic group and 70% and 15% in the open surgery group, respectively. The 1- and 3-year overall survival rates were 100% and 84% in the laparoscopic group and 73% and 48% in the open surgery group, respectively.

CONCLUSION

In selected patients, laparoscopic surgery for simultaneous resection of synchronous colorectal cancer with liver metastasis seems to be safe and had a similar outcome to that of open surgery.

Risk factors for postoperative pneumonia in elderly patients with colorectal cancer: a sub-analysis of a large, multicenter, case-control study in Japan

PURPOSE

Postoperative pneumonia affects the length of stay and mortality after surgery in elderly patients with colorectal cancer (CRC). We aimed to determine the risk factors of postoperative pneumonia in elderly patients with CRC, and to evaluate the impact of laparoscopic surgery on elderly patients with CRC.

METHODS

We retrospectively investigated 1473 patients ≥ 80 years of age who underwent surgery for stage 0-III CRC between 2003 and 2007. Using a multivariate analysis, we determined the risk factors for pneumonia occurrence from each baseline characteristic.

RESULTS

Among all included patients, 26 (1.8%) experienced postoperative pneumonia, and restrictive respiratory impairment, obstructive respiratory impairment, history of cerebrovascular events, and open surgery were determined as risk factors (odds ratio [95% confidence interval], 2.78 [1.22-6.20], 2.71 [1.22-6.30], 3.60 [1.37-8.55], and 3.57 [1.22-15.2], respectively). Furthermore, postoperative pneumonia was more frequently accompanied by increasing cumulative numbers of these risk factors (area under the receiver operating characteristic curve = 0.763).

CONCLUSIONS

Laparoscopic surgery may be safely performed in elderly CRC patients, even those with respiratory impairment and a history of cerebrovascular events.

Development and Validation of a Prediction Model for Postoperative Peritoneal Metastasis After Curative Resection of Colon Cancer

BACKGROUND

Detection of peritoneal metastasis remains challenging due to the limited sensitivity of current examination methods. This study aimed to establish a prediction model for estimating the individual risk of postoperative peritoneal metastasis from colon cancer to facilitate early interventions for high-risk patients.

METHODS

This study investigated 1720 patients with stages 1-3 colon cancer who underwent curative resection at the University of Tokyo Hospital between 1997 and 2015. The data for the patients were retrospectively retrieved from their medical records. The risk score was developed using the elastic net techniques in a derivation cohort (973 patients treated in 1997-2009) and validated in a validation cohort (747 patients treated in 2010-2015).

RESULTS

The factors selected using the elastic net approaches included the T stage, N stage, number of examined lymph nodes, preoperative carcinoembryonic antigen level, large bowel obstruction, and anastomotic leakage. The model had good discrimination (c-index, 0.85) and was well-calibrated after application of the bootstrap resampling method. Discrimination and calibration were favorable in external validation (c-index, 0.83). The model presented a clear stratification of patients' risk for postoperative peritoneal recurrence, and decision curve analysis showed its net benefit across a wide range of threshold probabilities.

CONCLUSIONS

This study established and validated a prediction model that can aid clinicians in optimizing postoperative surveillance and therapeutic strategies according to the individual patient risk of peritoneal recurrence.

Laparoscopic complete mesocolic excision via mesofascial separation for left-sided colon cancer

PURPOSE

To evaluate the safety and feasibility of laparoscopic complete mesocolic excision (CME) via mesofascial separation for left-sided colon cancer.

METHODS

We evaluated prospectively collected data on 65 consecutive patients with stage I-III left-sided colon cancer, who underwent laparoscopic CME between October 2011 and September 2016. After the exclusion of 5 patients who had T4b or other active tumors, 60 patients were the subjects of this analysis. The completeness of CME, preservation of the hypogastric nerve, operative data, pathological findings, complications, and length of hospital stay were assessed.

RESULTS

CME completeness was graded as the mesocolic and intramesocolic plane in 54 and 6 patients, respectively. The hypogastric nerve was preserved in all patients. A total of 17, 12, 28, and 3 patients had T1, T2, T3, and T4a tumors, respectively. The mean number of lymph nodes retrieved was 16.2, and lymph node metastasis was identified in 22 patients. The mean operative time and intraoperative blood loss were 283 min and 38 ml, respectively. One patient had an intraoperative complication and six patients had postoperative complications. The hospital stay was 12 days.

CONCLUSION

Laparoscopic CME via mesofascial separation is a safe and feasible procedure for left-sided colon cancer.

Comparing laparoscopic surgery with open surgery for long-term outcomes in patients with stage I to III colon cancer

BACKGROUND

Although the short-term advantages of laparoscopy for colon cancer (CC) over open surgery have been clearly demonstrated, there is little evidence available concerning the long-term outcomes. This study aimed to compare the long-term results of laparoscopic surgery versus open surgery in a cohort of CC patients from a single center.

METHODS

A series of 443 patients consecutively operated on for stage I to III CC between January 2006 and December 2013 were followed up. Patients were divided into two groups according to the surgical technique and were compared for disease-free survival (DFS) and overall survival (OS) before and after 1:1 propensity score matching.

RESULTS

Due to exclusions and drop-outs, the statistical analysis of the study is based on 398 patients. Open surgery was performed in 133 patients, and laparoscopic surgery was performed in 265. After propensity score matching, two comparable groups of 89 patients each were obtained. The 5-year DFS was 64.3% and 78.2% for patients in the open and laparoscopic resection groups, respectively [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.33-1.19; P = 0.148]. A 5-year OS of 72.1% and 86.8% was observed in the open and laparoscopic resection groups, respectively (HR 0.43, 95%CI 0.20-0.94; P = 0.026). The multivariate survival analysis demonstrated better results of laparoscopy compared with open surgery for both DFS (HR 0.43, 95%CI 0.23-0.78; P = 0.004) and OS (HR 0.28, 95%CI 0.14-0.59; P < 0.001).

CONCLUSIONS

Despite the limitations of a retrospective analysis, our study confirms better results for laparoscopic surgery in terms of DFS and OS compared with open surgery in CC treatment.

Short-Term and Long-Term Outcomes of Laparoscopic Versus Open Surgery for Low Rectal Cancer

AIM

To compare the short-term and long-term outcomes of laparoscopic versus open surgery for low rectal cancer.

METHODS

Patients with low rectal cancer who underwent laparoscopic or open surgery at our department from January 2009 to December 2013 were enrolled in this retrospective study. The primary end points were 3-year local recurrence and overall and disease-free survival (DFS) rates. Secondary end points were intraoperative and postoperative outcomes.

RESULTS

Laparoscopic group had longer operative time (165.0 versus 140.0, P < .001), less blood loss (20.0 versus 40.0, P < .001), shorter length of incision (5.0 versus 18.0, P < .001), and more lymph node harvested (11.0 versus 9.0, P = .002). However, time to first flatus (P = .941), postoperative hospital stay (P = .095), postoperative complications (P = .155), and 30-day mortality (P = .683) was similar between two groups. With the median follow-up period of 65 months, the 3-year local recurrence rate was 4.3% in laparoscopic group and 7.5% in open group (P = .077); the 3-year overall and DFS rates were similar in two groups (85.9% versus 88.8%, P = .229 and 76.9% versus 79.2%, P = .448, respectively); and the overall and DFS curves were comparable between two groups (hazard ratio [HR] = 0.858, 95% confidence intervals [CI] 0.709-1.037, P = .112 and HR = 1.076, 95% CI 0.834-1.389, P = .275, respectively).

CONCLUSIONS

Laparoscopic surgery is safe and has equivalent long-term oncologic outcomes for low rectal cancer when compared to open surgery. Furthermore, large-scale, prospective randomized clinical trials are needed to confirm the present findings.

Comparative analysis of outcomes after multiport and single-port laparoscopic colectomy in emergency situations: Is single-port laparoscopic colectomy safe and feasible?

BACKGROUND/OBJECTIVE

Although consensus has been reached on the superiority of laparoscopy for a majority of conditions underlying acute abdominal pain, the safety and feasibility of single-port laparoscopic colectomy (SPLC) in emergency situations have not been determined.

METHODS

A prospective electronic database of all emergency patients who underwent either multiport laparoscopic colectomy (MPLC) or SPLC between April 2006 and December 2014 was used to compare the surgical outcomes of these operative methods.

RESULTS

During the study period, 31 MPLCs and 76 SPLCs were performed. These two operative methods resulted in similar operating times, transfusion amounts, lengths of stay, postoperative complications, attainment of lymph nodes, and proximal and distal cut margins. However, the SPLC group had a shorter time to first flatus (2.8±1.9 days vs. 3.8±1.5 days, p=0.005), earlier reinitiation of free oral fluids (3.2±2.1 days vs. 4.4±1.8 days, p=0.002), and lesser requirement of narcotic analgesics (2.5±3.9 times vs. 4.7±4.8 times, p=0.017).

CONCLUSION

SPLC could be a safe and effective alternative to MPLC, even in emergency situations when performed by surgeons who have overcome the learning curve associated with single-port laparoscopic techniques. The tendency toward earlier returns to bowel function and decreased incidence of postoperative analgesic use would be potential benefits of SPLC in emergency situations.

Laparoscopic versus open treatment of gallbladder cancer: A systematic review and meta-analysis

Background:

The aim of this review was to evaluate the effect of laparoscopic surgery on the treatment of patients with gallbladder cancer (GBC).

Methods:

A comprehensive search of Medline and Cochrane Library was conducted to identify relevant articles. A meta-analysis was subsequently performed.

Results:

A total of 20 studies including 1217 patients met the inclusion criteria. The meta-analysis showed that the 5-year survival rate was significant higher in laparoscopic group than open group (48.4% vs. 38.5%; odds ratio [OR], 1.63; 95% confidence interval [CI], 1.22–2.19; P = 0.001). Although the scar recurrence rate was significant higher in laparoscopic group than open group (7.1% vs. 4.0%; OR, 2.10; 95% CI, 1.11–3.96; P = 0.02), the overall recurrence rates between two groups were not significant different (44.8% vs. 42.2%; OR, 0.86; 95% CI, 0.64–1.14; P = 0.29). In addition, compared with open extended cholecystectomy (EC), laparoscopic EC (LEC) was associated with less intraoperative blood loss, shorter post-operative hospital stays and insignificant less complication rate (10.0% vs. 18.3%; OR, 0.51; 95% CI, 0.15–1.73; P = 0.28).

Conclusion:

Laparoscopic simple cholecystectomy does not lead to a worse prognosis when applied on patients with GBC. LEC can be performed in specialised expert centres on elective patients.

C-reactive protein in predicting major postoperative complications are there differences in open and minimally invasive colorectal surgery? Substudy from a randomized clinical trial

BACKGROUND

In search of improvement of patient assessment in the postoperative phase, C-reactive protein (CRP) is increasingly being studied as an early marker for postoperative complications following major abdominal surgery. Several studies reported an attenuated immune response in minimally invasive surgery, which might affect interpretation of postoperative CRP levels. The aim of the present study was to compare the value of CRP as a predictor for major postoperative complications in patients undergoing open versus laparoscopic colorectal surgery.

METHODS

A subgroup analysis from a randomized clinical trial (LAFA-trial) was performed, including all patients with non-metastasized colorectal cancer. In the LAFA trial, patients were randomized to open or laparoscopic segmental colectomy. In a subgroup of 79 patients of the LAFA trial, postoperative assessment of CRP levels was conducted routinely preoperatively and 1, 2, 24 and 72 h after surgery.

RESULTS

Thirty-seven patients were randomized to the open group and 42 patients to the laparoscopic group. Major complications occurred in 19% of laparoscopic procedures and 13.5% of open procedures (p = 0.776). CRP levels rise following surgical procedures. In uncomplicated cases, the rise in CRP levels was significantly lower at 24 and 72 h following laparoscopic resection in comparison to open resection. No differences in CRP levels were observed when comparing open and laparoscopic resection in patients with major complications.

CONCLUSION

In patients with an uncomplicated postoperative course, CRP levels were lower following minimally invasive resection, possibly due to decreased operative trauma. No differences in CRP were observed stratified for surgical technique in patients with major complications. These results suggest that CRP may be applied as a marker for major postoperative complications in both open and minimally invasive colorectal surgery. Future research should aim to assess the role of standardized postoperative CRP measurements.

Laparoscopic vs open complete mesocolic excision with central vascular ligation for colon cancer: A systematic review and meta-analysis

AIM

To compare the effectiveness of laparoscopic complete mesocolic excision (CME) with central vascular ligation (L-CME) with its open (O-CME) counterpart.

METHODS

We conducted an electronic search of the PubMed/MEDLINE, Excerpta Medica Database, Web of Science Core Collection, Cochrane Center Register of Controlled Trails, Cochrane Database of Systematic Reviews, SciELO, and Korean Journal databases from their inception until May 2017. We considered randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that included patients with colonic cancer comparing L-CME and O-CME. Primary outcomes included the quality of the resected specimen (lymph nodes retrieved, complete mesocolic plane excision, tumor to arterial high tie, resected mesocolon surface). Secondary outcomes included the three-year and five-year overall and disease-free survival rates, recurrence of the disease, surgical data, and postoperative morbidity and mortality. Two authors of the review screened the methodological quality of the eligible trials and independently extracted data from individual studies.

RESULTS

A total of one RCT and eleven CCTs (four from Europe and seven from Asia) met the inclusion criteria for the current meta-analysis. These studies involved 1619 patients in L-CME and 1477 patients in O-CME. The L-CME was associated with the same quality of the resected specimen, with no differences regarding the retrieved lymphnodes (MD = -1.06, 95%CI: -3.65 to 1.53, P = 0.42), and tumor to high tie distance (MD = 14.26 cm, 95%CI: -4.30 to 32.82, P = 0.13); the surface of the resected mesocolon was higher in the L-CME group (MD = 11.75 cm2, 95%CI: 9.50 to 13.99, P < 0.001). The L-CME was associated with a lower rate of blood transfusions (OR = 0.45, 95%CI: 0.27 to 0.75, P = 0.002), faster recovery of gastrointestinal function, and less postoperative overall complication rate. The L-CME approach was associated with a statistical significant better three-year overall (OR = 2.02, 95%CI: 1.31 to 3.12, P = 0.001, I2 = 28%) and disease-free (OR = 1.45, 95% CI: 1.00 to 2.10, P = 0.05, I2 = 0%) survival.

CONCLUSION

The laparoscopic approach offers the same quality of the resected specimen as the open approach in complete mesocolic excision with central vascular ligation for colon cancer. The laparoscopic complete mesocolic excision with central vascular ligation is superior in all perioperative results and at least non-inferior in long-term oncological outcomes.