Laparoscopic versus open surgery for rectal cancer: long-term oncologic results

Laparoscopy for rectal cancer is oncologically adequate: a systematic review and meta-analysis of the literature

BACKGROUND

This review of cancer outcomes is based on key literature searches of the medical databases and meta-analysis of short-term benefits of laparoscopy in rectal cancer treatment.

METHODS

We carried out a systematic review of randomized clinical trials (RCTs) and prospective non-randomized controlled trials (non-RCTs) published between January 2000 and September 2013 listed in the MEDLINE and EMBASE databases (PROSPERO Registration number: CRD42013005076). The primary endpoint was clearance of the circumferential resection margin. Meta-analysis was performed using a fixed-effect model, and sensitivity analysis by a random-effect model; subgroup analysis was performed on subsets of patients with extraperitoneal cancer of the rectum. Relative risk (RR) and mean difference (MD) were used as outcome measures.

RESULTS

Twenty-seven studies (10,861 patients) met the inclusion criteria; eight were RCTs (2,659 patients). The RCTs reported involvement of the circumferential margin in 7.9 % of patients who underwent laparoscopic and in 6.9 % of those undergoing open surgery; the overall RR was 1.00 (95 % confidence interval 0.73-1.35) with no heterogeneity. Subgroup analysis of patients with extraperitoneal cancer showed equivalent involvement of the circumferential margin in the two treatment groups. Although significantly more lymph nodes were retrieved in the surgical specimen after open surgery, the MD of -0.56 was of marginal clinical significance. The sensitivity and subgroup analyses revealed no other significant differences between laparoscopic and open surgery in the rate of R0 resections, distal margin clearance, mesorectal fascia integrity, or local recurrence at 5 years.

CONCLUSIONS

Based on the evidence from RCTs and non-RCTs, the short-term benefit and oncological adequacy of laparoscopic rectal resection appear to be equivalent to open surgery, with some evidence potentially pointing to comparable long-term outcomes and oncological adequacy in selected patients with primary resectable rectal cancer.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Predicting the pathological features of the mesorectum before the laparoscopic approach to rectal cancer

Pelvic anatomy and tumour features play a role in the difficulty of the laparoscopic approach to total mesorectal excision in rectal cancer. The aim of the study was to analyse whether these characteristics also influence the quality of the surgical specimen. We performed a prospective study in consecutive patients with rectal cancer located less than 12 cm from the anal verge who underwent laparoscopic surgery between January 2010 and July 2013. Exclusion criteria were T1 and T4 tumours, abdominoperineal resections, obstructive and perforated tumours, or any major contraindication for laparoscopic surgery. Dependent variables were the circumferential resection margin (CMR) and the quality of the mesorectum. Sixty-four patients underwent laparoscopic sphincter-preserving total mesorectal excision. Resection was complete in 79.1% of specimens and CMR was positive in 9.7%. Univariate analysis showed tumour depth (T status) (P = 0.04) and promontorium-subsacrum angle (P = 0.02) independently predicted CRM (circumferential resection margin) positivity. Tumour depth (P < 0.05) and promontorium-subsacrum axis (P < 0.05) independently predicted mesorectum quality. Multivariate analysis identified the promontorium-subsacrum angle (P = 0.012) as the only independent predictor of CRM. Bony pelvis dimensions influenced the quality of the specimen obtained by laparoscopy. These measurements may be useful to predict which patients will benefit most from laparoscopic surgery and also to select patients in accordance with the learning curve of trainee surgeons.

Single-port laparoscopic colorectal resections in obese patients are as safe and effective as conventional laparoscopy

BACKGROUND

Obese patients pose additional operative technical difficulties, and it is unclear if the outcomes of single-port colorectal surgery are equivalent to those of conventional laparoscopy in such patients. The aim of this study was to compare perioperative variables and short-term outcomes of single-port versus conventional laparoscopy in obese patients undergoing colorectal surgery.

PATIENTS AND METHODS

Obese patients (BMI ≥ 30 kg/m(2)) undergoing single-port laparoscopic colorectal resections between March 2009 and September 2012 were case matched 1:1 with obese counterparts undergoing conventional (multi-port) laparoscopic surgery based on diagnosis and operation type.

RESULTS

Thirty-seven patients who underwent single-port surgery were matched with 37 conventional laparoscopic counterparts. Male gender predominated in the single-port group (26 vs 15, p = 0.02). The number of patients with a history of previous abdominal operations (17 vs 13, p = 0.48) and ASA score (3 vs 2, p = 0.6) were similar between the groups. No differences were observed with respect to conversion rate (2 vs 5, p = 0.43), operative time (146 vs 150 min, p = 0.48), estimated blood loss (159 vs 183 ml, p = 0.99), time to first flatus (3 vs 3 days, p = 0.91), time to first bowel movement (3 vs 4 days, p = 0.62), length of hospital stay (7 vs 6 days, p = 0.37), or reoperation (2 vs 1, p > 0.99), and readmission rates (2 vs 2, p > 0.99). There were no deaths.

CONCLUSION

For obese patients undergoing colorectal resections, single-port laparoscopy appears to be as safe and effective as conventional laparoscopy.

Safety of laparoscopic colorectal surgery in a low-volume setting: review of early and late outcome

Background. There is increasing evidence suggesting that the laparoscopic technique is the treatment of choice for large bowel resection, including for malignancy. The purpose of the study was to assess whether general surgeons, with particular skills in advanced laparoscopy, can adequately provide safe laparoscopic colorectal resections in a low-volume setting. Methods. A retrospective review of prospectively collected case series of all laparoscopic colorectal resections performed under the care of a single general surgeon is presented. The primary endpoint was postoperative clinical outcome in terms of morbidity and mortality. Secondary endpoints were adequacy of surgical margins and number of lymph nodes harvested for colorectal cancer cases. Results. Seventy-three patients underwent 75 laparoscopic resections between March, 2003, and May, 2011. There was no elective mortality and the overall 30-day postoperative morbidity was 9.3%. Conversion and anastomotic leakage rates were both 1.3%, respectively. None of the malignant cases had positive margins and the median number of lymph nodes retrieved was 17. Conclusions. Our results support the view that general surgeons with advanced skills in minimally invasive surgery may safely perform laparoscopic colorectal resection in a low-volume setting in carefully selected patient cases.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results of a 18-year single-centre experience

BACKGROUND AND OBJECTIVES

The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle-low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period.

METHODS

Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan-Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors.

RESULTS

A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2%, with a rate of anastomotic leakage of 13.8%. Average follow-up was 85.9 months (range 13-210). Actuarial local recurrence rate was 4.13% at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8% at 5 years, 71 and 73% at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery.

CONCLUSIONS

Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.

Laparoscopic resection for middle and low rectal cancer

AIMS

The purpose of this study was to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic resection for middle and low rectal cancers.

MATERIALS AND METHODS

From January 2004 to December 2011, review of prospectively collected database revealed a series of 97 laparoscopic resections for middle and low rectal cancer within 10 cm from the anal verge. Five patients with multiple primary cancers were excluded. Operation time, intra-operative blood loss, surgical complications, duration of hospital stay, retrieved lymph nodes, tumour, node, metastasis (TNM) stage and recurrence were retrospectively analysed.

RESULTS

Tumours were located within 5 cm of the anal verge in 28 patients (30.4%) and from 5 cm to 10 cm in 64 patients (69.6%). Abdominoperineal resection was performed in 12 patients (13%), and conversion to open surgery was necessary in four patients (4.3%). The mean operation time was 199.7 min (range 105-450 min) and the mean intra-operative blood loss was 169.9 mL (range 20-800 mL). The mean hospital stay was 11.8 days (range 5-45 days) and a mean of 12.2 lymph nodes were retrieved. The incidence of surgical complications was 11.9%, including anastomosis site leakage in five patients (5.4%). There were no mortalities resulting from laparoscopic surgery. The median follow-up period was 28.4 months (range 7-85 months). Recurrence occurred in eight patients (8.7%).

CONCLUSIONS

Laparoscopic resection can be applied for middle and low rectal cancers with acceptable surgical and oncological outcomes.

New trends in rectal cancer treatment

SUMMARY 

The treatment philosophy for rectal cancer has changed a lot during the last three decades. In the 1970s it was more or less a pure surgical business and rectal cancer was considered radiation resistant. Owing to the unacceptable high local recurrence rates, surgery was changed (the total mesorectal excision technique) during the 1980s and treatment was, in many countries, concentrated to lager units. Moreover, the addition of adjuvant radiotherapy was tested during the same period in several randomized trials and demonstrated that the local recurrence rate could be reduced by 50%, provided the radiation dose was high enough. Since then, treatment has changed very rapidly with several interesting approaches, such as timing and type of radiotherapy, the place of chemotherapy, surgery with modern technique including laparoscopy; natural orifice transendoscopic surgery or robotics; and the whole idea of ‘wait-and-watch’ program. All of these new aspects are covered and discussed in the view of the standard-of-care in 2014.

Laparoscopic versus open surgery following neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the short-term and pathological outcomes of laparoscopic surgery (LS) versus open surgery (OS) following neoadjuvant chemoradiotherapy (NCRT) for rectal cancer.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, and Chinese Biomedicine Literature databases were searched for eligible studies published up to July 2013. The rates of postoperative complication, positive circumferential resection margin (CRM), and the number of lymph nodes harvested were evaluated.

RESULTS

Three randomized controlled trials (RCTs) and five non-RCTs enrolling 953 patients were included. Compared to OS, LS had similar rate of postoperative complication [odds ratio (OR) 0.86; 95% confidence interval (CI), 0.60 to 1.22], comparable rate of positive CRM (OR 0.41; 95% CI, 0.16 to 1.02), and smaller number of lymph nodes (weighted mean difference -0.8; 95% CI, -1.1 to -0.5). LS also had significantly less blood loss, faster bowel movement recovery, and shorter postoperative hospitalization than those of OS.

CONCLUSION

LS is associated with favorable short-term benefits, similar postoperative complication rate, and comparable pathological outcomes for rectal cancer after NCRT compared to OS despite a slight difference in the number of lymph nodes. Additional high-quality studies are needed to validate long-term outcomes of LS following NCRT.

Minimal access surgery for rectal cancer: an update

Minimally invasive or minimal access surgery (MAS) for colon and rectal cancer was introduced in the early 1990s. Although laparoscopic colon surgery is now practiced worldwide, technical barriers, including a steep learning curve, preclude the widespread adoption of MAS techniques for rectal cancer. In addition, although randomized controlled trials have demonstrated that MAS techniques for colon cancer are oncologically equivalent to open surgery, similar confirmatory studies for rectal cancer have yet to be reported. In this Review, current evidence in support of laparoscopic and robotic total mesorectal excision for rectal cancer resection is presented. Other MAS approaches, such as transanal endoscopic microsurgery and natural orifice transluminal endoscopic surgery, are also discussed.

Functional long-term results after rectal cancer surgery--technique of the athermal mesorectal excision

PURPOSE

The total mesorectal excision (TME), embedded in a multimodal therapeutic concept, is accepted as the standard therapy of the advanced adenocarcinoma of the middle and lower thirds. The thermal damages of the autonomous nerves in the little pelvis caused by dissection devices remains a large problem. For our patients, we use water-jet dissection (WJD)-aided TME with the intention to minimise the rate of bladder and sexual function disorders.

METHODS

From October 2001 until June 2010, we recorded 125 patients with an adenocarcinoma of the middle and lower third of the rectum. Ninety deep anterior rectum resections and 35 abdominoperineal rectum extirpations by WJD were performed. Of the patients, 27.2 % received neoadjuvant radiochemotherapy. Bladder and sexual function disorders were assessed by International Prostate Symptom Score and International Index of Erectile Function.

RESULTS

The median follow-up period was 46 (2-117) months. Considering a local recurrence rate of 9.6 %, the tumour-specific 5-year survival of the entire collective was 75.4 %. Long-term bladder function disorders showed in 6.0 % (4/64) and sexual function disorders in 25.0 % (9/36) of the male patients in the course of time.

CONCLUSION

The specific advantage of the WJD technique is not only the facilitated dissection between the mesorectal fascia and the surrounding nervous structures in the little pelvis but also a completely athermal TME. The rate of bladder and sexual function disorders is an excellent result compared to that of international centres. Due to the size of the patient collective and the retrospective character of the study, further studies are necessary to validate the presented results.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

Factors affecting operating time in laparoscopic anterior resection of rectal cancer

Background

The objective of this study is to clarify the relationship between demographic and surgical factors and operating time, and thus operative difficulty, in patients undergoing laparoscopic anterior resection for mid-low rectal cancer, since different studies have derived different results.

Methods

The records of patients with mid-low rectal cancer who underwent laparoscopic anterior resection were retrospectively studied. Demographic data, tumor characteristics, and pelvimetry measurements were collected and analyzed with respect to operating time, using correlation coefficient analysis, principle component analysis, and linear regression.

Results

A total of 14 patients (10 males, 4 females; 65.50 ± 7.12 years of age) were included. Demographic and tumor characteristics not correlated with operating time. Body mass index (BMI) (P = 0.001); interacetabular distance (IA) (P = 0.001); anatomical transverse distance (IP) (P = 0.008); interischial distance (IS) (P = 0.002); intertuberous distance (IT) (P = 0.005); distance between the coccyx and symphysis (CoSy) (P = 0.013); and the angle of the lower border of the symphysis pubis, upper border of symphysis pubis, and sacral promontory (angle 5) (P = 0.004) were significantly associated with operating time. The equation was:

operatingtime=0.653×BMI+0.818×angle5-0.404×IA-0.380×IP-0.512×IS-0.405×IT-0.570×CoSy+330.8.

Conclusions

Transverse diameters of the pelvis, BMI, angle 5, and CoSy played the most important role in affecting operating time. The equation can be a very useful tool for preoperative assessment.

Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach

BACKGROUND AND OBJECTIVES

The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes.

METHODS

Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach.

RESULTS

Overall, 294 patients were analyzed-116 LAP (39.5%), 153 OPEN (52.0%), and 25 (8.5%) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1-20) LAP, 6 days (range 3-13) CONVERTED, and 8 days (range 1-35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)-complication rates were 43.8% OPEN, 32.0% CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6% OPEN, 16.0% CONVERTED, 12.1% LAP). Overall 3-year disease-free survival (DFS) was 98.3%, and local recurrence rate was 2.0%. By approach, DFS was 100% CONVERTED, 93.1% LAP, and 87.6% OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1% LAP, and 97.4%. OPEN. Local recurrence was 0% CONVERTED, 2% OPEN, and 2.6% LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43).

CONCLUSIONS

LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.

Evolving treatment strategies for colorectal cancer: A critical review of current therapeutic options

Management of rectal cancer has markedly evolved over the last two decades. New technologies of staging have allowed a more precise definition of tumor extension. Refinements in surgical concepts and techniques have resulted in higher rates of sphincter preservation and better functional outcome for patients with this malignancy. Although, preoperative chemoradiotherapy followed by total mesorectal excision has become the standard of care for locally advanced tumors, many controversial matters in management of rectal cancer still need to be defined. These include the feasibility of a non-surgical approach after a favorable response to neoadjuvant therapy, the ideal margins of surgical resection for sphincter preservation and the adequacy of minimally invasive techniques of tumor resection. In this article, after an extensive search in PubMed and Embase databases, we critically review the current strategies and the most debatable matters in treatment of rectal cancer.

Evaluation of short-term outcomes after laparoscopically assisted abdominoperineal resection for low rectal cancer

BACKGROUND

To investigate the feasibility, safety and short-term efficacy of laparoscopic techniques applied in the abdominoperineal resection (APR) for low rectal cancer.

METHODS

The clinical data of 236 patients with APR from January 2010 to January 2012 were analysed retrospectively, including 100 patients underwent laparoscopically assisted APR (LAAPR group), 136 cases of open APR (OAPR group). The demographics, tumor and procedure-related parameters, perioperative results and short-term oncological outcomes were evaluated using t-test or χ(2) -test.

RESULTS

The demographic data of the two groups were comparable. Perioperative results were better after laparoscopic surgery, with less intraoperative blood loss (P = 0.017), earlier return of bowel function (P < 0.05) and lower complication rates (P = 0.015). No significant differences were detected between the two groups in operation time, tumor size, specimen length, the distance of tumor from the anal verge, lymph nodes removed and the status of circumferential resection margin (P > 0.05). During the follow-up period of 17-38 months (average, 26 months), the overall survival rates were not significantly different between the two groups [82.5% (80/97) versus 82.7% (110/133), P > 0.05]. The differences in recurrence and metastasis between the two groups were not statistically significant.

CONCLUSION

Laparoscopically assisted APR for low rectal cancer is safe and effective. It has the advantages of less bleeding, rapid postoperative recovery and fewer complications, without affecting the radical degree of the surgery. Further studies are needed to fully assess oncological outcomes in the future.

Efficacy of laparoscopic versus Dixon radical resection for rectal cancer

AIM: To compare the clinical effects of laparoscopic versus Dixon radical operation for rectal cancer.

METHODS: Fifty-three patients who underwent laparoscopic operation and sixty-nine cases who underwent Dixon operation from January 2006 to January 2013 at our hospital were included in this study. The operative time, intraoperative bleeding, postoperative anal exhaust time, and postoperative complications as well as short-term and long-term curative effects were compared between the two groups.

RESULTS: Compared with the Dixon operation group, laparoscopic surgery had significantly shorter operative time (165.18 min ± 25.45 min vs 177.19 min ± 12.28 min, P = 0.014), less intraoperative bleeding volume (589.85 mL ± 127.45 mL vs 682.30 mL ± 122.76 mL, P = 0.004), and shorter postoperative anal exhaust time (3.94 d ± 1.0 d vs 4.62 d ± 1.3 d, P = 0.01), while the number of intraoperatively removed lymph nodes (3.8 ± 1.6 vs 3.7 ± 1.2, P = 0.756) did not significantly between the two groups. In addition, the satisfaction to low incidence of postoperative complications, such as anastomotic leakage, wound infection and adhesion obstruction, as well as urinary and sexual functions was significantly higher in the laparoscopic operation group (P = 0.033, 0.049, 0.000), although there were no statistical differences in local tumor recurrence or distant metastasis and 5-year survival rate between the two groups (P = 0.701, 0.583).

CONCLUSION: Compared with Dixon operation for rectal cancer, laparoscopic surgery was associated with minimal invasion, quicker recovery, fewer postoperative complications and higher satisfaction to sexual and urinary functions, although the 5-year survival rate, local tumor recurrence and distant metastasis showed no significant differences between the two groups.

Short-term efficacy of laparoscopic and open Dixon surgery for rectal cancer

AIM: To compare the short-term efficacy of laparoscopic and open Dixon surgery for rectal cancer.

METHODS: The clinical data for 109 patients who received Dixon surgery for rectal cancer at our hospital between June 2011 and June 2013 were reviewed retrospectively and perioperative results were compared. The patients were divided into two groups, a laparoscopy group (n = 48) and an open surgery group (n = 61).

RESULTS: The operation was successfully performed on all patients. The mean operation time for the laparoscopy group was significantly longer than that for the open surgery group (231.0 min ± 60.3 min vs 201.7 min ± 46.9 min, P < 0.05). The length of operative incision (5.9 cm ± 0.7cm vs 15.1 cm ± 2.6 cm), blood loss (96.2 mL ± 20.0 mL vs 181.2 mL ± 117.7 mL), postoperative administration of anodyne (0.5 ± 0.6 vs 0.9 ± 0.8), time to anal exhaust (2.1 d ± 0.8 d vs 3.0 d ± 0.7 d), time of liquid food intake (3.3 d ± 0.5 d vs 4.3 d ± 0.4 d), urinary catheterization time (4.5 d ± 0.5 d vs 6.2 d ± 0.4 d), pelvic cavity drainage tube placement time (7.5 d ± 0.6 d vs 8.2 d ± 0.4 d), and postoperative hospitalization time (11.7 d ± 2.1 d vs 13.8 d ± 2.8 d) were significantly less in the laparoscopy group than in the open surgery group (all P < 0.05). The postoperative complication, mass maximal diameter, the distance between the distal and proximal margin and the mass in rectum specimens, resected lymph node number and positive lymph node number were not significantly different between the two groups (all P > 0.05).

CONCLUSION: The laparoscopic Dixon surgery for rectal cancer is safe and feasible in terms of favorable short-term outcomes and minimal invasiveness.

Long-term oncologic outcomes of laparoscopic versus open surgery for rectal cancer: a pooled analysis of 3 randomized controlled trials

OBJECTIVE

To compare long-term oncologic outcomes between laparoscopic and open surgery for rectal cancer and to identify independent predictors of survival.

BACKGROUND

Few randomized trials comparing laparoscopic and open surgery for rectal cancer have reported long-term survival data.

METHODS

Data from the 3 randomized controlled trials comparing curative laparoscopic (n=136) and open surgery (n=142) for upper, mid, and low rectal cancer conducted at the Prince of Wales Hospital, Hong Kong, between September 1993 and August 2007 were pooled together for this analysis. Survival and disease status were updated to February 2012. Survival was calculated using the Kaplan-Meier method, and independent predictors of survival were determined using the Cox regression analysis.

RESULTS

The demographic data of the 2 groups were comparable. The median follow-up time of living patients was 124.5 months in the laparoscopic group and 136.6 months in the open group. At 10 years, there were no significant differences in locoregional recurrence (5.5% vs. 9.3%; P=0.296), cancer-specific survival (82.5% vs. 77.6%; P=0.443), and overall survival (63.0% vs. 61.1%; P=0.505) between the laparoscopic and open groups. There was a trend toward lower recurrence rate at 10 years in the laparoscopic group than in the open group among patients with stage III cancer (P=0.078). The Cox regression analysis showed that stage III cancer, lymphovascular permeation, and blood transfusion, but not the operative approach, were independent predictors of poorer cancer-specific survival.

CONCLUSIONS

This pooled analysis with a follow-up of more than 10 years confirms the long-term oncologic safety of laparoscopic surgery for rectal cancer.

Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.

Short-term follow-up after laparoscopic versus conventional total mesorectal excision for low rectal cancer in a large teaching hospital

PURPOSE

Laparoscopic resection for low rectal cancer remains controversial, and large randomized studies on oncologic outcome are lacking. The objective of this study was to analyze the short-term results of laparoscopic resection versus conventional total mesorectal excision (TME) for low rectal cancer (≤10 cm from the anal verge).

METHODS

The institutional colorectal surgery database was reviewed, and 166 consecutive patients operated for low rectal cancer between 2006 and 2011 were included in this analysis which focuses on the first 18 months of follow-up.

RESULTS

Eighty patients underwent conventional TME, whereas 86 patients underwent laparoscopic TME. Patient characteristics were comparable between groups. Conversion rate was 17 %. Laparoscopic rectal resection resulted in significantly less blood loss (200 versus 475 ml, p = <0.001) and a 3-day shorter hospital stay (median, 7 versus 10 days; p = 0.06). Oncologic results from resected specimens were comparable, although significantly more lymph nodes were harvested in laparoscopic resections (median, 13 versus 11; p = 0.005). Disease-free survival after curative resection was better in the laparoscopic group (p = 0.04), but this was no longer significant after correction for potential confounders.

CONCLUSIONS

This analysis of short-term results of laparoscopic versus conventional TME for low rectal cancer demonstrates that laparoscopic surgery is feasible and safe, resulting in similar oncologic outcomes with less blood loss, a trend towards less postoperative complications and shorter duration of hospital stay. Further randomized studies are needed to attribute to the body of evidence of equivalence or even superiority of laparoscopic resections compared to conventional resections for distal rectal cancer.

Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy for patients with colorectal cancer peritoneal carcinomatosis: initial results from a single center

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.

Urinary and erectile function in men after total mesorectal excision by laparoscopic or robot-assisted methods for the treatment of rectal cancer: a case-matched comparison

BACKGROUND

Urinary and sexual dysfunction are recognized complications of rectal cancer surgery in men. This study compared robot-assisted total mesorectal excision (RTME) and laparoscopic total mesorectal excision (LTME) with regard to these functional outcomes.

METHODS

A series of 32 men who underwent RTME between February 1, 2009 and December 31, 2010 were matched 1:1 with patients who underwent LTME. The matching criteria were age, body mass index, tumor distance from the anal verge, neoadjuvant chemoradiation therapy, and tumor stage. Urinary and erectile function were evaluated using the International Prostatic Symptom Score (IPSS) and the five-item version of the International Index of Erectile Function (IIEF-5) scale. Data were collected from the two groups at baseline and at 3, 6, and 12 months after surgery and compared.

RESULTS

The mean IPSS score did not differ between the two groups at baseline at any point of measurement. The mean baseline IIEF-5 score was similar between the two groups and was decreased at 3 months. The mean IIEF-5 score was significantly higher in the RTME group at 6 months than in the LTME group (14.1 ± 6.1 vs. 9.4 ± 6.6; p = 0.024). The interval decrease in IIEF-5 scores was significantly higher in the LTME group than in the RTME group at 6 months (4.9 ± 4.5 vs. 9.2 ± 4.7; p = 0.030).

CONCLUSIONS

The men in the RTME group experienced earlier restoration of erectile function than did those in the LTME group. Bladder function was similar during the 12 months after RTME or LTME.

Early rehabilitation programs after laparoscopic colorectal surgery: evidence and criticism

During the past several decades, early rehabilitation programs for the care of patients with colorectal surgery have gained popularity. Several randomized controlled trials and meta-analyses have confirmed that the implementation of these evidence-based detailed perioperative care protocols is useful for early recovery of patients after colorectal resection. Patients cared for based on these protocols had a rapid recovery of bowel movement, shortened length of hospital stay, and fewer complications compared with traditional care programs. However, most of the previous evidence was obtained from studies of early rehabilitation programs adapted to open colonic resection. Currently, limited evidence exists on the effects of early rehabilitation after laparoscopic rectal resection, although this procedure seems to be associated with a higher morbidity than that reported with traditional care. In this article, we review previous studies and guidelines on early rehabilitation programs in patients undergoing rectal surgery. We investigated the status of early rehabilitation programs in rectal surgery and analyzed the limitations of these studies. We also summarized indications and detailed protocol components of current early rehabilitation programs after rectal surgery, focusing on laparoscopic resection.

Transanal natural orifice specimen extraction for laparoscopic anterior resection in rectal cancer

AIM: To investigate whether transanal natural orifice specimen extraction (NOSE) is a better technique for rectal cancer resection.

METHODS: A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal cancer with various tumor-node-metastasis classifications from March 2011 to February 2012 at the First Affiliated Hospital of Sun Yat-Sen University was analyzed. Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of tumor size and distance of rectal lesions from the anal verge. Demographic data, operative parameters, and postoperative outcomes were assessed.

RESULTS: None of the patients was converted to laparotomy. Respectively, there were 16 cases in the low anastomosis and five in the ultralow anastomosis groups. Mean age of the patients was 45.4 years, and mean body mass index was 23.1 kg/m². Mean distance of the lower edge of the lesion from the anal verge was 8.3 cm. Mean operating time was 132 min, and mean intraoperative blood loss was 84 mL. According to the principle of rectal cancer surgery, we performed D2 lymph node dissection in 13 cases and D3 in eight. Mean lymph nodes harvest was 17.8, and the number of positive lymph nodes was 3.4. Median hospital stay was 6.7 d. No serious postoperative complication occurred except for one anastomotic leakage. All patients remained disease free. Mean Wexner score was 3.7 at 11 mo after the operation.

CONCLUSION: Transanal NOSE for total laparoscopic low/ultralow anterior resection is feasible, safe and oncologically sound. Further studies with long-term outcomes are needed to explore its potential advantages.

Long-term oncologic outcome after laparoscopic surgery for rectal cancer

BACKGROUND

Recent studies demonstrated favorable short- and mid-term results after laparoscopic surgery for rectal cancer. However, long-term results from large series are lacking. The present study analyses long-term results of laparoscopic rectal cancer surgery from a large-volume center.

METHODS

From January 1998 until March 2005, 225 patients underwent laparoscopic rectal resection due to carcinoma at the Medical Centre of the University of Regensburg. From 224 patients, a follow-up over 10 years was performed using the data of the Tumour Centre of the University of Regensburg. The data were analysed using oncological data (tumour recurrence) as well as overall survival. In addition, the effect of conversion to open resection on overall survival was analysed.

RESULTS

With a median of 10 years at follow-up, the overall and disease-free survival was 50.5 and 50.1 %, respectively. Local recurrence of all patients was 5.8 % and none of the converted patients was within this group. The median time interval for the development of local recurrence was 30 months. Six of the 13 patients with local recurrence (46.1 %) had received neoadjuvant radiochemotherapy before surgery. Patients with a conversion to open surgery had primarily a significantly worse outcome than patients resected completely laparoscopically (p = 0.003). However, this difference was no longer apparent using a multivariant analysis (hazard ratio 1.221; p = 0.478).

CONCLUSIONS

Overall survival and local recurrence rate of patients undergoing laparoscopic resection of rectal cancer are comparable to open surgery. However, in our analysis, patients undergoing laparoscopic anterior resection had a higher survival rate compared with patients with abdominoperineal resection.

Outcome of laparoscopic versus open hepatectomy for colorectal liver metastases

BACKGROUND

Liver resection provides one of the best oncological outcomes for liver metastases in patients with colorectal cancer. However, long-term results concerning laparoscopic resection versus open hepatectomy for stage IV colon cancer are still limited. The aim of this study is to compare the survival outcome of laparoscopic liver resection with open liver resection for colorectal metastases.

METHOD

Between October 2002 and September 2011, a total of 1697 patients underwent liver resection for liver tumour and 60 patients underwent pure laparoscopic liver resection. Twenty patients had laparoscopic resection for colorectal liver metastases. Case-matched control patients who received open liver resection were included for comparison. The immediate operative outcomes and survival outcomes including operation morbidity were compared.

RESULTS

Twenty patients underwent laparoscopic resection of liver metastases. Forty patients who had open hepatectomy for colorectal metastases were selected as case control. Comparing the laparoscopic group with the open resection group, the median operating time was 180 min versus 210 min P = 0.059, the median blood loss was 200 versus 310 mL (P = 0.043). Hospital stay was 4.5 versus 7 days (P = 0.021), disease-free survival was 9.8 versus 10.9 months (P = 0.299), and the median survival was 69.4 versus 42.1 months (P = 0.235).

CONCLUSIONS

Laparoscopic liver resection is a safe and effective treatment for liver metastases in patients with colorectal cancer. It is associated with less blood loss and shorter hospital stay when compared with open surgery. Long-term survival is comparable to the conventional open approach.

What factors influence 10-year survival after curative resection of a colorectal carcinoma?

BACKGROUND

Ten-year survival rates are only rarely reported and frequently include a large proportion of censored data-that is, most of the patients have not survived the 10 years. We therefore selected patients in a prospectively maintained, hospital-based tumor register who had been operated on for colorectal carcinoma (CRC) more than 10 years earlier and who were classified as long-term survivors.

METHODS

For 589 consecutive CRC patients who underwent R0 resection in the period 1990-1998, we compared prognosis-relevant characteristics and calculated the survival rate as a function of age, sex, location of the tumor, general state of health, urgency of the operation, and pT and pN class. All patients were observed until their death or until at least 10 years after resection. Patients who died of other causes were censored. Overall survival and relative survival (the latter based on tumor-related death) were assessed.

RESULTS

The 10-year survivors were more often female (not significant), younger (p < 0.001), in good general health (p < 0.001), had undergone elective resection (p < 0.001), and had early-stage tumors (p < 0.001). In the univariate analysis emergency operation, impaired general health, invasion beyond the muscularis propria, and lymph-node metastasis were found to reduce relative survival. In the multivariate analysis, location, emergency resection, pT, and pN were found to be statistically independent risk factors.

CONCLUSIONS

Long-term freedom from tumor recurrence, like-short-term, is influenced largely by factors that are beneficially influenced by early recognition. The patient's age at resection is immaterial.

Risk factors and predictive factors for anastomotic leakage after resection for colorectal cancer: reappraisal of the literature

Anastomotic leakage is a serious complication that can occur after colorectal surgery. Several risk factors for anastomotic leakage have been reported based on the findings of prospective and retrospective studies, including patient characteristics, the use of neoadjuvant therapy, the tumor location, intraoperative events, etc. However, as these risk factors affect each other, the statistical results have differed in each study. In addition, differences in surgical methods, including laparoscopy versus laparotomy or stapling anastomosis versus handsewn anastomosis, may influence the incidence of anastomotic leakage. This mini-review summarizes the results of reported papers to clarify the current evidence of risk factors for anastomotic leakage.

Laparoscopic surgery for rectal cancer: outcomes in 513 patients

BACKGROUND

Few reports have demonstrated the feasibility and efficacy of laparoscopic resection in patients with rectal cancer (RC). The objective of the present study was to assess the effectiveness of laparoscopic resection for RC, with an emphasis on perioperative variables and long-term oncological outcomes.

METHODS

This prospective study was carried out between January 2005 and September 2010 and included 513 patients diagnosed with RC who underwent laparoscopic surgery. Patients with locally advanced RC (cT3/cT4 or N+) received neoadjuvant treatment. Adjuvant treatment was applied to patients with stage II/III disease or according to the neoadjuvant protocol. All patients were followed-up prospectively for the evaluation of complications and oncological outcome. Survival rate analysis was performed using the Kaplan-Meier method.

RESULTS

Sphincter-preserving surgery was performed on 389 patients, and the remaining 124 patients underwent abdominoperineal resection. Perioperative mortality occurred in only one patient (0.2 %), and 27 (5.3 %) intraoperative complications were recorded. The most common postoperative complication was anastomotic leakage (5.5 %). The conversion rate was 6.4 %. The mean number of harvested lymph nodes was 23.6 ± 13. The mean distance to the distal margin was 2.6 ± 1.9 (0-7) cm. Distal margin positivity was detected in 9 (1.7 %) patients. The circumferential margin was positive in 39 (7.6 %) cases. After a median follow-up period of 30 (1-78) months, recurrence occurred in a total of 59 patients (11.5 %). Local recurrence was detected in 16 patients (3.1 %), and both local and distant recurrence was found in 7 patients (1.4 %). Distant recurrence only was detected in 43 patients (8.4 %). The overall 5-year survival rate was 84 %, and the 5-year disease-free survival rate was 77.4 %. The local recurrence-free survival rate was 98.4 % at 2 years, 95.7 % at 3 years, and 94.3 % at 5 years.

CONCLUSIONS

Our results, together with the review of the literature, clearly demonstrate that laparoscopic resection for RC is a feasible method at specialized high-volume centers. The long-term outcomes are at least as good as those from open surgery as long as the principles of oncologic surgery are respected and faithfully performed.

Laparoscopic versus open surgery for stage I rectal cancer: long-term oncologic outcomes

BACKGROUND

Laparoscopic resection is increasingly being performed for rectal cancer. However, few data are available to compare long-term outcomes after open versus laparoscopic surgery for early-stage rectal cancer.

METHODS

Included in this retrospective study were 160 patients who underwent surgery for stage I rectal cancer between 2001 and 2008. Perioperative outcomes, overall survival (OS), and disease-free survival (DFS) were compared for open versus laparoscopic surgery.

RESULTS

Altogether, 85 patients were treated using open surgery and 80 with laparoscopic surgery. Postoperative mortality (0 vs. 1.3%; p = 1.00), morbidity (31.3 vs. 25.0%; p = 0.38), and harvested lymph nodes (22.5 vs. 20.0; p = 0.84) were similar for the two groups. However, operating time was longer (183.8 vs. 221.0 min; p = 0.008), volume of intraoperative bleeding was less (200.0 vs. 150.0 ml; p = 0.03), time to first bowel movement was shorter (3.54 vs. 2.44 days; p < 0.001), rate of superficial surgical-site infection was lower (7.5 vs. 0%; p = 0.03), and postoperative hospital stay was shorter (11.0 vs. 8.0 days; p < 0.001) in the laparoscopy group than in the open surgery group. At 5 years, there was no difference in OS (98.6 vs. 97.1%; p = 0.41) or DFS (98.2 vs. 96.4%; p = 0.30) between the open and laparoscopy groups.

CONCLUSIONS

Long-term outcomes of laparoscopic surgery for stage I rectal cancer were comparable to those of open surgery. Laparoscopic surgery, however, produced more favourable short-term outcomes than open surgery.

Influence of conversion on the perioperative and oncologic outcomes of laparoscopic resection for rectal cancer compared with primarily open resection

BACKGROUND

This study aimed to evaluate the influence of conversion on perioperative and short- and long-term oncologic outcomes in laparoscopic resection for rectal cancer and to compare these with those for an open control group.

METHODS

The data of 276 consecutive patients who underwent surgery for rectal cancer between 2006 and 2010 at a single institution were prospectively collected. Of the 276 patients, 114 underwent primarily open surgery, and 162 underwent laparoscopic surgery (on an intention-to-treat basis). Of the 162 laparoscopic patients, 38 (23.5%) underwent conversion to open surgery. The three groups of patients were compared: the conversion surgery group, the open surgery group, and the completed laparoscopy surgery group.

RESULTS

The converted patients had more wound infections (18.4 vs 4.8%, p = 0.009), but the wound infection rate in the primarily open group also was significantly higher than in the laparoscopic resection group (p = 0.007). No further differences in perioperative morbidity, including anastomotic leakage, were found. The perioperative 30-day mortality rate was comparable between all the groups (0.6 vs 2.6 vs 2.6%, nonsignificant difference). The oncologic parameters such as number of harvested lymph nodes and rate of R0 resection were equal in all the groups. The completed laparoscopy group had a shorter hospital stay [12 vs 16 days in the primarily open group (p = 0.02) vs 15 days in the converted group (p = 0.03)]. The rates for survival, local recurrence (4.5 vs 3 vs 3%), and metachronous metastasis (10.1 vs 9.3 vs 9%) did not differ significantly between the three groups after a period of 3 years.

CONCLUSION

Conversion to open surgery in laparoscopic rectal resection has no negative effect on perioperative or long-term oncologic outcome.

Laparoscopic and open colorectal resections for colorectal cancer

BACKGROUND

Surgical resection is the mainstay of treatment for colorectal cancer with curative intent.

AIM

To evaluate the postoperative results of laparoscopic and laparotomic colorectal resections for colorectal cancer.

METHODS

A retrospective study of a series of 189 patients. The descriptive variables were age and gender, and for outcome were type of resection, number of lymph nodes resected, free margins, the need for colostomy, complications, operative time and hospital stay. They were analyzed using the chi-square, Student t and Mann-Whitney test, with significance level <0.05.

RESULTS

Of the 189 operated patients, 110 met the inclusion criteria, 75 (68.2%) operated by open surgery and 35 (31.8%) by laparoscopic. The sigmoid colon was the most common site presented by neoplasia and rectosigmoidectomy was performed more by open colorectal resection (p = 0.042). The conversion rate was 7.9% (3/38). The patients were operated by open surgery in 81.5% of time less than 180 minutes (p <0.001). In both pathways, the average number of removed lymph nodes was greater than 12, but laparotomy enabled, more frequently, the resection of 12 or more nodes (p = 0.012). No patient had surgical margins involved, but laparotomy allowed a greater number of patients with a margin greater than 5 cm from the tumor (p = 0.036). Increased number of patients treated by open surgery were hospitalized for more than seven days (p <0.001). There were no statistically significant differences regarding the need for ostomies, complications and mortality.

CONCLUSIONS

The laparoscopic approach was as safe and effective as laparotomy in the treatment of colorectal cancer, and was associated with increased operative time, shorter hospital stay and less morbidity.

Does conversion affect short-term and oncologic outcomes after laparoscopy for colorectal cancer?

BACKGROUND

Conversion of laparoscopic colorectal resection (LCR) for cancer has been associated with adverse short-term and oncologic outcomes. However, most studies have had small sample sizes and short follow-up periods. This study aimed to evaluate the impact of conversion to open surgery on early postoperative outcomes and survival among patients undergoing LCR for nonmetastatic colorectal cancer.

METHODS

A prospective database of consecutive LCRs for nonmetastatic colorectal cancer was reviewed. Patients who required conversion (CONV group) were compared with those who had completed laparoscopic resection (LAP group). Only patients with a minimum 5-year follow-up period were included in the oncologic analysis. Kaplan-Meier curves were compared to analyze survival. A multivariate analysis was performed to identify predictors of poor survival.

RESULTS

The conversion rate was 10.9%. The most common reason for conversion was a locally advanced tumor (48.4%). Conversion was associated with a significantly longer operative time and a greater blood loss. No differences were observed in terms of postoperative morbidity, mortality, or hospital stay between the CONV and LAP patients. During a median follow-up period of 120 months (range, 60-180 months), the CONV group had a significantly worse 5-year overall survival (OS) (79.4 vs 87.4%; p = 0.016) and disease-free survival (DFS) (65.4 vs 79.6%; p = 0.013). Univariate analysis showed that conversion to open surgery, postoperative complications, anastomotic leakage, pT4 cancer, stage 3 disease, and adjuvant chemotherapy were significant risk factors for OS and DFS. On multivariate analysis, pT4 cancer and a lymph node ratio (LNR) of 0.25 or greater were the only independent predictors of DFS and OS, whereas a LNR of 0.01 to 0.24 showed a trend that did not reach statistical significance.

CONCLUSION

Conversion to open surgery per se is not associated with worse early postoperative outcomes and does not adversely affect long-term survival per se.

Laparoscopic versus robotic rectal resection for rectal cancer in a veteran population

BACKGROUND

Robotic rectal cancer resection remains controversial. We compared the safety and efficacy of laparoscopic vs robotic rectal cancer resection in a high-risk Veterans Health Administration population.

METHODS

Patients who underwent minimally invasive rectal cancer resection were identified from an institutional colorectal cancer database. Baseline characteristics and outcomes were compared between robotic and laparoscopic groups.

RESULTS

The robotic group (n = 13) did not differ significantly from the laparoscopic group (n = 59) with respect to baseline characteristics except for a higher rate of previous abdominal surgery. Robotic patients had significantly lower tumors, more advanced disease, a higher rate of preoperative chemoradiation, and were more likely to undergo abdominoperineal resection. Robotic rectal resection was associated with longer operative time. There were no differences in blood loss, conversion rates, postoperative morbidity, lymph nodes harvested, margin positivity, or specimen quality between groups.

CONCLUSIONS

The robotic approach for rectal cancer resection is safe with similar postoperative and oncologic outcomes compared with laparoscopy.

Intraoperative rectal washout in rectal cancer surgery: a survey of current practice in the UK

OBJECTIVES

Due to concerns about implantation of malignant cells during surgery for rectal cancer, traditionally, intraoperative rectal washout (IORW) has been performed to prevent local recurrence. But with the advent of laparoscopic surgery, many surgeons have abandoned this practice. The aim of this study was to assess current practice among colorectal surgeons in the UK.

METHODS

A 10-item questionnaire was sent by email to 452 consultant surgeons, who were members of the Association of Coloproctology of Great Britain & Ireland, and had previously agreed to participate in research projects.

RESULTS

The mean age of the 149 responders (n = 149, 33.0%) was 49.2 years. The mean number of years in independent practice was 12.1, and the mean number of rectal cancer cases performed per year was 20.3 and 20.6, in the years 2010 and 2011 respectively. 74.3% of the responders believed that there is an advantage in performing IORWs in rectal cancer resections. Of the 71.8% of all responders who performed laparoscopic rectal cancer resections, 54.8% routinely performed IORWs during laparoscopic resections. However, 87.2% of all responders performed IORWs in open resections for rectal cancer, and 79.2% had routinely performed IORWs before the advent of laparoscopic rectal cancer surgery.

CONCLUSIONS

Most colorectal surgeons believe that there is an advantage in performing IORWs. Although, most surgeons would routinely perform IORWs in open resections, they do not routinely perform these in laparoscopic resections.

Laparoscopic colorectal fellowship training programme : a 6-year experience in a university colorectal unit

BACKGROUND

The aim of this study was to evaluate a structured training programme for laparoscopic colorectal surgery in a university colorectal unit over a 6-year period.

METHODS

Data on patients who underwent laparoscopic colectomy between November 2004 and October 2010 were analyzed. Operations were performed either by the consultant colorectal surgeons or colorectal fellows. The effectiveness and safety of our structured training programme were evaluated.

RESULTS

During the study period, 813 patients (478 men) with a median age 69 years (range 22-93) underwent laparoscopic colectomy. A total of 370 cases (45.5 %) were performed by four colorectal fellows. Overall, 674 patients (82.9 %) were classified as ASA I or II. The conversion rate was 3.7 %. The conversion rate, intra-operative blood loss, number of lymph nodes retrieved and post-operative recovery were similar between the two groups. When comparing with consultant group, the patients operated by fellows were: (1) significantly older; (2) more were operated on as emergency cases; (3) had pathologically less advanced tumours; (4) less patients with low rectal cancers. There were two surgical mortalities in this series. The morbidities between the two groups were similar. At the end of 3 years of training, the fellows had performed more than 85 cases of laparoscopic colectomies. The level of supervision decreased with increased experience. Finally, experienced fellows were able to supervise more junior colleagues on laparoscopic colectomies.

CONCLUSIONS

Our results confirmed a structured training programme for laparoscopic colectomy is safe and effective. Reasonable results were achieved even though a high volume of cases were performed by surgical fellows.

Long-term outcomes after laparoscopic surgery versus open surgery for rectal cancer: a propensity score analysis

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.

Low rectal cancer: classification and standardization of surgery

BACKGROUND

Surgical treatment of low rectal cancer is controversial, and one of the reasons is the lack of definition and standardization of surgery in low rectal cancer.

OBJECTIVE

We classified low rectal cancers in 4 groups with the aim of demonstrating that most patients with low rectal cancer can receive conservative surgery without compromising oncologic outcome.

DESIGN

Patients with low rectal cancer <6 cm from anal verge were defined in 4 groups: type I (supra-anal tumors: >1 cm from anal ring) had coloanal anastomosis, type II (juxta-anal tumors: <1 cm from anal ring) had partial intersphincteric resection, type III (intra-anal tumors: internal anal sphincter invasion) had total intersphincteric resection, and type IV (transanal tumors: external anal sphincter invasion) had abdominoperineal resection. Patients with ultra-low sphincter-preserving surgery (types II-III) were compared with those with conventional sphincter-preserving surgery (type I).

OUTCOME MEASURES

Postoperative mortality, morbidity, surgical margins, local and distant recurrence, and survival were analyzed.

RESULTS

Of 404 patients with low rectal cancer, 135 were type I, 131 type II, 55 type III, and 83 type IV. There was no difference in local recurrence (5% to 9% vs 6%), distant recurrence (23% vs 23%), and disease-free survival (70%-73% vs 68%) at 5 years between ultra-low (types II-III) and conventional (type I) sphincter-preserving surgery. Predictive factors of survival were tumor stage and R1 resection but not the type of tumor or type of surgery.

LIMITATIONS

This study is limited by the retrospective analysis of a database, obtained from a single institution and covering a 16-year period.

CONCLUSION

Classification of low rectal cancers and standardization of surgery permitted sphincter-preserving surgery in 79% of patients with low rectal cancer without compromising oncologic outcome. This new surgical classification should be used to standardize surgery and increase sphincter-preserving surgery in low rectal cancer.

Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group

OBJECTIVE

To assess the risk factors for clinical anastomotic leakage (AL) in patients undergoing laparoscopic surgery for rectal cancer.

BACKGROUND

Little data are available about risk factors for AL after laparoscopic rectal cancer resection.

METHODS

This was a retrospective analysis of 1609 patients with rectal cancer who had undergone laparoscopic surgery for rectal cancer with sphincter preservation. Clinical data related to AL were collected from 11 institutions. Univariate and multivariate analyses were performed to determine the risk factors for AL.

RESULTS

AL was noted in 101 (6.3%) of the patients. The leakage rate ranged from 2.0% to 10.3% for each hospital (P = 0.04). In patients without protective stomas (n = 1187), male sex [hazard ratio (HR), 3.468], advanced tumor stage (HR, 2.520), lower tumor level (HR, 2.418), preoperative chemoradiation (HR, 6.284), perioperative transfusion (HR, 10.705), and multiple firings of the linear stapler (HR, 6.181) were significantly associated with AL. Our theoretical model suggested that the HR for patients with 2 risk factors was significantly higher than that the HR for patients with no or only 1 risk factor.

CONCLUSIONS

Male sex, low anastomosis, preoperative chemoradiation, advanced tumor stage, perioperative bleeding, and multiple firings of the linear stapler increased the risk of AL after laparoscopic surgery for rectal cancer. A diverting stoma might be mandatory in patients with 2 or more of the risk factors identified in this analysis.

Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis

BACKGROUND

In rectal surgery, some situations can be critical, such as anterior topography of locally advanced low tumors with a positive predictive radial margin, especially in a narrow pelvis of men who are obese. Transanal proctectomy is a new laparoscopic technique that uses the transanal endoscopic microsurgery device.

OBJECTIVE

The aim of this study is to evaluate the technical feasibility of laparoscopic transanal proctectomy in patients with unfavorable features.

DESIGN AND PATIENTS

This is a single-center, prospective analysis of selected patients with rectal cancer operated on from January 2009 to June 2011.

MAIN OUTCOME MEASURES

Intraoperative details and short-term postoperative outcome were described.

RESULTS

Thirty men with advanced or recurrent low rectal tumors associated with unfavorable anatomical and/or tumor characteristics underwent a sphincter-sparing transanal endoscopic proctectomy. Twenty-nine patients had received preoperative treatment. We report a 6% conversion rate, no postoperative mortality, and a 30% morbidity rate. At the beginning of our experience, a urethral injury was diagnosed in 2 patients and easily sutured intraoperatively, without postoperative after-effect. The mesorectal resection was graded as "good" in all patients. R0 resection was achieved in 26 patients (87%). The short-term stoma closure rate was 85%. After a median follow-up of 21 months, 4 patients experienced locoregional recurrence alone. Overall survival rates at 12 and 24 months were 96.6% (95% CI, 78.0-99.5) and 80.5% (95% CI, 53.0-92.9). Relapse-free survival rates at 12 and 24 months were 93.3% (95% CI, 75.9-98.3) and 88.9% (95% CI, 69.0-96.3).

LIMITATIONS

Although the transanal endoscopic proctectomy was performed by trained surgeons, we report a slight increase in early postoperative morbidity and relatively poor early outcome. There was a clear selection bias related to the study cohort exclusively composed of high-risk patients, but we need to be cautious before generalizing this technique.

CONCLUSION

The transanal endoscopic proctectomy is a feasible alternative surgical option to conventional laparoscopy for radical rectal resection in selected cases with unfavorable characteristics. Further investigations with larger cohorts are required to validate its safety and to clarify its best indication.

The multiphasic learning curve for robot-assisted rectal surgery

BACKGROUND

Robotic rectal surgery is gaining in popularity. We aimed to define the learning curve of an experienced laparoscopic colorectal surgeon in performing robot-assisted rectal surgery. We hypothesized that there are multiple phases in this learning process.

METHODS

We performed a retrospective analysis. Consecutive patients who underwent robot-assisted rectal surgery between July 2007 and August 2011 were identified. Operating times were analyzed using the CUSUM (cumulative sum) technique. CUSUMs were model fitted as a fourth-order polynomial. χ(2), Fisher's exact, two independent samples t test, one-way ANOVA, Kruskal-Wallis, and Mann-Whitney tests were used. A p value of <0.05 was considered statistically significant.

RESULTS

We identified 197 patients. The median (range) total operative, robot, console, and docking times (min) were 265 (145-515), 140 (59-367), 135 (50-360), and 5 (3-40), respectively. CUSUM analysis of docking time showed a learning curve of 35 cases. CUSUM analysis of total operative, robot, and console times demonstrated three phases. The first phase (35 patients) represented the initial learning curve. The second phase (93 patients) involved more challenging cases with increased operative time. The third phase (69 patients) represented the concluding phase in the learning curve. There was increased complexity of cases in the latter two phases. Of phase 1 patients, 45.7% had tumors ≤7 cm from the anal verge compared to 64.2% in phases 2 and 3 (p = 0.042). Of phase 1 patients, 2.9% had neoadjuvant chemoradiotherapy compared to 32.7% of patients in phases 2 and 3 (p < 0.001). Splenic flexure was mobilized in 8.6% of phase 1 patients compared to 56.8% of patients in phases 2 and 3 (p < 0.001). Median blood loss was <50 ml in all three phases. The patients in phases 2 and 3 had a longer hospital stay compared to those in phase 1 (9 vs. 8 days, p = 0.002). There were no conversions.

CONCLUSION

At least three phases in the learning curve for robot-assisted rectal surgery are defined in our study.

Long-term survival analysis of pure laparoscopic versus open hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a single-center experience

INTRODUCTION

Laparoscopic liver resection has been reported as a safe and effective approach to the management of liver cancer. However, studies of long-term outcomes regarding tumor recurrence and patient survival in comparison with the conventional open approach are limited. The aim of this study was to analyze the survival outcome of laparoscopic liver resection versus open liver resection.

PATIENTS AND METHODS

Between October 2002 and September 2009, 32 patients underwent pure laparoscopic liver resection for hepatocellular carcinoma (HCC). Case-matched control patients (n = 64) who received open liver resection for HCC were included for comparison. Patients were matched in terms of cancer stage, tumor size, location of tumor, and magnitude of resection. Immediate operation outcomes, operation morbidity, disease-free survival, and overall survival were compared between groups.

RESULTS

With the laparoscopic group compared with the open resection group, operation time was 232.5 minutes versus 204.5 minutes (P = 0.938), blood loss was 150 mL versus 300 mL (P = 0.001), hospital stay was 4 days versus 7 days (P < 0.0001), postoperative complication was 2 (6.3%) versus 12 (18.8%) (P = 0.184), disease-free survival was 78.5 months versus 29 months (P = 0.086), and overall survival was 92 months versus 71 months (P = 0.142). The disease-free survival for stage II HCC was 22.1 months versus 12.4 months (P = 0.075).

CONCLUSIONS

Laparoscopic liver resection for HCC is associated with less blood loss, shorter hospital stay, and fewer postoperative complications in selected patients with no compromise in survival.

Oncologic outcomes and perioperative clinicopathologic results after robot-assisted tumor-specific mesorectal excision for rectal cancer

BACKGROUND

Robot-assisted surgery is a new and emerging surgical procedure for rectal cancer patients. However, there is a lack of information regarding oncologic outcomes for this procedure. We aimed to evaluate oncologic and perioperative clinicopathologic outcomes of surgical resection using robotic instruments for rectal cancer.

METHODS

Data from rectal cancer patients (n = 370) diagnosed with stage I-IV disease sited below 15 cm from the anal verge who underwent robot-assisted tumor-specific mesorectal excision consecutively from June 2006 to December 2010 were evaluated. Clinicopathologic and follow-up data were recorded prospectively and analyzed retrospectively. Perioperative clinicopathologic outcomes, postoperative complications, 3-year overall survival rate, and 3-year disease-free survival rate were analyzed.

RESULTS

All patients underwent robot-assisted tumor-specific mesorectal excision. Of all postoperative pathologic stages, 15 (4.1 %) were stage 0 (pathologic complete remission), 126 (34.1 %) stage I, 95 (25.7 %) stage II, 118 (31.9 %) stage III, and 16 (4.3 %) stage IV. The 3-year overall survival rate was 93.1 % (pathologic complete remission = 100 %, stage I = 99.2 %, stage II = 97.1 %, stage III = 90.1 %, and stage IV = 48.4 %). The 3-year disease-free survival rate was 79.2 % (pathologic complete remission = 100 %, stage I = 93.7 %, stage II = 79.8 %, stage III = 69.6 %, and stage IV = 0.0 %). The 3-year cumulative local recurrence rate was 3.6 % (n = 10). The circumferential resection margin positive rate was 5.7 % (n = 21). Local recurrence developed in one patient and systemic recurrence developed in five patients. The total number of patients with postoperative complications was 86 (23.2 %).

CONCLUSIONS

These data show the feasibility and safety of robot-assisted tumor-specific mesorectal excision for rectal cancer in terms of oncologic outcomes.

The association of hospital volume with rectal cancer surgery outcomes

PURPOSE

An association between hospital volume and postoperative mortality has been identified for several oncologic surgical procedures. Our objective was to analyze differences in surgical outcomes for patients with rectal cancer according to hospital volume in the state of California.

METHODS

A cross-sectional study from 2000 to 2005 was performed using the state of California Office of Statewide Health Planning and Development database. Hospitals were categorized into low (≤30)-, medium (31-60)-, and high (>60)-volume groups based on the total number of rectal cancer operations performed during the study period.

RESULTS

Overall, 7,187 rectal cancer operations were performed. Of the 321 hospitals in the study cohort, 72 % (n = 232), 20 % (n = 65), and 8 % (n = 24) were low-, medium-, and high-volume hospitals, respectively. Postoperative mortality was significantly lower- in high-volume hospitals (0.9 %) when compared to medium- (1.1 %) and low-volume hospitals (2.1 %; p < 0.001). High-volume hospitals also performed more sphincter-preserving procedures (64 %) when compared to medium- (55 %) and low-volume hospitals (51 %; p < 0.001).

CONCLUSIONS

These data indicate that hospital volume correlates with improved outcomes in rectal cancer surgery. Rectal cancer patients may benefit from lower mortality and increased sphincter preservation in higher-volume centers.