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Zhong Y, Jian GL, Li QX, Xiao YY, Ye JY, Liu QX, Zhong MY, Ni D, Pei XQ, Huang WJ. Abdominal Ultrasonography After Transrectal Filling With Contrast Agents in Colorectal Cancer With Severely Stenotic Lesions. ULTRASOUND IN MEDICINE & BIOLOGY 2023:S0301-5629(23)00206-5. [PMID: 37423829 DOI: 10.1016/j.ultrasmedbio.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/26/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Abdominal ultrasonography after transrectal filling with contrast agent (AU-TFCA) was retrospectively evaluated with respect to determination of T stage and lesion length in patients with colorectal cancer (CRC) who had previously failed colonoscopy because of severe intestinal stenosis. METHODS The population comprised 83 patients with CRC with intestinal stenosis and previously failed colonoscopy who underwent AU-TFCA, and in addition contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI), 2 wk before surgery. The diagnostic performance of AU-TFCA and CECT/MRI was evaluated relative to the post-operative pathological results (PPRs) by paired sample t-test, receiver operator characteristic (ROC) curve, Pearson's χ2-test and κ and intraclass correlation coefficients. RESULTS The T staging identified via AU-TFCA, but not CECT/MRI, was relatively consistent with that of the PPRs (linearly weighted κ coefficient: 0.558, p < 0.001, and linearly weighted κ coefficient: 0.237, p < 0.001, respectively). The overall diagnostic accuracy of T staging based on AU-TFCA (83.1%) was significantly higher than that based on CECT/MRI (50.6%). Regarding lesion length, the results of AU-TFCA and PPRs were comparable (t = 1.852, p = 0.068), but those of CECT/MRI and PPRs were significantly different (t = 8.450, p < 0.001). CONCLUSION AU-TFCA is effective in evaluation of lesion length and T stage in patients with severely stenotic CRC lesions who previously failed colonoscopy. The diagnostic accuracy of AU-TFCA is significantly better compared with that of CECT/MRI.
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Affiliation(s)
- Yuan Zhong
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Guo-Liang Jian
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Qin-Xiang Li
- Department of Medical Radiology, First People's Hospital of Foshan, Foshan, China
| | - Yan-Yan Xiao
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Jie-Yi Ye
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Qin-Xue Liu
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Min-Ying Zhong
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Dong Ni
- Shenzhen University, Faculty of Medicine, School of Biomedical Engineering, Nanshan District, Shenzhen, China
| | - Xiao-Qing Pei
- Department of Medical Ultrasound, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wei-Jun Huang
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China.
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Jia W, Cheng X, Zhao R. Editorial: Laparoscopic surgery in colorectal cancer. Front Oncol 2022; 12:960730. [PMID: 36119542 PMCID: PMC9477083 DOI: 10.3389/fonc.2022.960730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wenqing Jia
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Digestive surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xi Cheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Digestive surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Xi Cheng, ; Ren Zhao,
| | - Ren Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Digestive surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Xi Cheng, ; Ren Zhao,
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Preliminary results of a program for the implementation of laparoscopic colorectal surgery in an Italian comprehensive cancer center during the COVID-19 pandemic. Updates Surg 2022; 74:1271-1279. [PMID: 35606625 PMCID: PMC9126695 DOI: 10.1007/s13304-022-01283-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022]
Abstract
Despite operative benefit and oncological non-inferiority, videolaparoscopic (VLS) colorectal surgery is still relatively underutilized. This study analyzes the results of a program for the implementation of VLS colorectal surgery started in an Italian comprehensive cancer center shortly before COVID-19 outbreak. A prospective database was reviewed. The study period was divided in four phases: Phase-1 (Open surgery), Phase-2 (Discretional phase), Phase-3 (VLS implementation phase), and Phase-4 (VLS consolidation phase). Formal surgical and perioperative protocols were adopted from Phase-3. Postoperative complications were scored by the Clavien–Dindo classification. 414 surgical procedures were performed during Phase-1, 348 during Phase-2, 360 during Phase-3, and 325 during Phase-4. In the four phases, VLS primary colorectal resections increased from 11/214 (5.1%), to 55/163 (33.7%), 85/151 (57.0%), and 109/147 (74.1%), respectively. The difference was statistically significant (P < 0.001). All-type VLS procedures were 16 (3.5%), 61 (16.2%), 103 (27.0%), and 126 (38.6%) (P < 0.001). Conversions to open surgery of attempted laparoscopic colorectal resections were 17/278 in the overall series (6.1%), and 12/207 during Phase-3 and Phase-4 (4.3%). Severe (grades IIIb-to-V) postoperative complications of VLS colorectal resections were 9.1% in Phase-1, 12.7% in Phase-2, 12.8% in Phase-3, and 5.3% in Phase-4 (P = 0.677), with no significant differences with open resections in each of the four phases: 9.4% (P = 0.976), 11.1% (P = 0.799), 13.8% (P = 1.000), and 8.3% (P = 0.729). Despite the difficulties deriving from the COVID-19 outbreak, our experience suggests that volume of laparoscopic colorectal surgery can be significantly and safely increased in a specialized surgical unit by means of strict operative protocols.
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Udwadia TE. Training for laparoscopic colorectal surgery creating an appropriate porcine model and curriculum for training. J Minim Access Surg 2021; 17:180-187. [PMID: 33723182 PMCID: PMC8083748 DOI: 10.4103/jmas.jmas_86_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Laparoscopic colorectal surgery (LCRS) was first described in 1991, and its safety, efficacy and patient benefit were adequately documented in literature. However, its penetration and acceptability is poor in most countries, due to its long learning curve and lack of surgeons training and confidence. A Minimal Access Surgery (MAS) Training Center in Mumbai has over the last 7 years trained more than 8000 surgeons in various MAS specialities. The centre has initiated courses for LCRS training. Materials and Methods The anatomy of the pig colon is very different from human anatomy. The pig colon anatomy is altered to mimic human colon anatomy in the porcine abdomen, permitting hands-on practice on most laparoscopic colorectal surgical procedures, as part of the LCRS training course, under mentorship of expert faculty, who simultaneously assess participants performance. Results Each participant performs and assists for at least three procedures and is evaluated at each step of the procedure by a structured format. The overall evaluation by Faculty which though subjective, is detailed and favourable. Feedback of each participant is good and acceptable as a very helpful course. Conclusion This porcine model is ideal for hands-on training for LCRS. Participants achieve a good degree of skill level and confidence in performing LCRS procedures on fresh bleeding porcine cadaver models. The centre is factual and pragmatic and stresses that it needs more than a course to make a safe surgeon; operation room mentorship is the finishing school.
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Affiliation(s)
- Tehemton Erach Udwadia
- Center of Excellence for Minimal Access Surgery Training; Department of Surgery, Grant Medical College, Grant Medical College and J.J. Hospital; Department of Surgery, B. D. Petit Parsee General Hospital, Breach Candy Hospital, Mumbai, Maharashtra, India
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Laparoscopic versus open rectal resection: a 1:2 propensity score-matched analysis of oncological adequateness, short- and long-term outcomes. Int J Colorectal Dis 2021; 36:801-810. [PMID: 33483843 PMCID: PMC7952358 DOI: 10.1007/s00384-021-03841-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Laparoscopic resections for rectal cancer are routinely performed in high-volume centres. Despite short-term advantages have been demonstrated, the oncological outcomes are still debated. The aim of this study was to compare the oncological adequateness of the surgical specimen and the long-term outcomes between open (ORR) and laparoscopic (LRR) rectal resections. METHODS Patients undergoing laparoscopic or open rectal resections from January 1, 2013, to December 31, 2019, were enrolled. A 1:2 propensity score matching was performed according to age, sex, BMI, ASA score, comorbidities, distance from the anal verge, and clinical T and N stage. RESULTS Ninety-eight ORR were matched to 50 LRR. No differences were observed in terms of operative time (224.9 min. vs. 230.7; p = 0.567) and postoperative morbidity (18.6% vs. 20.8%; p = 0.744). LRR group had a significantly earlier soft oral intake (p < 0.001), first bowel movement (p < 0.001), and shorter hospital stay (p < 0.001). Oncological adequateness was achieved in 85 (86.7%) open and 44 (88.0%) laparoscopic resections (p = 0.772). Clearance of the distal (99.0% vs. 100%; p = 0.474) and radial margins (91.8 vs. 90.0%, p = 0.709), and mesorectal integrity (94.9% vs. 98.0%, p = 0.365) were comparable between groups. No differences in local recurrence (6.1% vs.4.0%, p = 0.589), 3-year overall survival (82.9% vs. 91.4%, p = 0.276), and disease-free survival (73.1% vs. 74.3%, p = 0.817) were observed. CONCLUSIONS LRR is associated with good postoperative results, safe oncological adequateness of the surgical specimen, and comparable survivals to open surgery.
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Horie T, Shida D, Ahiko Y, Takamizawa Y, Inoue M, Tanabe T, Nakamura Y, Imaizumi J, Tsukamoto S, Kanemitsu Y. Laparoscopic versus Open Colectomy for Elderly Patients with Colon Cancer: A Propensity Score Analysis with the Controlling Nutritional Status (CONUT) Score. Nutr Cancer 2020; 73:246-251. [PMID: 32252556 DOI: 10.1080/01635581.2020.1743868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The feasibility of laparoscopic surgery for elderly patients remains unclear, as these patients usually present with comorbidities. Recently, the controlling nutritional status (CONUT) score has drawn attention as an evaluation score of patients' general status as well as a predictor of survival. We retrospectively analyzed overall survival in 424 patients aged ≥75 years with colon cancer, who underwent curative surgery (laparoscopic (n = 167) or open surgery (n = 257)) between January 2004 and December 2013. To adjust for heterogeneity in both groups, a propensity score-matched analysis was performed, with the CONUT score as a confounding covariate. 5-year overall survival rates of patients with normal (0-1), mildly abnormal (2-4), or abnormal (≥5) CONUT score were 88.6%, 79.4%, and 41.4%, respectively (p < 0.001). T3 or less, N negative, late period (2009-2013), and normal CONUT score were associated with the tendency to undergo laparoscopic surgery (p < 0.001). The analysis of the propensity score-matched cohort (124 pairs) revealed that patients in the laparoscopic surgery group had a similar prognosis to those in the open surgery group, with a 5-year overall survival of 91.9% vs. 82.0%, respectively (p = 0.102). Laparoscopic surgery for colon cancer is an acceptable surgical approach in elderly patients.
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Affiliation(s)
- Tomoko Horie
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Dai Shida
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yuka Ahiko
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuyuki Takamizawa
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Manabu Inoue
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Taro Tanabe
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yuya Nakamura
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Imaizumi
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
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Ringressi MN, Boni L, Freschi G, Scaringi S, Indennitate G, Bartolini I, Bechi P, Taddei A. Comparing laparoscopic surgery with open surgery for long-term outcomes in patients with stage I to III colon cancer. Surg Oncol 2018; 27:115-122. [PMID: 29937160 DOI: 10.1016/j.suronc.2018.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/19/2018] [Accepted: 02/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although the short-term advantages of laparoscopy for colon cancer (CC) over open surgery have been clearly demonstrated, there is little evidence available concerning the long-term outcomes. This study aimed to compare the long-term results of laparoscopic surgery versus open surgery in a cohort of CC patients from a single center. METHODS A series of 443 patients consecutively operated on for stage I to III CC between January 2006 and December 2013 were followed up. Patients were divided into two groups according to the surgical technique and were compared for disease-free survival (DFS) and overall survival (OS) before and after 1:1 propensity score matching. RESULTS Due to exclusions and drop-outs, the statistical analysis of the study is based on 398 patients. Open surgery was performed in 133 patients, and laparoscopic surgery was performed in 265. After propensity score matching, two comparable groups of 89 patients each were obtained. The 5-year DFS was 64.3% and 78.2% for patients in the open and laparoscopic resection groups, respectively [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.33-1.19; P = 0.148]. A 5-year OS of 72.1% and 86.8% was observed in the open and laparoscopic resection groups, respectively (HR 0.43, 95%CI 0.20-0.94; P = 0.026). The multivariate survival analysis demonstrated better results of laparoscopy compared with open surgery for both DFS (HR 0.43, 95%CI 0.23-0.78; P = 0.004) and OS (HR 0.28, 95%CI 0.14-0.59; P < 0.001). CONCLUSIONS Despite the limitations of a retrospective analysis, our study confirms better results for laparoscopic surgery in terms of DFS and OS compared with open surgery in CC treatment.
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Affiliation(s)
- Maria Novella Ringressi
- Department of Surgery and Translational Medicine, University of Florence, Careggi University Hospital, Largo Brambilla 3, Florence 50134, Italy.
| | - Luca Boni
- Clinical Trials Coordinating Center, Careggi University Hospital and Tumor Institute of Tuscany, Florence 50134, Italy
| | - Giancarlo Freschi
- Department of Surgery and Translational Medicine, University of Florence, Careggi University Hospital, Largo Brambilla 3, Florence 50134, Italy
| | - Stefano Scaringi
- Department of Surgery and Translational Medicine, University of Florence, Careggi University Hospital, Largo Brambilla 3, Florence 50134, Italy
| | | | - Ilenia Bartolini
- Department of Surgery and Translational Medicine, University of Florence, Careggi University Hospital, Largo Brambilla 3, Florence 50134, Italy
| | - Paolo Bechi
- Department of Surgery and Translational Medicine, University of Florence, Careggi University Hospital, Largo Brambilla 3, Florence 50134, Italy
| | - Antonio Taddei
- Department of Surgery and Translational Medicine, University of Florence, Careggi University Hospital, Largo Brambilla 3, Florence 50134, Italy
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Implementation of laparoscopic approach in colorectal surgery - a single center's experience. Wideochir Inne Tech Maloinwazyjne 2018; 13:27-32. [PMID: 29643955 PMCID: PMC5890849 DOI: 10.5114/wiitm.2018.72748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/02/2017] [Indexed: 01/31/2023] Open
Abstract
Introduction Implementation of the laparoscopic approach in colorectal surgery has not happened as rapidly as in cholecystectomy, because of concerns about oncological safety. The results of controlled trials in multiple centers showed the method to be safe. Consequently, surgeons decided to try the approach with colorectal surgery. This process, in our clinic, began in earnest about four years ago. Aim To analyze and present the clinical outcomes of applying the laparoscopic approach to colorectal surgery in a single center. Material and methods We retrospectively identified patients from a hospital database who underwent colorectal surgery – laparoscopic and open – between 2013 and 2016. Our focus was on laparoscopic cases. Study points included operative time, duration of the hospital stay, postoperative mortality and rates of complications, conversion, reoperation and readmission. Results Of 534 cases considered, the results showed that the relation between open and laparoscopic procedures had reversed, in favor of the latter method (2013: open: 82% vs. laparoscopic: 18%; 2016: open: 22.4% vs. laparoscopic: 77.6%). The most commonly performed procedure was right hemicolectomy. The total complication rate was 22%. The total rate of conversion to open surgery was 9.3%. The postoperative mortality rate was 3%. Conclusions Use of the laparoscopic approach in colorectal surgery has increased in recent years world-wide – including in Poland – but the technique is still underused. Rapid implementation of the miniinvasive method in colorectal surgery, in centers with previous laparoscopic experience, is not only safe and feasible, but also highly recommended.
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Takeda M, Tokuoka M, Hirose H, Ide Y, Hashimoto Y, Matsuyama J, Yokoyama S, Morimoto T, Fukishima Y, Nomura T, Kodama K, Sasaki Y. Short-term outcomes following single-port laparoscopic surgery in elderly patients with colon cancer compared with younger patients. Oncol Lett 2017; 14:1595-1601. [PMID: 28789384 DOI: 10.3892/ol.2017.6344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 02/03/2017] [Indexed: 11/06/2022] Open
Abstract
Surgeons are increasingly being faced with the challenge of treating elderly patients with colon cancer. The present study therefore aimed to compare the short-term outcomes of single-port laparoscopic surgery (SILS) for elderly patients with colon cancer (≥70 years) with those in younger patients (41-69 years; control group). Among 100 patients with colorectal cancer who had been treated with single-port laparoscopic surgery between January 2011 and December 2014, 56 (56.0%) were ≥70 years of age. The results of treatment and short-term outcomes in the elderly group (n=56) were retrospectively compared with the younger patients in the control group (n=44). The sex distribution, body mass index, history of prior surgery and the American Society of Anesthesiologists physical status classification were similar between the groups. Onodera's prognostic nutritional index demonstrated significant differences between the elderly and control groups (38.3 vs. 49.8; P<0.05). No significant differences were observed in the mean length of surgery (219.5±73.5 vs. 201.4±76.5 min; P=0.43), estimated blood loss (32.2±74.5 vs. 36.1±90.2 ml; P=0.10), postoperative complications (10.9 vs. 7.1%; P=0.78), length of postoperative hospital stay (9.6±12.5 vs. 7.3±3.0 days; P=0.23) or number of harvested lymph nodes (21.8±24.3 vs. 22.5±11.3; P=0.87) between the elderly and control groups. In conclusion, the results of the present study demonstrate that SILS may be carried out feasibly in elderly patients with colon cancer.
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Affiliation(s)
- Mitsunobu Takeda
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Masayoshi Tokuoka
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Hajime Hirose
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Yoshihito Ide
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Yasuji Hashimoto
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Jin Matsuyama
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Shigekazu Yokoyama
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Takashi Morimoto
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Yukio Fukishima
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Takashi Nomura
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Ken Kodama
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
| | - Yo Sasaki
- Department of Surgery, Yao Municipal Hospital, Yao, Osaka 581-0069, Japan
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Hojo S, Kawahara H, Ogawa M, Suwa K, Eto K, Yanaga K. Laparoscopic surgical challenge for T4a colon cancer. Ann Gastroenterol Surg 2017; 1:69-74. [PMID: 29863127 PMCID: PMC5881306 DOI: 10.1002/ags3.12009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/30/2017] [Indexed: 01/17/2023] Open
Abstract
For patients with T4a colon cancer, the risk of peritoneal dissemination after surgery remains unclear. Seven hundred and eleven patients with T3 or T4a colon cancer, 80 years of age or younger, underwent curative resection (open surgery in 512 and laparoscopic surgery in 199) at the four Jikei University hospitals between 2006 and 2012. Their risk factors for peritoneal dissemination after surgery were evaluated retrospectively. Number of lymph node metastases, postoperative liver metastases and postoperative peritoneal dissemination events in the T4a group were significantly greater than the number in the T3 group. Peritoneal dissemination after surgery developed in four patients (0.7%) in the T3 group and in six patients (5%) in the T4a group. Risk factors for peritoneal dissemination consisted of macroscopic type (P = 0.016), serosal invasion (P = 0.017) and number of lymph node metastases (P = 0.009) according to the Cox proportional hazards regression model. However, tumor diameter and surgical approach (laparoscopic vs open) were not significant factors for peritoneal dissemination. There were no significant differences between the postoperative relapse‐free survival rates for each surgical approach within the T3 or T4a group. Because of comparable postoperative peritoneal dissemination in T3 and T4a colon cancer by the surgical approach (laparoscopic or open), laparoscopic surgery for patients with T4a colon cancer seems justified.
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Affiliation(s)
- Seishi Hojo
- Department of Surgery The Jikei University School of Medicine Tokyo Japan
| | - Hidejiro Kawahara
- Department of Surgery The Jikei University School of Medicine Tokyo Japan
| | - Masaichi Ogawa
- Department of Surgery The Jikei University School of Medicine Tokyo Japan
| | - Katsuhito Suwa
- Department of Surgery The Jikei University School of Medicine Tokyo Japan
| | - Ken Eto
- Department of Surgery The Jikei University School of Medicine Tokyo Japan
| | - Katsuhiko Yanaga
- Department of Surgery The Jikei University School of Medicine Tokyo Japan
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O'Boyle S, Stephenson K. More is better: Lymph node harvesting in colorectal cancer. Am J Surg 2017; 213:926-930. [PMID: 28438260 DOI: 10.1016/j.amjsurg.2017.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/10/2017] [Accepted: 03/16/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION We sought to determine if lymph node harvesting and survival for CRC were comparable between laparoscopic and open resections in a community hospital setting. METHODS A retrospective chart review of patients at two community hospitals who underwent open or laparoscopic resection for CRC between January 2008 and September 2013 was performed. RESULTS Three hundred seventy-one patients had open and 110 had laparoscopic resections. There was no difference between open (17.85) and laparoscopic (18.91) approaches (p = 0.171) in the number of lymph nodes harvested. Patients who had more nodes removed tended toward improved survival, independent of stage (p = 0.052), an effect that was more pronounced in the open resection group (p = 0.031). There was no difference in survival between the open and laparoscopic groups overall (HR 1.52, p = 0.208). DISCUSSION No survival advantage was found between the open and laparoscopic resection groups, affirming that the choice of operative approach for CRC does not affect the quality of the oncologic procedure in a community hospital setting. Patients who had more lymph nodes removed tended toward improved survival. The explanation for this effect remains unclear.
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Affiliation(s)
- Sean O'Boyle
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Keith Stephenson
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.
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Current Status of Laparoscopic Surgery in Colorectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0345-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Single-incision Plus One Port Laparoscopic Total Mesorectal Excision and Bilateral Pelvic Node Dissection for Advanced Rectal Cancer--A Medial Umbilical Ligament Approach. Int Surg 2016; 100:417-22. [PMID: 25785320 DOI: 10.9738/intsurg-d-14-00091.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
We prove the safety and feasibility of single-incision plus 1 port (SILS+1) laparoscopic total mesorectal excision (TME) + lateral pelvic lymph node dissection (LPLD) via a medial umbilical approach for rectal cancer. Only a few reports have been published about single-incision multiport laparoscopic low anterior resection with LPLD. Recently, minimally invasive surgery such as single-incision plus 1 port (SILS + 1) for advanced rectal cancer has been reported as safe and feasible. To our knowledge, this is the first reported case of SILS + 1 used for LPLD. A wound protector was inserted through a 30-mm transumbilical incision. Next, a single-port access device was mounted to the wound protector and 3 ports (5 mm each) were placed. A 12-mm port was inserted in the right lower quadrant. Super-low anterior resection of the rectum and bilateral LPLD and temporary ileostomy were performed with SILS + 1, with a blood loss of 50 mL and a total surgical time of 525 minutes. The time for right lateral dissection was 74 minutes; the time for left lateral dissection was 118 minutes. The total number of dissected lymph nodes was 57 and the number of lateral lymph nodes dissected was 21 (8 left pelvic lymph nodes, 13 right pelvic lymph nodes). No postoperative anastomotic insufficiency or voiding dysfunction was observed. We have documented the safety and feasibility of SILS + 1-TME + LPLD via a medial umbilical approach for rectal cancer.
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Armstrong KW, Bravo-Iñiguez CE, Jacobson FL, Jaklitsch MT. Recent trends in surgical research of cancer treatment in the elderly, with a primary focus on lung cancer: Presentation at the 2015 annual meeting of SIOG. J Geriatr Oncol 2016; 7:368-74. [PMID: 27460994 DOI: 10.1016/j.jgo.2016.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 06/16/2016] [Accepted: 07/07/2016] [Indexed: 11/27/2022]
Abstract
Surgical research concentrating on cancer in the elderly has changed from small single institution outcome studies of carefully selected patients to larger studies that test specific aspects of surgical selection, treatment, and outcome. The purpose of this paper is to review major new trends in surgical geriatric oncology research within the last decade. Reviewing PubMed listings of the last 10years reveals several identifiable areas of particular concentration. Although we use specific studies primarily from lung cancer treatment, the generalizations can be seen across the spectrum of geriatric cancers. These trends include screening for disease that can be successfully treated, integration of operative and non-operative therapies that are changing the indications for surgery, the use of prehabilitation to allow more borderline frail patients to be treated surgically, the use of rehabilitation to facilitate rapid and complete recovery, prevention and treatment of common morbidities, with a special recent focus on delirium and cognitive impairment. New areas of surgical research include research on team building in the OR and ICU. Recent surgical research is becoming quantitative and multi-institutionally based. Overall surgical mortality has dropped over the past 25years in both academic and community hospitals. Prevention of morbidity and loss of functional status is a major focus of research. Funding for new Quality Assurance Projects for elderly patients has been awarded to the American College of Surgeons, and should provide multi-institutional quality outcome data within 5years.
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Askari A, Nachiappan S, Currie A, Bottle A, Athanasiou T, Faiz O. Selection for laparoscopic resection confers a survival benefit in colorectal cancer surgery in England. Surg Endosc 2016; 30:3839-47. [PMID: 27059969 DOI: 10.1007/s00464-015-4686-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 11/14/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Laparoscopic surgery is being increasingly used in colorectal cancer resections. The aim of this national study was to determine whether laparoscopy confers a long-term survival advantage in colorectal cancer. METHODS A national administrative data set (Hospital Episode Statistics-HES) encompassing all elective hospital admissions in England between 2001 and 2011 was analysed. All patients that had a colorectal cancer resection (open or laparoscopic) were identified. Cox hazard regression was used to determine differences in overall survival (10 year) between the open and laparoscopy groups. RESULTS A total of 141,682 patients underwent elective surgery for colorectal cancer, of which 20.9 % (n = 29,550) had a laparoscopic procedure. The median 5-year survival in the open group was 36.1 months compared with 46.1 months in the laparoscopic group (p = <0.001). Survival analysis demonstrated laparoscopy to be an independent predictor of survival. Patients who underwent laparoscopic resection were 18 % less likely to die than patients who had an open CRC resection (HR 0.82, CI 0.79-0.83, p < 0.001). This survival benefit persisted even when initial post-operative mortality (90 day) was excluded (HR 0.87, CI 0.85-0.90, p < 0.001). Subgroup analysis, exploring the effect of CRC laparoscopic surgery on survival in the elderly (>79 years old), demonstrated similar survival benefit amongst patients treated using laparoscopy (HR 0.90, CI 0.86-0.94, p < 0.001). Patients not undergoing adjuvant chemotherapy were more likely to survive if they underwent laparoscopic resection (HR 0.81, CI 0.78-0.83, p < 0.001). Similarly, patients undergoing adjuvant chemotherapy demonstrated a survival benefit if a minimal access surgical approach was utilised (HR 0.86, CI 0.81-0.91, p < 0.001). CONCLUSION Laparoscopy confers a survival benefit, irrespective of age and administration of adjuvant chemotherapy, beyond the initial post-operative period in patients selected for elective colorectal cancer resection.
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Affiliation(s)
- Alan Askari
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, Imperial College London, Harrow, Middlesex, HA1 3UJ, UK.
| | - Subramanian Nachiappan
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, Imperial College London, Harrow, Middlesex, HA1 3UJ, UK
| | - Andrew Currie
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, Imperial College London, Harrow, Middlesex, HA1 3UJ, UK
| | - Alex Bottle
- Faculty of Medicine, School of Public Health, Dr Foster Unit, Imperial College London, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Faculty of Medicine, St Mary's Hospital, Praed Street, London, W2 1NY, UK
| | - Omar Faiz
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, Imperial College London, Harrow, Middlesex, HA1 3UJ, UK
- Department of Surgery and Cancer, Faculty of Medicine, St Mary's Hospital, Praed Street, London, W2 1NY, UK
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Pascual M, Salvans S, Pera M. Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations. World J Gastroenterol 2016; 22:704-717. [PMID: 26811618 PMCID: PMC4716070 DOI: 10.3748/wjg.v22.i2.704] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.
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Ecker BL, Savulionyte GE, Datta J, Dumon KR, Kucharczuk J, Williams NN, Dempsey DT. Laparoscopic transhiatal esophagectomy improves hospital outcomes and reduces cost: a single-institution analysis of laparoscopic-assisted and open techniques. Surg Endosc 2015; 30:2535-42. [PMID: 26416370 DOI: 10.1007/s00464-015-4519-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 08/06/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Several case series have demonstrated that laparoscopic transhiatal esophagectomy (LTHE) is associated with favorable perioperative outcomes compared to historical data for open transhiatal esophagectomy (OTHE). Contemporaneous evaluation of open and laparoscopic THE is rare, limiting meaningful comparison of techniques. METHODS All patients who underwent OTHE (n = 32) and LTHE (n = 41) during the introduction of the latter procedure at our institution (1/2012-4/2014) were identified, and patient charts were retrospectively reviewed. RESULTS Indications for operation included 69 patients with esophageal malignancy (adenocarcinoma: 64; squamous cell carcinoma: 4; melanoma: 1) and 4 patients with benign disease. There were no significant differences in clinicopathologic variables between OTHE and LTHE cohorts, except for an increased rate of cardiovascular disease in the LTHE cohort (p = 0.04). There was no significant difference in median operative time or operative complications, yet LTHE was associated with a lower incidence of intraoperative blood transfusion (p < 0.01). There were no 30-day mortalities. LTHE was associated with a reduced time to reach 24-h tube feeding goals (p = 0.02), shorter length of hospital stay (p = 0.01), and 6 % reduced median direct cost (p = 0.04). There were no significant differences in rates of major perioperative morbidities. Patients were followed for a median of 11.0 months during which there were no significant differences between cohorts in disease-free survival or overall survival. CONCLUSION When compared to OTHE, LTHE improves surgical outcomes and decreases hospital costs; short-term oncologic outcomes are similar. LTHE is preferable to OTHE in patients requiring transhiatal esophagectomy.
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Affiliation(s)
- Brett L Ecker
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Goda E Savulionyte
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Jashodeep Datta
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Kristoffel R Dumon
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - John Kucharczuk
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Noel N Williams
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Daniel T Dempsey
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA.
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Cianchi F, Trallori G, Mallardi B, Macrì G, Biagini MR, Lami G, Indennitate G, Bagnoli S, Bonanomi A, Messerini L, Badii B, Staderini F, Skalamera I, Fiorenza G, Perigli G. Survival after laparoscopic and open surgery for colon cancer: a comparative, single-institution study. BMC Surg 2015; 15:33. [PMID: 25887554 PMCID: PMC4376079 DOI: 10.1186/s12893-015-0013-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 02/24/2015] [Indexed: 12/14/2022] Open
Abstract
Background Some recent studies have suggested that laparoscopic surgery for colorectal cancer may provide a potential survival advantage when compared with open surgery. This study aimed to compare cancer-related survivals of patients who underwent laparoscopic or open resection of colon cancer in the same, high volume tertiary center. Methods Patients who had undergone elective open or laparoscopic surgery for colon cancer between January 2002 and December 2010 were analyzed. A clinical database was prospectively compiled. Survival analysis was calculated by using the Kaplan-Meier method. Results A total of 460 resections were performed. There were no significant differences between the laparoscopic (n = 227) and the open group (n = 233) apart from tumor stage: stage I tumors were more frequent in the laparoscopic group whereas stage II tumors were more frequent in the open group. The mean number of harvested lymph nodes was significantly higher in the laparoscopic than in the open group (20.0 ± 0.7 vs 14.2 ± 0.5, P < 0.01). The 5-year cancer-related survival for patients undergoing laparoscopic resection was significantly higher than that following open resections (83.1% vs 68.5%, P = 0.01). By performing a stage-to-stage comparison, we found that the improvement in survival in the laparoscopic group occurred mainly in patients with stage II tumors. Conclusions Our study shows a survival advantage for patients who had undergone laparoscopic surgery for stage II colon cancer. This may be correlated with a higher number of harvested lymph nodes and thus a better stage stratification of these patients.
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Affiliation(s)
- Fabio Cianchi
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy.
| | - Giacomo Trallori
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Giuseppe Macrì
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Maria Rosa Biagini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Gabriele Lami
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Siro Bagnoli
- Unit of Gastroenterology, AOU Careggi, Florence, Italy
| | | | - Luca Messerini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Benedetta Badii
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
| | - Fabio Staderini
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
| | - Ileana Skalamera
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
| | - Giulia Fiorenza
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
| | - Giuliano Perigli
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
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Bates AT, Divino C. Laparoscopic surgery in the elderly: a review of the literature. Aging Dis 2015; 6:149-55. [PMID: 25821642 DOI: 10.14336/ad.2014.0429] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic techniques are gradually replacing many common surgical procedures that are performed in an increasingly aging population. Laparoscopy places different physiologic demands on the body than in open surgery. PubMed was searched for evidence related to the use of laparoscopy in the elderly population to treat common surgical pathologies. Randomized trials, systematic reviews, and meta-analyses were preferred. Currently, over 40% of all surgeries performed in the U.S. are on patients older than 65 years. By the end of the 21st century, Americans are expected to live 20 years longer than the current average. However, elderly patients clearly show higher rates of surgical morbidity and mortality overall. Laparoscopic techniques show decreased wound complications, post-operative ileus, intraoperative blood loss, and reduced need for post-operative rehabilitation. In conclusion, laparoscopic surgery is safe in the elderly population and affords multiple advantages including decreased pain and convalescence. However, the physiology of laparoscopy places demands on elderly patients that typically present with more medical comorbidities.
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Affiliation(s)
| | - Celia Divino
- Mount Sinai Medical Center, New York, NY 10029, USA
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20
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Vallribera Valls F, Landi F, Espín Basany E, Sánchez García JL, Jiménez Gómez LM, Martí Gallostra M, Salgado Cruz L, Armengol Carrasco M. Laparoscopy-assisted versus open colectomy for treatment of colon cancer in the elderly: morbidity and mortality outcomes in 545 patients. Surg Endosc 2014; 28:3373-8. [DOI: 10.1007/s00464-014-3597-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 05/09/2014] [Indexed: 12/13/2022]
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21
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Nakamura Y, Hasegawa Y, Shirota K, Suetome N, Nakamura T, Chomnawang MT, Thirapanmethee K, Khuntayaporn P, Boonyaritthongchai P, Wongs-Aree C, Okamoto S, Shigeta T, Matsuo T, Park EY, Sato K. Differentiation-inducing effect of piperitenone oxide, a fragrant ingredient of spearmint (Mentha spicata), but not carvone and menthol, against human colon cancer cells. J Funct Foods 2014. [DOI: 10.1016/j.jff.2014.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Moirangthem G. Laparoscopic Colorectal Surgery: An Update (with Special Reference to Indian Scenario). J Clin Diagn Res 2014; 8:NE01-6. [PMID: 24959478 PMCID: PMC4064916 DOI: 10.7860/jcdr/2014/8269.4285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/05/2014] [Indexed: 01/22/2023]
Abstract
Laparoscopic cholecystectomy, being already declared as gold standard technique, laparoscopic surgery has advanced far and wide, touching almost every corner of the abdomen. This advancement has gradually expanded to colorectal surgery which is done for malignant diseases as well. However, laparoscopic colorectal surgery has not been accepted as quickly as was laparoscopic cholecystectomy. This is because of its steep learning curve, concerns with oncological outcomes, lack of randomized control trials (RCTs) and initial reports on high port site recurrences which occurred after curative resections. But all these initial concerns have been overcome by doing a series of RCTs globally, in the past decade, that revealed that laparoscopic colorectal surgery for malignant disease offered short term benefits without compromising on oncological principles of radicality of resection, tumour resection margins and completeness of lymph node harvesting as compared to those of open surgery. Favourable post-operative results with respect to less blood loss, less pain, lesser surgical site infections, lesser requirement of analgesics, early return of bowel function and shorter hospital stay in patients who underwent laparoscopic colorectal resections were obtained in studies done on individual series, including those done in India and more recently, in large trials. An update on recent studies done on laparoscopic colorectal surgery by reviewing many RCTs and individual series, including our experiences, was made, to support the advantages of this procedure which were obtained when it was carried out by skilled hands.
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Affiliation(s)
- G.S. Moirangthem
- Professor and Head, Department of Surgery & Gastrointestinal and Minimal Access Surgery Unit, Regional Institute of Medical Sciences, Imphal, India
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23
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Single-access laparoscopic rectal surgery is technically feasible. Minim Invasive Surg 2013; 2013:687134. [PMID: 23577248 PMCID: PMC3615606 DOI: 10.1155/2013/687134] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 02/24/2013] [Indexed: 01/21/2023] Open
Abstract
Introduction. Single-access laparoscopic surgery (SALS) has been successfully introduced for colectomy surgery; however, for mid to low rectum procedures such as total mesorectal excision, it can be technically complicated. In this study, we introduced a single-access technique for rectum cancer operations without the use of other instruments. Aims. To show the short-term results of single-access laparoscopic rectal surgery in terms of pathologic results and immediate complications. Settings and Design. Prospective study. Materials and Methods. We selected middle rectum to anal canal cancer patients to undergo single-access laparoscopic rectal resection for rectal cancer. All patients had total mesorectal excisions. An umbilical incision was made for the insertion of a single multichannel port, and a mesocolic window was created to identify the inferior mesenteric artery and vein. Total mesorectal excision was performed. There were no perioperative complications. The mean operative time was 269 minutes; the median hospital stay was 7 days; the mean wound size was 5.5 cm; the median number of harvested lymph nodes was 15; and all patients had intact mesorectal capsules. Statistical Analysis Used. Mean, minimum–maximum. Conclusion. Single-access laparoscopic surgery for rectal cancer is feasible while oncologic principles and patient safety are maintained.
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Singh A, Kuo YF, Goodwin JS. Many patients who undergo surgery for colorectal cancer receive surveillance colonoscopies earlier than recommended by guidelines. Clin Gastroenterol Hepatol 2013; 11:65-72.e1. [PMID: 22902760 PMCID: PMC3776496 DOI: 10.1016/j.cgh.2012.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 07/07/2012] [Accepted: 08/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients treated with surgery for colorectal cancer (CRC) should undergo colonoscopy examinations 1, 4, and 9 years later, to check for cancer recurrence. We investigated the use patterns of surveillance colonoscopies among Medicare patients. METHODS We used the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to identify patients who underwent curative surgery for colorectal cancer from 1992 to 2005 and analyzed the timing of the first 3 colonoscopies after surgery. Early surveillance colonoscopy was defined as a colonoscopy, for no reason other than surveillance, within 3 months to 2 years after a colonoscopy examination with normal results. RESULTS Approximately 32.1% and 27.3% of patients with normal results from their first and second colonoscopies, respectively, underwent subsequent surveillance colonoscopies within 2 years (earlier than recommended). Of patients who were older than 80 years at their first colonoscopy, 23.6% underwent a repeat procedure within 2 years for no clear indication. In multivariable analysis, early surveillance colonoscopy was not associated with sex, race, or patients' level of education. There was significant regional variation in early surveillance colonoscopies among the Surveillance, Epidemiology, and End Results regions. There was a significant trend toward reduced occurrence of second early surveillance colonoscopies. CONCLUSIONS Many Medicare enrollees who have undergone curative resection for colorectal cancer undergo surveillance colonoscopy more frequently than recommended by the guidelines. Reducing overuse could free limited resources for appropriate colonoscopy examinations of inadequately screened populations.
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Affiliation(s)
- Amanpal Singh
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Yong-Fang Kuo
- Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX,Sealy Center on Aging, University of Texas Medical Branch (UTMB), Galveston, TX
| | - James S. Goodwin
- Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX,Sealy Center on Aging, University of Texas Medical Branch (UTMB), Galveston, TX
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Cianchi F, Qirici E, Trallori G, Mallardi B, Badii B, Perigli G. Single-incision laparoscopic colectomy: technical aspects and short-term results. Updates Surg 2012; 64:19-23. [PMID: 21976113 DOI: 10.1007/s13304-011-0112-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 09/16/2011] [Indexed: 02/07/2023]
Abstract
Single-incision laparoscopic surgery (SILS) is currently regarded as the next major advance in the progress of minimally invasive techniques in colorectal surgery. We describe our initial experience using SILS for the management of colorectal disease and present preliminary short-term results. Between February 2010 and April 2011, 7 patients (4 females and 3 males, mean age 55 years, range 32–74) underwent SILS for either benign or malignant colorectal disease. Preoperative diagnosis was diverticular disease of the sigmoid colon in two patients, malignant polyps of the sigmoid colon in two other patients and large villous tumor of the right colon in three patients. Surgical procedures, 4 anterior resections of the rectum and 3 right hemicolectomies, were performed through a 3 cm single umbilical incision using a SILS multi port device with conventional or articulated laparoscopic instruments. There were no intraoperative complications or conversions in the standard laparoscopic procedure. The mean operative time for anterior resections was 160.0 ± 10.6 min, whereas it was 160.6 ± 20 for right hemicolectomies. Blood loss was minimal. No postoperative complications were reported in any of the patients. The overall mean hospital stay was 4.8 ± 0.2 days (range 4–5). For the subset of patients with malignant or pre-malignant disease, the mean number of retrieved lymph nodes was 15.6 ± 4.4 (range 6–31). Cosmetic results were considered excellent by all the patients after 15 days. In conclusion, our preliminary experience shows that SILS for colorectal disease is feasible and safe with potential reproducible oncologic results.
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Affiliation(s)
- Fabio Cianchi
- Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy.
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Guerrieri M, Campagnacci R, De Sanctis A, Lezoche G, Massucco P, Summa M, Gesuita R, Capussotti L, Spinoglio G, Lezoche E. Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy. Surg Today 2012; 42:1071-7. [PMID: 22903270 DOI: 10.1007/s00595-012-0292-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 08/28/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE There is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3 years. METHODS The subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; n = 164) or laparoscopic surgery (LS group; n = 126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0 months after OS and LS, respectively. RESULTS There were 10 (6.1 %) versus 9 (7.1 %) deaths unrelated to cancer, 15 (9.1 %) versus 5 (4 %) cases of local recurrence, 7 (4.2 %) versus 5 (4 %) cases of peritoneal carcinosis, and 37 (22.5 %) versus 14 (11.1 %) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8 %). The OS group had a significantly higher probability of local recurrence and metastases (p < 0.001) with a significant higher probability of cancer-related death (p = 0.001) than the LS group. CONCLUSIONS These findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.
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Affiliation(s)
- Mario Guerrieri
- Clinica di Chirurgia Generale e Metodologia Chirurgica, Ospedali Riuniti Ancona-Università Politecnica delle Marche, via Conca 1, 60121, Ancona, Italy
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Adequacy of lymphadenectomy in laparoscopic colorectal cancer surgery: a single-centre, retrospective study. Surg Laparosc Endosc Percutan Tech 2012; 22:33-7. [PMID: 22318057 DOI: 10.1097/sle.0b013e31824332dc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE This study aimed at evaluating the lymph node (LN) harvest after both open and laparoscopic colorectal cancer surgery. METHODS In the period between 1996 and 2009, 404 patients with colorectal cancer underwent open resection, whereas 147 patients underwent laparoscopic surgery. RESULTS The overall number of harvested LNs was significantly higher in the laparoscopic group than in the open one (16.5 vs. 14.3, P<0.001). A higher number of LNs was found in moderately differentiated tumors of the laparoscopic group when compared with the open surgery group (16.7 vs. 14.2, P<0.01). The numbers of harvested LNs in the proximal tumors and in stage II and III tumors were higher in the laparoscopic group than in the open group (18.9 vs. 15.4, P<0.001; 17.9 vs. 14.2, P=0.002; 17.3 vs. 15.3, P=0.02, respectively). CONCLUSIONS Laparoscopic surgery for colorectal cancer can achieve LN retrieval similar to that achieved by the open approach.
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Systemic inflammatory response after laparoscopic and conventional colectomy for cancer: a matched case-control study. Surg Endosc 2011; 26:1436-43. [PMID: 22179443 DOI: 10.1007/s00464-011-2052-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 10/27/2011] [Indexed: 01/10/2023]
Abstract
BACKGROUND Studies dealing with laparoscopic colectomy for cancer have reached conflicting results in regards to various inflammatory cytokines. Most of them have not examined potential differences with the open procedures at later postoperative days, when the immunologic advantage of laparoscopic surgery would be more demanding to demonstrate (for earlier administration of adjuvant treatment). The aim of this work is to detect differences of proinflammatory cytokines between conventional and laparoscopic colectomy for cancer. PATIENTS AND METHODS 30 patients who underwent laparoscopic colectomy were age, sex, and preoperative stage-matched with 30 patients treated by open surgery. C-reactive protein (CRP), interleukin (IL)-1, -6, and -8, and interferon (IFN)-γ serum levels were measured preoperatively, at 24 h, and at the 7th postoperative day (POD). RESULTS CRP and IL-6 postoperative values (24 h and 7th POD) were significantly higher than baseline for both groups (p = 0.001), but the respective values at the 7th POD were less than at 24 h (p = 0.001). IL-1 and -8 levels did not show any differences between assessment timepoints. A higher IFN-γ measurement was demonstrated at 24 h compared with baseline for the laparoscopic group only (p = 0.03). This difference was not maintained at the 7th POD. IFN-γ levels at 24 h and the 7th POD were significantly less for the open compared with the laparoscopic group of patients (p = 0.001). No correlation was revealed between measured serum values and age, sex, tumor location, or stage. CONCLUSIONS This matched case-control study verifies the already reported lack of differences regarding IL-1. Controversy still exists on likely IL-6 differences. The inadequately studied IL-8 does not seem to play an important role in immunologic differences. The immunologically beneficial IFN-γ, produced by the principal effectors of cell-mediated immunity Th1 cells, seems to have a more active presence following laparoscopic colectomy, potentially contributing to an immunologic "advantage" by counteracting "harmful" cytokines, such as IL-1.
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Shukla PJ, Barreto G, Gupta P, Shrikhande SV. Laparoscopic surgery for colorectal cancers: Current status. J Minim Access Surg 2011; 2:205-10. [PMID: 21234147 PMCID: PMC3016481 DOI: 10.4103/0972-9941.28181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Accepted: 09/21/2006] [Indexed: 01/25/2023] Open
Abstract
Laparoscopy was introduced more than 15 years ago into clinical practice. However, its role in colorectal surgery was not well established for want of better skills and technology. This coupled with high incidences of port site recurrences, prevented laparoscopic surgery from being incorporated into mainstream colorectal cancer surgery. A recent increase in the number of reports, retrospective analyses, randomized trials and multicentric trials has now provided sufficient data to support the role of laparoscopy in colorectal cancer surgery. We, thus, present a review of the published data on the feasibility, safety, short - and long-term outcomes following laparoscopic surgery for colorectal cancers. While the data available strongly favors the use of laparoscopic surgery in colonic cancer, larger well powered studies are required to prove or disprove its role in rectal cancer.
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Affiliation(s)
- Parul J Shukla
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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Bedin N, Agresta F. Colorectal surgery in a community hospital setting: have attitudes changed because of laparoscopy? A general surgeons' last 5 years experience review. Surg Laparosc Endosc Percutan Tech 2011; 20:30-5. [PMID: 20173618 DOI: 10.1097/sle.0b013e3181cdb5be] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Laparoscopy is rapidly emerging as the preferred surgical approach to a number of different diseases because it permits a correct diagnosis and accurate treatment; however, it is not yet being applied in a widespread manner in the management of benign or malignant colorectal disease. The aim of this work is to illustrate retrospectively the results of our experience of laparoscopic colorectal surgery carried out in a community hospital over the last 5 years to document its feasibility, safety, and benefits when carried out by general surgeons in this setting. MATERIALS AND METHODS Between January 2003 and December 2007 a total of 628 patients underwent a colorectal procedure. Among them, 328 (52.2%) were operated on with a laparoscopic approach. RESULTS In 12 cases, we had to convert to the open approach. Major complications occurred in 3.6% whereas minor occurrences occurred in up to 10%. CONCLUSIONS Even if limited by its retrospective design, our experience exhibits that the laparoscopic may well be a safe and effective approach to colon pathology in a community hospital setting. Such features make laparoscopy a challenging alternative to open surgery in the approach to colon disease and it can be proven to be cost-effective without undue risk, as long adequate laparoscopic training is undertaken by the surgeon and proper preparation observed.
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Affiliation(s)
- Natalino Bedin
- Department of General Surgery, Civil Hospital, Vittorio Veneto (TV), Italy
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Lee JE, Joh YG, Yoo SH, Jeong GY, Kim SH, Chung CS, Lee DG, Kim SH. Long-term Outcomes of Laparoscopic Surgery for Colorectal Cancer. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2011; 27:64-70. [PMID: 21602964 PMCID: PMC3092077 DOI: 10.3393/jksc.2011.27.2.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 03/29/2011] [Indexed: 12/21/2022]
Abstract
Purpose The long-term results of a laparoscopic resection for colorectal cancer have been reported in several studies, but reports on the results of laparoscopic surgery for rectal cancer are limited. We investigated the long-term outcomes, including the five-year overall survival, disease-free survival and recurrence rate, after a laparoscopic resection for colorectal cancer. Methods Using prospectively collected data on 303 patients with colorectal cancer who underwent a laparoscopic resection between January 2001, and December 2003, we analyzed sex, age, stage, complications, hospital stay, mean operation time and blood loss. The overall survival rate, disease-free survival rate and recurrence rate were investigated for 271 patients who could be followed for more than three years. Results Tumor-node-metastasis (TNM) stage I cancer was present in 55 patients (18.1%), stage II in 116 patients (38.3%), stage III in 110 patients (36.3%), and stage IV in 22 patients (7.3%). The mean operative time was 200 minutes (range, 100 to 535 minutes), and the mean blood loss was 97 mL (range, 20 to 1,200 mL). The mean hospital stay was 11 days and the mean follow-up period was 54 months. The mean numbers of resected lymph nodes were 26 and 21 in the colon and the rectum, respectively, and the mean distal margins were 10 and 3 cm. The overall morbidity rate was 26.1%. The local recurrence rates were 2.2% and 4.4% in the colon and the rectum, respectively, and the distant recurrence rates were 7.8% and 22.5%. The five-year overall survival rates were 86.1% in the colon (stage I, 100%; stage II, 97.6%; stage III, 77.5%; stage IV, 16.7%) and 68.8% in the rectum (stage I, 90.2%; stage II, 84.0%; stage III, 57.6; stage IV, 13.3%). The five-year disease-free survival rates were 89.8% in the colon (stage I, 100%; stage II, 97.7%; stage III, 74.2%) and 74.5% in the rectum (stage I, 90.0%; stage II, 83.9%; stage III, 59.2%). Conclusion Laparoscopic surgery for colorectal cancer is a good alternative method to open surgery with tolerable oncologic long-term results.
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Affiliation(s)
- Jeong-Eun Lee
- Department of Surgery, Hansol Hospital, Seoul, Korea
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Offodile AC, Balik E, Hoffman A, Moon V, Baxter R, Grieco M, Moradi D, Kim IY, Nasar A, Cekic V, Feingold DL, Arnell TD, Huang E, Whelan RL. Is there a role for a strict incision length criterion for determining conversions during laparoscopic colorectal resection? Surg Innov 2010; 17:120-6. [PMID: 20504788 DOI: 10.1177/1553350610366715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE There's no consensus about what defines a conversion for laparoscopic-assisted colorectal resection (LACR). This study's goal was to assess the utility of a strict incision length (IL) definition of conversion (incision > 7 cm) and compare it with results obtained when the surgeon determined (SD) if a LACR had been successfully completed. METHODS The demographic and perioperative data for 580 elective LACRs were reviewed. The short-term outcomes for each conversion definition were determined and compared. RESULTS Conversion rates were 22% using the IL definition and 16% via the SD method. Both methods detected significant differences between completed and converted groups regarding the following: incision size, hospital stay, time to flatus, bowel movement, and regular diet as well as rate of wound infection and ileus. The IL method alone detected significant differences in the rate of pulmonary complications and BMI between the completed and converted groups. CONCLUSIONS The 2 methods yielded similar results for most parameters. The IL method better separated the patients in regard to 2 parameters. This method is objective and easy to apply; however, it may discriminate against obese patients whose extraction incisions are often longer. A conversion definition that considers BMI and IL is needed.
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Affiliation(s)
- Anaeze C Offodile
- New York-Presbyterian Hospital, Columbia Campus, New York, NY 10032, USA
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Abstract
Laparoscopic surgery as an alternative to traditional open surgery, has been accepted by an increasing number of surgeons and patients. In this paper, we review the advances in laparoscopic surgery for colorectal cancer and summarize its pros and cons by comparing with open surgery, including patient inclusion and exclusion, intraoperative outcomes, and short- and long-term outcomes. Furthermore, we provide an initial overview of the Da Vinci robotic system and the single-port laparoscopic surgery.
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Kotze PG, Freitas CD, Froehner Junior I, Steckert JS, Ishie E, Steckert Filho Á, Martins JF, Miranda EF. Análise do número de linfonodos em espécimes de ressecções colorretais por neoplasia entre a cirurgia aberta e videolaparoscópica. ACTA ACUST UNITED AC 2010. [DOI: 10.1590/s0101-98802010000200001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introdução: o estadiamento patológico com a análise do número de linfonodos dissecados é fator importante na determinação da segurança oncológica das ressecções por câncer colorretal, independentemente da via de acesso. Em fase inicial de curva de aprendizado em laparoscopia colorretal, a equivalência entre a cirurgia convencional e laparoscópica pode ser comprometida. O objetivo do presente estudo foi analisar o número de linfonodos dissecados em espécimes de ressecções por câncer colorretal pela via convencional e laparoscópica, e verificar a equivalência oncológica entre ambas. Método: estudo retrospectivo de uma série de casos de pacientes submetidos a ressecções por câncer colorretal por via convencional e laparoscópica. Variáveis analisadas: idade, sexo, via de acesso, tipo de procedimento, estadiamento de Dukes e número de linfonodos dissecados nas peças. Análise estatística pelo método de Mann-Whitney. Resultados: 50 pacientes foram analisados (33 operados por via convencional, 17 por via laparoscópica). Houve maior número de colectomias direitas e retossigmoidectomias altas nos dois grupos. O número médio de linfonodos dissecados foi de 10,35 no grupo laparoscópico e de 10,15 no grupo de acesso convencional (p=0,859). Conclusões: não houve diferença estatística entre o número médio de linfonodos dissecados entre os espécimes ressecados por via convencional e laparoscópica, numa fase inicial de curva de aprendizado.
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Soumarova R, Skrovina M, Bartos J, Gruna J, Wendrinski A, Czudek S, Kycina R, Parvez J. Neoadjuvant chemoradiotherapy with capecitabine followed by laparoscopic resection in locally advanced tumors of middle and low rectum - toxicity and complications of the treatment. Eur J Surg Oncol 2009; 36:251-6. [PMID: 19879716 DOI: 10.1016/j.ejso.2009.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2009] [Revised: 09/21/2009] [Accepted: 10/01/2009] [Indexed: 01/04/2023] Open
Abstract
AIMS The aim of this prospective study is to elucidate feasibility of protocol of neoadjuvant concomitant radiochemotherapy with capecitabine and long course radiotherapy with subsequent laparoscopic rectal resection. We assessed treatment toxicity, downstaging rate, pathological response to the neoadjuvant treatment, surgery complications, rate of conversions and sphincter-preserving surgical procedures, and intraoperative and early postoperative complications too. METHODS We acquired data of 78 patients from 1 January 2005 to 31 December 2007 with a locally advanced rectal cancer in our study. All patients were indicated for the neoadjuvant concomitant chemoradiotherapy due to locally advanced tumor (T3 or T4) or lymph nodes involvement suspicion (N+). Both radiotherapy (to pelvic region) and chemotherapy (capecitabine) were administered. Rectal tumors were localized within 12 cm from the anocutaneous verge. The average follow-up time was 23.9 months. RESULTS All patients completed their treatment according to the planned regimen and dose. The surgery was performed laparoscopicaly within 4-8 weeks following the concomitant chemoradiotherapy - in 17% cases was converted into conventional surgery. Downstaging was achieved in 69% of patients, pathological complete response in 10%, histologically negative lymph nodes were documented in 58% of patients. Grade 3 toxicity of the concomitant chemoradiotherapy was present in 3%; grade 2 in 29% of patients, particularly skin and gastrointestinal form. Intraoperative and early postoperative complications of the surgery were 18%. Re-operation was needed in 5% cases. CONCLUSIONS We demonstrated safety and low toxicity of the concomitant chemoradiotherapy with capecitabine.
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Affiliation(s)
- R Soumarova
- Department of Radiotherapy and Oncology, J. G. Mendel Cancer Center Novy Jicin, Purkynova 2138/16, Novy Jicin, 741 01, Czech Republic.
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[Therapy of refractory proctocolitis and Crohn's disease. Incisionless laparoscopic proctocolectomy with a Brooke ileostomy]. Chirurg 2009; 80:730-3. [PMID: 19533065 DOI: 10.1007/s00104-009-1723-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Laparoscopic colorectal surgery is nowadays also widely used in surgery of inflammatory bowel disease. With the correct indications laparoscopic surgery is an attractive cosmetic alternative for the predominantly juvenile patients. Refractory fistulizing Crohn's proctocolitis is a very severe disease with a maximal limitation on the quality of life. Proctocolectomy with a Brooke ileostomy represents a very effective option for these patients. The laparoscopic technique can at least spare the patients a salvage laparotomy incision. We report about our preliminary experiences PATIENTS AND METHOD A total of 8 patients (mean age 25 years, range 19 Background 31 years, female:male ratio 5:3) were operated on. The mean preoperative time course of the disease was 28 months (range 12 Background 156 months). All patients had received long-term prednisolone therapy of >15mg, 2 patients received azathioprine medication, 2 underwent anti TNF-alpha therapy and 6 received 5-aminosalicylic acid (5-ASA). The mean preoperative BMI was 19 (range 15 Background 21). All patients suffered from Crohn's pancolitis with anorectal fistulas. Laparoscopic proctocolectomy was performed using 4 trocars place in a semicircular fashion. The resected tissue was salvaged transanally and the Brooke ileostomy was drained via the right lateral trocar. The terminal exit of the rectum occurred transanally with preservation of the pelvic floor and the anal sphincter and the anal fistulas were separated. The small pelvis was filled by a transanally fixed omentum. RESULTS The median time for surgery was 236.5 mins (range 220-330 mins). A complication of postoperative paralysis of the bowel occurred in two patients and 4 patients could be discharged problem-free according to the fast-track concept. Cosmetic results were excellent in all cases. Perianal and perirectal manifestations healed completely after a median of 4 weeks. CONCLUSIONS Incisionless proctocolectomy represents a good and realizable alternative to open surgery. The main advantages are excellent cosmetic results and a better preservation of the external integrity of the abdomen.
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El-Gazzaz G, Hull T, Hammel J, Geisler D. Does a laparoscopic approach affect the number of lymph nodes harvested during curative surgery for colorectal cancer? Surg Endosc 2009; 24:113-8. [PMID: 19517186 DOI: 10.1007/s00464-009-0534-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 04/14/2009] [Accepted: 05/01/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study aimed to assess the number of lymph nodes (LNs) harvested after laparoscopic and open colorectal cancer resections. METHODS Between 1996 and 2007, 431 colorectal cancer patients underwent laparoscopic resection. During the periods of 1996-1997, 2002-2003, and 2006-2007, 243 patients undergoing laparoscopic colorectal cancer resection were matched 1-2 by age, operation, gender, operation date, body mass index (BMI), and tumor stage (TNM) to 486 patients undergoing open surgery. The numbers of examined and involved LNs were compared according to tumor location and year of surgery. RESULTS Colorectal cancer resections (243 laparoscopic and 486 open procedures) were performed for 729 patients (447 men) with a mean age of 66.2 +/- 12.3 years and a mean BMI of 28.5 +/- 7.3. The mean number of LNs per case was 24.8 +/- 20.6. The number of LNs retrieved did not differ between laparoscopic and open surgery (p = 0.4). A significant difference was observed between the number of involved LNs retrieved laparoscopically (2.2 +/- 3.8) and the number retrieved by open surgery (1.6 +/- 4; p = 0.03). There were significant differences between the numbers of LNs retrieved from the right colon (28.1 +/- 14.6), left colon (24.5 +/- 17.6), and rectum (19.1 +/- 15.1) (p < 0.001). There were significantly fewer examined LNs in laparoscopic than in open cases during 2002 and 2003 (p = 0.003). CONCLUSION Laparoscopic resection of colorectal cancer can achieve lymph node retrieval similar to that achieved by the open approach. In this era of new technology, laparoscopic lymph node harvest is becoming more optimized.
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Affiliation(s)
- Galal El-Gazzaz
- A30 Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Shabbir A, Roslani AC, Wong KS, Tsang CBS, Wong HB, Cheong WK. Is laparoscopic colectomy as cost beneficial as open colectomy? ANZ J Surg 2009; 79:265-70. [PMID: 19432712 DOI: 10.1111/j.1445-2197.2009.04857.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Laparoscopic colectomy has yet to gain widespread acceptance in cost-conscious health-care institutions. The aim of the present study was to define the cost-benefit relationship of laparoscopic versus open colectomy. METHODS Thirty-two consecutive patients undergoing elective laparoscopic colectomy (LC) by a single colorectal surgeon between August 2004 and September 2005 were reviewed. Cases were matched with a historical cohort undergoing elective open colectomy (OC) between June 2003 and July 2004. Demography, perioperative data, histopathology and cost were compared. RESULTS Both groups had similar demographics. Most resections (90.6%) were for cancer. Operative time was significantly longer for LC compared to OC (180 min vs 110 min, P < 0.001). Four patients (12.5%) in the LC group required conversion. LC patients, however, had lower median pain scores (3, 2 and 1 vs 6, 4 and 2 at 24, 48 and 72 h postoperatively, P < 0.001), faster resolution of ileus (3 vs 4 days, P < 0.001) and earlier discharge (6 vs 9 days, P < 0.001) compared to the OC group. As a result, overall hospital cost for both procedures was not significantly different (US$7943 vs US$7253, P = 0.41). CONCLUSION Laparoscopic colectomy is as cost-beneficial in the short term as open colectomy.
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Affiliation(s)
- Asim Shabbir
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
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Abstract
UNLABELLED Although laparoscopic surgery for colorectal cancer improves post operative recovery, its use for curative treatment especially for rectal cancer is still controversial. The present study is an attempt to analyze the results of the safety and feasibility of laparoscopic surgery including short-term results for rectal cancer. METHODS This study accumulated 109 patients with rectal cancer retrospectively who underwent laparoscopic surgery. Patients with rectosigmoid colon cancer were excluded from this study. Patients' data, perioperative data including morbidity and mortality, surgical data were analyzed, and the 3-year disease-free survival data were calculated by Kaplan-Meier method, according to the location of the tumor and the UICC stage. RESULTS There were 71 males and 38 females who underwent laparoscopic surgery for rectal cancer. Mean age of them was 63.7+/-12.5 years. The mean BMI was 22.6+/-2.8 kg/m(2). The operative procedure was low anterior resection (LAR) in 80 cases, abdominoperineal resection (APR) in 14 cases, intersphincteric resection (ISR) in 14 cases, and Hartmann's procedure in 1 case. The operation time was 237.0+/-71.6 minutes. Blood loss was 165.0+/-163.8. The postoperative morbidity was 22.9%. The postoperative mortality within 30 days after surgery was not experienced. The 3-year disease-free survival rate was 94.2% after curative surgery. According to the UICC stage, the 3-year disease survival rate was 100% in stage 0/I, 89.1% in stage II, and 84.6% in stage III. CONCLUSIONS Laparoscopic surgery for rectal cancer was safe and feasible including postoperative morbidity, mortality and postoperative short-term results. Further study is necessary to clarify the quality of laparoscopic surgery including the postoperative long-term results.
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The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Ann Surg 2008; 248:1-7. [PMID: 18580199 DOI: 10.1097/sla.0b013e31816a9d65] [Citation(s) in RCA: 417] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to compare the long-term outcome of laparoscopy-assisted colectomy (LAC) and open colectomy (OC) for nonmetastatic colon cancer. METHODS From November 1993 to July 1998 all patients with adenocarcinoma of the colon were assessed for entry in this single center, clinically randomized trial. Adjuvant therapy and postoperative follow-up were similar in both groups. The primary endpoint was cancer-related survival and secondary endpoints were probability of overall survival and probability of being free of recurrence. Data were analyzed according the intention-to-treat principle. RESULTS Two hundred and nineteen patients entered the study (111 LAC group and 108 OC group). The median follow-up was 95 months (range, 77-133). There was a tendency of higher cancer-related survival (P = 0.07, NS) and overall survival (P = 0.06, NS) for the LAC group. Probability of cancer-related survival was higher in the LAC group (P = 0.02) when compared with OC. The regression analysis showed that LAC was independently associated with a reduced risk of tumor relapse (hazard ratio 0.47, 95% CI 0.23-0.94), death from a cancer-related cause (0.44, 0.21-0.92) and death from any cause (0.59, 0.35-0.98). CONCLUSIONS LAC is more effective than OC in the treatment of colon cancer.
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Benedix F, Köckerling F, Lippert H, Scheidbach H. Laparoscopic resection for endoscopically unresectable colorectal polyps: analysis of 525 patients. Surg Endosc 2008; 22:2576-82. [PMID: 18626704 DOI: 10.1007/s00464-008-0059-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 06/04/2008] [Accepted: 06/15/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND For the management of endoscopically irretrievable polyps, several minimally invasive procedures are currently available as alternatives to conventional laparotomy. However, the high rate of malignant transformation despite initially benign histology continues to be a problem. METHODS Within the framework of a prospective multicenter observational study, all patients with adenomatous polyps unsuitable for endoscopic removal and with benign histology were investigated. In addition to an analysis of the perioperative course and the definitive histology, the overall and disease-free survival rates of patients with malignant transformation of colorectal adenomas were also calculated. RESULTS A total of 525 patients (median age 65.3 years; median body mass index 25.6 kg/m(2)) underwent a laparoscopic resection. Conversion to laparotomy became necessary in 17 (3.2%) cases. The perioperative morbidity rate was 20.8%, and malignant transformation occurred in a total of 18.1% of the adenomatous polyps. The median number of lymph nodes removed was 12, and lymph node metastases were seen in a total of 14.8% of the patients (T1--4.8%, T2--19.4%, T3--25%, T4--100%). Estimated 5-year overall and disease-free survival rates were 92.4% and 80.6%, respectively. CONCLUSIONS For the management of endoscopically unresectable polyps, laparoscopic resection is currently the technique of choice. In addition to the benefits of minimally invasive surgery, in the hands of an experienced surgeon it achieves results comparable with those of open surgery. In view of the high rate of malignant transformation and the absence of unequivocal factors predictive of already present malignant transformation, an oncologically radical operation is essential. In the elderly patient presenting with comorbidities limited resection aiming to minimize surgical trauma in potentially benign disease may be considered. In such a case, however, frozen-section histology is obligatory.
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Affiliation(s)
- Frank Benedix
- Department of Surgery, Otto-von-Guericke-University Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany.
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Thome MA, Ehrlich D, Koesters R, Müller-Stich B, Unglaub F, Hinz U, Büchler MW, Gutt CN. The point of conversion in laparoscopic colonic surgery affects the oncologic outcome in an experimental rat model. Surg Endosc 2008; 23:1988-94. [DOI: 10.1007/s00464-008-9971-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Revised: 04/08/2008] [Accepted: 04/24/2008] [Indexed: 12/29/2022]
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Nakamura Y, Nakayama Y, Ando H, Tanaka A, Matsuo T, Okamoto S, Upham BL, Chang CC, Trosko JE, Park EY, Sato K. 3-Methylthiopropionic acid ethyl ester, isolated from Katsura-uri (Japanese pickling melon, Cucumis melo var. conomon), enhanced differentiation in human colon cancer cells. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2008; 56:2977-84. [PMID: 18426216 PMCID: PMC2435010 DOI: 10.1021/jf072898i] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The fully ripened fruit of Katsura-uri Japanese pickling melon ( Cucumis melo var. conomon) has rarely been used for food because the midripened fruit is utilized for making pickles, but the fully ripened fruit is no longer valuable for pickles due to the fruit body being too soft. We have considered the utilization of the fully ripened Katsura-uri fruit that may be used for nonpickling products, particularly if the fully ripened fruit demonstrated health benefits such as anticarcinogenic properties. The phytochemical extract from the fully ripened fruit of Katsura-uri Japanese pickling melon was purified via a bioassay-guided fractionation scheme, which was based on the induction of differentiation in a RCM-1 human colon cancer cell line. On the criteria of two differentiation markers (duct formation and alkaline phosphatase activity), the most potent fraction contained a compound identified as 3-methylthiopropionic acid ethyl ester, based on GC retention time, EI-MS, (1)H NMR, and (13)C NMR spectra. Previously, the role of 3-methylthiopropionic acid ethyl ester was considered as an odor producing compound in many fruits, but this study indicates potential medical benefits of this compound.
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Affiliation(s)
- Yasushi Nakamura
- Department of Food Sciences and Nutritional Health, Kyoto Prefectural University, Shimogamo-Hangi, Sakyo, Kyoto 606-8522, Japan.
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Moreno-Sanz C, Picazo-Yeste J, Seoane-Gonzáles J, Manzanera-Díaz M, Tadeo-Ruiz G. Division of the small bowel with the LigaSure Atlas device during the right laparoscopic colectomy. J Laparoendosc Adv Surg Tech A 2008; 18:99-101. [PMID: 18266584 DOI: 10.1089/lap.2007.0014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Bowel division and anastomosis were facilitated greatly with the advent of stapling techniques. Since then, there have not been any new evolving technologies to facilitate these maneuvers. For this reason, we recently applied the LigaSure Atlas device (Valleylab, Boulder, CO) to the division of the small bowel during this procedure to obtain a reliable and low-cost division of the ileum. METHODS After vessel ligation and ileocolic mobilization, the terminal ileum is sealed and divided with the LigaSure Atlas. This device is applied sequentially along the small bowel twice to ensure an adequate seal before the cut. A terminolateral ileotransversostomy is performed extracorporeally with a mechanical circular stapling device, installing the anvil of the circular stapler into the ileal stump. RESULTS We have not encountered any problems with this technique since its introduction in our institution, and no leakage or bursting of the ileal stumps. CONCLUSIONS This technique enables an easy, reliable, and inexpensive technical option to optimize the right laparoscopic colectomy procedure.
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Affiliation(s)
- Carlos Moreno-Sanz
- Department of Surgery, La Mancha-Centro General Hospital, Alcazar de San Juan, Spain.
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Wright RC, Kim CA, Horner I, Wright R. Superior Lymph Node Resection is Achievable with Laparoscopic Colectomy: Even in Initial 30 Cases. Am Surg 2008. [DOI: 10.1177/000313480807400314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Recent studies demonstrated the validity of the laparoscopic technique in colon cancer resection. Recent node resection data for open colectomies show inadequate nodal removal is common. In this study, two experienced laparoscopic surgeons evaluated their initial outcomes with laparoscopic colectomy, including resections for malignancies. This retrospective review of clinic and hospital records involved 69 consecutive patients subjected to laparoscopic colectomies from July 2000 through December 2005. Outcomes were compared with 1000 patients from Senagore and Delaney. Adequacy of oncologic resection was compared with the published National Cancer Institute database. Sixty-nine resections were performed. Overall complication and conversion rates were comparable to Senagore and Delaney except for days of hospitalization at 6.0 compared with 3.7 (P < 0.01) and readmission of 4.2 per cent compared with 9.1 per cent (P < 0.01). Adequate node resection occurred in 26 of 32 patients (81%) compared with 37 per cent of open colectomies in the National Cancer Institute nationwide database (P < 0.05). The overall median number of nodes resected was 18. For veteran laparoscopic surgeons in a community hospital, the initial experience with laparoscopic colectomy can provide excellent results, meeting standards set in large published series. In addition, the resection of nodes in colon cancer can be significantly better when performed laparoscopically or by hand-assisted laparoscopy.
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Affiliation(s)
- Robert C. Wright
- Department of Surgery, Good Samaritan Hospital, Puyallup, Washington
| | - C. Anthony Kim
- Department of Surgery, Good Samaritan Hospital, Puyallup, Washington
| | - Ian Horner
- Touro University, Vallejo, California; and
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Osarogiagbon RU, Ogbeide O, Ogbeide E, George RK. Hand-Assisted Laparoscopic Colectomy Compared with Open Colectomy in a Nontertiary Care Setting. Clin Colorectal Cancer 2007; 6:588-92. [PMID: 17681106 DOI: 10.3816/ccc.2007.n.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Laparoscopic colectomy allows oncologic resection equivalent to open colectomy while reducing postoperative morbidity, at the cost of longer operating time. Hand-assisted laparoscopy might yield the benefits of laparoscopy while reducing operating time. PATIENTS AND METHODS We compared the intraoperative and postoperative experience of patients undergoing hand-assisted laparoscopic colectomy (HALC) to those who had open colectomy. In this retrospective case review of consecutive patients undergoing HALC for colon tumors from April 2003 to September 2004 compared with patients who had open colectomy, patients with rectal cancer and stage IV disease were excluded, and reported variables were compared by the nonparametric Mann-Whitney U test; all P values are 2-tailed. RESULTS The number of patients with HALC versus open colectomy was 39 and 55, respectively. The locations of tumors were as follows: right colon, 62% versus 56%; left colon, 2.5% versus 11%; sigmoid colon, 31% versus 33%; and rectosigmoid colon, 5% versus 0. Stage distribution was as follows: stage 0, 23% versus 11%; stage I, 23% versus 23%; stage II, 31% versus 36%; and stage III, 23% versus 31%. Median operating room time was 139 minutes versus 137 minutes (P = 0.94). Four 39 (10%) HALC procedures were converted to open colectomy. Duration of hospitalization was 6 days versus 10 days (P = 0.007). Median number of lymph nodes in resection specimen was 12 versus 9 (P = 0.043). There were 3 cases of serious postoperative infection in the HALC group versus 9 in the open colectomy cohort. CONCLUSION Hand-assisted laparoscopic colectomy is technically feasible in the nontertiary care setting, with duration of surgery equivalent to that of open colectomy but significantly shorter duration of hospitalization and equivalent or superior quality resection and pathologic staging.
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Affiliation(s)
- Raymond U Osarogiagbon
- Division of Hematology/Medical Oncology, Department of Medicine, University of Tennessee Cancer Institute, Memphis 38104, USA.
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Jacob B, Salky B. Laparoscopic colectomy for colon cancer: lymph node number and survival rates. Surg Endosc 2006; 21:492-3. [PMID: 17180294 DOI: 10.1007/s00464-006-9010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Accepted: 04/02/2006] [Indexed: 10/23/2022]
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Abstract
Since its first described case in 1991, laparoscopic colon surgery has lagged behind minimally invasive surgical methods for solid intra-abdominal organs in terms of acceptability, dissemination, and ease of learning. In colon cancer, initial concerns over port site metastases and adequacy of oncologic resection have considerably dampened early enthusiasm for this procedure. Only recently, with the publication of several large, randomized controlled trials, has the incidence of port site metastases been shown to be equivalent to that of open resection. Laparoscopic surgery for colon cancer has also been demonstrated to be at least equivalent to traditional laparotomy in terms of adequacy of oncologic resection, disease recurrence, and long-term survival. In addition, numerous reports have validated short-term benefits following laparoscopic resection for cancer, including shorter hospital stay, shorter time to recovery of bowel function, and decreased analgesic requirements, as well as other postoperative variables. In benign colonic disease, much less high-quality literature exists supporting the use of laparoscopic methods. Two recent randomized controlled trials have demonstrated some short-term benefits to laparoscopic ileocolic resection for CD, in addition to evident cosmetic advantages. On the other hand, the current evidence on laparoscopic surgery for UC does not support its routine use among nonexpert surgeons outside of specialized centers. Laparoscopic colonic resection for diverticular disease appears to provide several short-term benefits, although these advantages may not translate to cases of complicated diverticulitis. Despite the increasing acceptability of minimally invasive methods for the management of benign and malignant colonic pathologies, laparoscopic colon resection remains a prohibitively difficult technique to master. Numerous technological innovations have been introduced onto the market in an effort to decrease the steep learning curve associated with laparoscopic colon surgery. Good evidence exists supporting the use of second-generation, sleeveless, hand-assist devices in this context. Similarly, new hemostatic devices such as the ultrasonic scalpel and the electrothermal bipolar vessel sealer may be particularly helpful for extensive colonic mobilizations, in which several vascular pedicles must be taken. The precise role of these hemostatic technologies has yet to be established, particularly in comparison with stapling devices and significantly cheaper laparoscopic clips. Finally, recent advances in camera systems are promising to improve the ease with which difficult colonic dissections can be performed.
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Affiliation(s)
- Guillaume Martel
- Division of General Surgery, Minimally Invasive Surgery Research Group, University of Ottawa, The Ottawa Hospital-General Campus, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
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Polignano F, Henderson N, Alishahi SM, Zito A. Laparoscopic colectomy for cancer and adequate lymphadenectomy. Surg Endosc 2006; 20:996-7. [PMID: 16739001 DOI: 10.1007/s00464-005-0555-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 12/21/2005] [Indexed: 10/24/2022]
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