A multicenter, propensity score-matched cohort study about short-term and long-term outcomes after laparoscopic versus open surgery for locally advanced rectal cancer

Clinical and economic effects of the transformation from an open to a laparoscopic center for colorectal surgery

PURPOSE

The purpose of this study was to assess the feasibility of transitioning from open to laparoscopic surgery for colorectal carcinoma in a primary care hospital setting. Despite the recognized benefits of laparoscopic surgery in postoperative recovery and its demonstrated oncological equivalence, only a minority of patients (30-40%) in Germany undergo laparoscopic procedures, primarily due to concerns which, in addition to the perioperative quality data and economic aspects, focus on patient safety.

METHODS

Over a three-year period (2012-2014), the transformation process was observed in a colorectal cancer center. Data from 237 patients (115 laparoscopic; 122 open) were collected prospectively and analyzed retrospectively. Short-term outcomes, including demographic data, perioperative complications, and quality metrics, as well as long-term survival data, were included.

RESULTS

Laparoscopic surgery demonstrated several advantages. Postoperative intensive care needs decreased significantly (average length of stay: laparoscopic 1.2 days vs. open 2.5 days; p = 0.032). Hospital stays were also shorter following laparoscopic surgery (median laparoscopic 10 days vs. median open 14 days; p = 0.011). Quality of specimens, particularly lymph node retrieval, remained comparable (median laparoscopic = 18 vs. median open = 19). Survival data showed non- inferiority of the laparoscopic approach. Despite higher initial costs, laparoscopic surgery yielded cost savings of approximately 3150 € per case due to reduced intensive care and shorter hospital stays.

CONCLUSION

In conclusion, this study demonstrates the feasibility of transitioning from open to laparoscopic oncologic colorectal surgery in a primary care hospital setting. The findings suggest that such a transition can be accomplished without compromising the quality of specimens, while also realizing cost savings and maintaining patient safety.

Outcomes of Minimally Invasive Rectal Cancer Resection: Insights From a Resource-Limited Setting

BACKGROUND

Minimally invasive approaches for rectal cancer treatment are emerging as the standard of care. Robotic surgery is unfeasible across the country due to constrained resource allocation. This study aimed to assess the oncologic efficacy of laparoscopic resection for rectal cancer in a resource-limited setting.

METHODS

A propensity score-matched analysis was carried out to compare the oncological outcomes of laparoscopic and open rectal cancer resection at a high-volume tertiary cancer centre in South India.

RESULTS

Two hundred and twenty patients were included (110 patients in each group). The median follow-up was 93 months. There was no difference in positive circumferential resection margin between laparoscopic and open group (4.5% vs. 6.4%, p = 0.55), with a significantly better nodal yield in laparoscopic group. There was no significant difference between the laparoscopic and open groups in terms of local recurrence (5.1% vs. 8.3%, p = 0.12), 5-year disease-free survival (86% vs. 81%, p = 0.22, HR 0.699, 95% CI 0.353-1.27) or overall survival (85% vs. 76%, p = 0.21, HR 0.658, 95% CI 0.340-1.27). The mean cost between the two groups had no difference.

CONCLUSION

In a resource-limited setting with good expertise, laparoscopic surgery is an effective minimally invasive option that has good survival outcomes without imposing a financial burden on patients.

Risk factors for anastomotic leakage after low anterior resection for obese patients with rectal cancer

PURPOSE

We aimed to analyze the risk factors for anastomotic leakage (AL) after low anterior resection (LAR) in obese patients (body mass index [BMI] ≥ 25 kg/m2) with rectal cancer.

METHODS

Data were collected from four hundred two obese patients who underwent LAR for rectal cancer in 51 institutions.

RESULTS

Forty-six (11.4%) patients had clinical AL. The median BMI (27 kg/m2) did not differ between the AL and non-AL groups. In the AL group, comorbid respiratory disease was more common (p = 0.025), and the median tumor size was larger (p = 0.002). The incidence of AL was 11.5% in the open surgery subgroup and 11.4% in the laparoscopic surgery subgroup. Among the patients who underwent open surgery, the AL group showed a male predominance (p = 0.04) in the univariate analysis, but it was not statistically significant in the multivariate analysis. Among the patients who underwent laparoscopic surgery, the AL group included a higher proportion of patients with comorbid respiratory disease (p = 0.003) and larger tumors (p = 0.007).

CONCLUSION

Comorbid respiratory disease and tumor size were risk factors for AL in obese patients with rectal cancer. Careful perioperative respiratory management and appropriate selection of surgical procedures are required for obese rectal cancer patients with respiratory diseases.

A systematic review and meta-analysis of minimally invasive versus conventional open proctectomy for locally advanced colon cancer

BACKGROUND

Locally advanced colon cancer is considered a relative contraindication for minimally invasive proctectomy (MIP), and minimally invasive versus conventional open proctectomy (COP) for locally advanced colon cancer has not been studied.

METHODS

We have searched the Embase, Cochrane Library, PubMed, Medline, and Web of Science for articles on minimally invasive (robotic and laparoscopic) and COP. We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42023407029).

RESULTS

There are 10132 participants including 21 articles. Compared with COP, patients who underwent MIP had less operation time (SMD 0.48; CI 0.32 to 0.65; I2 = 0%, P = .000), estimated blood loss (MD -1.23; CI -1.90 to -0.56; I2 = 95%, P < .0001), the median time to semi-liquid diet (SMD -0.43; CI -0.70 to -0.15; I2 = 0%, P = .002), time to the first flatus (SMD -0.97; CI -1.30 to -0.63; I2 = 7%, P < .0001), intraoperative blood transfusion (RR 0.33; CI 0.24 to 0.46; I2 = 0%, P < .0001) in perioperative outcomes. Compared with COP, patients who underwent MIP had fewer overall complications (RR 0.85; CI 0.73 to 0.98; I2 = 22.4%, P = .023), postoperative complications (RR 0.79; CI 0.69 to 0.90; I2 = 0%, P = .001), and urinary retention (RR 0.63; CI 0.44 to 0.90; I2 = 0%, P = .011) in perioperative outcomes.

CONCLUSION

This study comprehensively and systematically evaluated the difference between the safety and effectiveness of minimally invasive and open treatment of locally advanced colon cancer through meta-analysis. Minimally invasive proctectomy is better than COP in postoperative and perioperative outcomes. However, there is no difference in oncological outcomes. This also provides an evidence-based reference for clinical practice. Of course, multi-center RCT research is also needed to draw more scientific and rigorous conclusions in the future.

Impact of laparoscopic versus open surgery on humoral immunity in patients with colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery (LS) is hypothesized to result in milder proinflammatory reactions due to less severe operative trauma, which may contribute to the observed clinical benefits after LS. However, previous systematic reviews and meta-analyses on the impact of LS on immunocompetence are outdated, limited and heterogeneous. Therefore, the humoral response after laparoscopic and open colorectal cancer (CRC) resections was evaluated in a comprehensive systematic review and meta-analysis.

METHODS

Included were randomized controlled trials (RCTs) measuring parameters of humoral immunity after LS compared to open surgery (OS) in adult patients with CRC of any stage. MEDLINE, Embase, Web of Science (SCI-EXPANDED), Cochrane Library, Google Scholar, ClinicalTrials.gov and ICTRP (World Health Organization) were systematically searched. Risk of bias (RoB) was assessed using the Cochrane RoB2 tool. Weighted inverse variance meta-analysis of mean differences was performed for C-reactive protein (CRP), interleukin (IL)-6, IL-8, tumour necrosis factor (TNF)α and vascular endothelial growth factor (VEGF) using the random-effects method. Methods were prospectively registered in PROSPERO (CRD42021264324).

RESULTS

Twenty RCTs with 1131 participants were included. Narrative synthesis and meta-analysis up to 8 days after surgery was performed. Quantitative synthesis found concentrations to be significantly lower after LS at 0-2 h after surgery (IL-8), at 3-9 h (CRP, IL-6, IL-8, TNFα) and at postoperative day 1 (CRP, IL-6, IL-8, VEGF). At 3-9 h, IL-6 was notably lower in the LS group by 86.71 pg/ml (mean difference [MD] - 86.71 pg/ml [- 125.05, - 48.37], p < 0.00001). Combined narratively, 13 studies reported significantly lower concentrations of considered parameters in LS patients, whereas only one study reported lower inflammatory markers (for CRP and IL-6) after OS.

CONCLUSION

The increase in postoperative concentrations of several proinflammatory parameters was significantly less pronounced after LS than after OS in this meta-analysis. Overall, the summarized evidence reinforces the view of a lower induction of inflammation due to LS.

Short- and long-term results of open vs laparoscopic multisegmental resection and anastomosis for synchronous colorectal cancer located in separate segments

BACKGROUND

It remains unclear whether laparoscopic multisegmental resection and anastomosis (LMRA) is safe and advantageous over traditional open multisegmental resection and anastomosis (OMRA) for treating synchronous colorectal cancer (SCRC) located in separate segments.

AIM

To compare the short-term efficacy and long-term prognosis of OMRA as well as LMRA for SCRC located in separate segments.

METHODS

Patients with SCRC who underwent surgery between January 2010 and December 2021 at the Cancer Hospital, Chinese Academy of Medical Sciences and the Peking University First Hospital were retrospectively recruited. In accordance with the inclusion and exclusion criteria, 109 patients who received right hemicolectomy together with anterior resection of the rectum or right hemicolectomy and sigmoid colectomy were finally included in the study. Patients were divided into the LMRA and OMRA groups (n = 68 and 41, respectively) according to the surgical method used. The groups were compared regarding the surgical procedure's short-term efficacy and its effect on long-term patient survival.

RESULTS

LMRA patients showed markedly less intraoperative blood loss than OMRA patients (100 vs 200 mL, P = 0.006). Compared to OMRA patients, LMRA patients exhibited markedly shorter postoperative first exhaust time (2 vs 3 d, P = 0.001), postoperative first fluid intake time (3 vs 4 d, P = 0.012), and postoperative hospital stay (9 vs 12 d, P = 0.002). The incidence of total postoperative complications (Clavien-Dindo grade: ≥ II) was 2.9% and 17.1% (P = 0.025) in the LMRA and OMRA groups, respectively, while the incidence of anastomotic leakage was 2.9% and 7.3% (P = 0.558) in the LMRA and OMRA groups, respectively. Furthermore, the LMRA group had a higher mean number of lymph nodes dissected than the OMRA group (45.2 vs 37.3, P = 0.020). The 5-year overall survival (OS) and disease-free survival (DFS) rates in OMRA patients were 82.9% and 78.3%, respectively, while these rates in LMRA patients were 78.2% and 72.8%, respectively. Multivariate prognostic analysis revealed that N stage [OS: HR hazard ratio (HR) = 10.161, P = 0.026; DFS: HR = 13.017, P = 0.013], but not the surgical method (LMRA/OMRA) (OS: HR = 0.834, P = 0.749; DFS: HR = 0.812, P = 0.712), was the independent influencing factor in the OS and DFS of patients with SCRC.

CONCLUSION

LMRA is safe and feasible for patients with SCRC located in separate segments. Compared to OMRA, the LMRA approach has more advantages related to short-term efficacy.

Influence of Laparoscopic Surgery on Cellular Immunity in Colorectal Cancer: A Systematic Review and Meta-Analysis

Colorectal cancer (CRC) is the third most common cancer worldwide. The main treatment options are laparoscopic (LS) and open surgery (OS), which might differ in their impact on the cellular immunity so indispensable for anti-infectious and antitumor defense. MEDLINE, Embase, Web of Science (SCI-EXPANDED), the Cochrane Library, Google Scholar, ClinicalTrials.gov, and ICTRP (WHO) were systematically searched for randomized controlled trials (RCTs) comparing cellular immunity in CRC patients of any stage between minimally invasive and open surgical resections. A random effects-weighted inverse variance meta-analysis was performed for cell counts of natural killer (NK) cells, white blood cells (WBCs), lymphocytes, CD4+ T cells, and the CD4+/CD8+ ratio. The RoB2 tool was used to assess the risk of bias. The meta-analysis was prospectively registered in PROSPERO (CRD42021264324). A total of 14 trials including 974 participants were assessed. The LS groups showed more favorable outcomes in eight trials, with lower inflammation and less immunosuppression as indicated by higher innate and adaptive cell counts, higher NK cell activity, and higher HLA-DR expression rates compared to OS, with only one study reporting lower WBCs after OS. The meta-analysis yielded significantly higher NK cell counts at postoperative day (POD)4 (weighted mean difference (WMD) 30.80 cells/µL [19.68; 41.92], p < 0.00001) and POD6-8 (WMD 45.08 cells/µL [35.95; 54.21], p < 0.00001). Although further research is required, LS is possibly associated with less suppression of cellular immunity and lower inflammation, indicating better preservation of cellular immunity.

Robotic surgery for locally advanced T4 rectal cancer: feasibility and oncological quality

For T4 rectal tumours and local recurrences (LR) of rectal cancer, a radical resection beyond TME, sometimes by multi-visceral resection, is important to obtain safe margins and improve survival. The use of the laparoscopic approach (LA) for these cases is still controversial and associated with a high rate of conversion. However, robotic surgery might offer some advantages that can overcome some of the limitations of LA. Therefore, we aimed to analyse the postoperative outcomes and medium-term oncological results of robotic surgery for locally advanced rectal cancer (pathological T4) and LR. A retrospective analysis was performed including patients who had undergone robotic rectal resection in a single institution over an 11-year period, and had a T4 tumour confirmed in the pathological report. Primary endpoint was to analyse postoperative complications (30-day) and the rate of conversion. Secondary endpoints include pathological assessment of the quality of the specimen, local recurrence and survival [2-year disease-free survival (DFS) and overall survival (OS)]. A total of 41 patients were analysed, including a total of 24 patients (60%) that required a multivisceral resection. The median distance from the tumour to the anorectal junction was 7 (4-12) cm. Conversion to open surgery was necessary in 2 cases (5%). The overall morbidity rate was 78% (n = 32), with 37% of major complications, most of them urinary (n = 7). Median length of hospital stay (LOS) was 13 (7-27) days. The 30-day mortality rate was 7% (n = 3). An R0 resection was achieved in 85.4% of the cases (n = 35) due to 6 cases of the positive circumferential resection margin. 2-year disease-free survival (DFS) and overall survival (OS) for the T4 tumours were 72% and 85%, respectively. There were 8 cases of local recurrence (22.2%); 6 of them met the selection criteria for salvage surgery. Robotic surgery for locally advanced T4 rectal cancer and multi-visceral resections is safe and feasible, with a low rate of conversion and an acceptable rate of postoperative morbidity in this subgroup of patients. Oncological results have shown to be comparable with the laparoscopic series published, preserving a good quality of the resected specimen. However, comparative studies and a longer follow-up period is needed to confirm the oncologic findings and to support the general adoption of the robotic system for these complex interventions.