Laparoscopic lateral pelvic lymph node dissection is achievable and offers advantages as a minimally invasive surgery over the open approach

Two cases of strangulated bowel obstruction due to exposed vessel and nerve after laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer

BACKGROUND

The majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood vessels and nerves during pelvic lymphadenectomy (PL). In this report, we present two cases of SBO following laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer, one case each, of which obstructions were attributed to the exposure of blood vessels and nerves during the procedures.

CASE PRESENTATION

Case 1: A 68-year-old man underwent laparoscopic perineal rectal amputation and LLND for rectal cancer. Four years and three months after surgery, he visited to the emergency room with a chief complaint of left groin pain. Computed tomography (CT) revealed a closed-loop in the left pelvic cavity. We performed an open surgery to find that the small intestine was fitted into the gap between the left obturator nerve and the left pelvic wall, which was exposed by LLND. The intestine was not resected because coloration and peristalsis of the intestine improved after the hernia was released. The obturator nerve was preserved. Case 2: A 57-year-old man underwent a robot-assisted rectal amputation with LLND for rectal cancer. Eight months after surgery, he presented to the emergency room with a complaint of abdominal pain. CT revealed a closed-loop in the right pelvic cavity, and he underwent a laparoscopic surgery with a diagnosis of strangulated SBO. The small intestine was strangulated by an internal hernia caused by the right umbilical arterial cord, which was exposed by LLND. The incarcerated small intestine was released from the gap between the umbilical arterial cord and the pelvic wall. No bowel resection was performed. The umbilical arterial cord causing the internal hernia was resected.

CONCLUSION

Although strangulated SBO due to an exposed intestinal cord after PL has been a rare condition to date, it is crucial for surgeons to keep this condition in mind.

Laparoscopic resection of schwannoma in the lateral pelvic space based on the fascia plane: how we do it (with video)

BACKGROUND

Research on laparoscopic schwannoma resection (LSR) in the lateral pelvic space (LPS) remains limited. This study aimed to compare the short-term and oncological outcomes of LSR and conventional open schwannoma resection (OSR).

METHODS

Clinical data of 38 patients with lateral pelvic schwannomas were retrospectively collected. LSR in the LPS was based on fascial-oriented techniques. Operation-related results, neurological function, and oncological outcomes were compared.

RESULTS

A total of 38 patients were enrolled, including 18 and 20 patients who underwent LSR and OSR, respectively. The baseline characteristics showed no significant differences between the groups. The median blood loss and incision length in the LSR group were significantly lower (40.0 vs. 300 mL, 4.5 vs. 15 cm, P < 0.001). The LSR group showed less time to the first flatus (2.0 vs. 3.0 days, P = 0.029), time to pull drainage (5.0 vs. 6.0 days, P = 0.042), time to pull catheter (3.0 vs. 4.0 days, P = 0.027), and postoperative hospital stay (6.0 vs. 8.0 days, P = 0.048). The LSR group also showed fewer postoperative complications than the OSR group, although the difference was not significant (40.0% vs. 16.7%, P = 0.113). At a median follow-up of 36 months, no local recurrence was observed.

CONCLUSIONS

Fascial-oriented laparoscopic resection of schwannomas in the LPS is feasible without compromising oncological safety. LSR shows clear advantages, most notably small incisions, less blood loss, and quick recovery, as well as potential benefits of neurological function.

Benefits of a laparoscopic approach for second colorectal resection after colectomy or proctectomy -a retrospective study

BACKGROUND

A laparoscopic approach generally provides several benefits in patients who undergo colon or rectal surgery without jeopardizing oncological outcomes. However, there is a paucity of studies on comparative outcomes of laparoscopic versus open approaches for second primary colorectal lesions after colectomy or proctectomy.

METHODS

From patients with colorectal disease who underwent surgery between 2008 and 2022 at our hospital, we collected 69 consecutive patients who had previous colorectal surgery for this retrospective study. Based on the second surgery approach (laparoscopic or open), patients were classified into the Lap (n = 37) or Op group (n = 32). Patients' baseline data and perioperative and postoperative outcomes were compared between the two groups.

RESULTS

Four patients (11%) of the Lap group needed conversion to laparotomy. The intraoperative blood loss was lower in the Lap group than the Op group (median: 45 ml vs. 205 ml, p = 0.001). The time to first bowel movement was shorter in the Lap group than the Op group (median: 2.8 days vs. 3.6 days, p = 0.007). The operative time, frequencies of postoperative morbidities, and overall survival did not differ between the two groups.

CONCLUSION

Laparoscopic surgery appeared feasible and beneficial for selected patients undergoing second colorectal resection after colectomy or proctectomy regarding blood loss and bowel function recovery without affecting other outcomes.

Robotic versus laparoscopic approach for minimally invasive lateral pelvic lymph node dissection of advanced lower rectal cancer: a retrospective study comparing short-term outcomes

PURPOSE

The importance of lateral pelvic lymph node dissection (LLND) for advanced low rectal cancer is gradually being recognized in Europe and the USA, where some patients were affected by uncontrolled lateral pelvic lymph node (LLNs) metastasis, even after total mesorectal excision (TME) with neoadjuvant chemoradiotherapy (CRT). The purpose of this study was thus to compare robotic LLND (R-LLND) with laparoscopic (L-LLND) to clarify the safety and advantages of R-LLND.

METHODS

Sixty patients were included in this single-institution retrospective study between January 2013 and July 2022. We compared the short-term outcomes of 27 patients who underwent R-LLND and 33 patients who underwent L-LLND.

RESULTS

En bloc LLND was performed in significantly more patients in the R-LLND than in the L-LLND group (48.1% vs. 15.2%; p = 0.006). The numbers of LLNs on the distal side of the internal iliac region (LN 263D) harvested were significantly higher in the R-LLND than in the L-LLND group (2 [0-9] vs. 1 [0-6]; p = 0.023). The total operative time was significantly longer in the R-LLND than in the L-LLND group (587 [460-876] vs. 544 [398-859]; p = 0.003); however, the LLND time was not significantly different between groups (p = 0.718). Postoperative complications were not significantly different between the two groups.

CONCLUSION

The present study clarified the safety and technical feasibility of R-LLND with respect to L-LLND. Our findings suggest that the robotic approach offers a key advantage, allowing significantly more LLNs to be harvested from the distal side of the internal iliac region (LN 263D). Prospective clinical trials examining the oncological superiority of R-LLND are thus necessary in the near future.

Short-term outcomes of near-infrared imaging using indocyanine green in laparoscopic lateral pelvic lymph node dissection for middle-lower rectal cancer: A propensity score-matched cohort analysis

Laparoscopic lateral pelvic lymph node dissection (LPND) is limited by complex neurovascular bundles in the narrow pelvic sidewall and various post-operative complications. Indocyanine green (ICG) has been applied to increase the number of harvested lymph nodes and reduce the injury of irrelevant vessels in patients with rectal cancer. However, few studies on the recurrence rate of ICG fluorescence imaging-guided laparoscopic LPND were reported. This retrospective study enrolled 50 middle- low rectal cancer patients who were treated by LPND. After propensity score matching, 20 patients were matched in each of the indocyanine green (ICG) guided imaging group (ICG group) and non-ICG guided imaging group (non-ICG group). The average follow-up time was 13.5 months (12-15 months). Our results showed that the total number of harvested lymph nodes in the ICG group was significantly higher than that in the non-ICG group (P < 0.05), and intraoperative blood loss and post-operative hospital stay times in the ICG group were less than those in the non-ICG group (P < 0.05). After 12 months of follow-up, no residual lymph node and local tumor recurrence were found for patients in the ICG group. Four patients in the non-ICG group detected residual lymph nodes at the 3-month visit. Our findings highlighted the importance of ICG fluorescence-guided imaging in LPND because it has unique advantages in improving the number of lymph node dissections, surgical accuracy, and decreasing the residual lymph nodes and local tumor recurrence. In addition, ICG fluorescence guidance technology can effectively shorten the operation time, and it is simple to operate, which is worth popularizing.

Short- and long-term outcomes of laparoscopic versus open selective lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer: Results of a multicentre lateral node study in China

AIM

Lateral pelvic lymph node dissection (LPND) is a technically challenging procedure, and the safety and feasibility of laparoscopic LPND remains undetermined. Here, we compared the short- and long-term survival outcomes of laparoscopic LPND with those of open LPND.

METHODS

From January 2012 to December 2019, locally advanced middle-low rectal cancer patients with clinical evidence of lateral pelvic lymph node metastasis (LPNM) who underwent total mesorectal excision with LPND at three institutions were included. Propensity score matching was used to minimize selection bias. The short-term and oncological outcomes of open and laparoscopic LPND were compared.

RESULTS

Overall, 384 patients were enrolled into the study including 277 and 107 patients who underwent laparoscopic and open LPND, respectively. After matching, patients were stratified into laparoscopic (n = 100) and open (n = 100) LPND groups. Patients in the laparoscopic LPND group had a shorter operation time (255 vs. 300 min, p = 0.001), less intraoperative blood loss (50 vs. 300 ml, p < 0.001), lower incidence of postoperative complications (32.0% vs. 15.0%, p = 0.005), shorter postoperative hospital stay (8 vs. 14 days, p < 0.001), and excision of more lateral pelvic lymph nodes (9 vs. 7, p = 0.025) than those in the open LPND group. The 3-year overall survival (p = 0.581) and 3-year disease-free survival (p = 0.745) rates were similar between the groups, and LPNM was an independent predictor of survival.

CONCLUSION

Laparoscopic LPND is technically safe and feasible with favourable short-term results and similar oncological outcomes as open surgery in selected patients.

OUP accepted manuscript

Background

Method

Results

Conclusion

Extended Lymphadenectomy in Locally Advanced Rectal Cancers: A Systematic Review

Purpose

The surgical treatment of advanced low rectal cancer remains controversial. Extended lymphadenectomy (EL) is the preferred option in the East, especially in Japan, while neoadjuvant radiotherapy is the treatment of choice in the West. This review was undertaken to review available evidence supporting each of the therapies.

Methods

All studies looking at EL were included in this review. A comprehensive search was conducted as per PRISMA guidelines. Primary outcome was defined as 5-year overall survival, with secondary outcomes including 3-year overall survival, 3- and 5-year disease-free survival, length of operation, and number of complications.

Results

Thirty-one studies met the inclusion criteria. There was no significant publication bias. There was statistically significant difference in 5-year survival for patient who underwent EL (odds ratio, 1.34; 95 confidence interval, 0.09–0.5; P=0.006). There were no differences noted in secondary outcomes except for length of the operations.

Conclusion

There is evidence supporting EL in rectal cancer; however, it is difficult to interpret and not easily transferable to a Western population. Further research is necessary on this important topic.

Open versus laparoscopic lateral lymph node dissection for mid- and low- rectal cancer: a propensity score matching study

BACKGROUND

This study aimed to evaluate the perioperative, pathological and oncological outcomes of open versus laparoscopic total mesorectal excision (TME) plus lateral lymph node dissection (LLND) for mid- and low- rectal cancer using propensity score matching.

METHODS

Between September 2009 and December 2018, consecutive patients who underwent open or laparoscopic TME plus LLND were collected. Based on the propensity score matching analysis, laparoscopic TME plus LLND was compared with open TME plus LLND for the perioperative, pathological, and oncological outcomes.

RESULTS

A total of 77 patients were collected. There were 13 patients who underwent open TME plus LLND (open group) and 64 patients who underwent laparoscopic TME plus LLND (laparoscopic group). After propensity score matching, 13 patients in the open group were matched to 39 patients in the laparoscopic group (1:3). The laparoscopic group had a significantly shorter length of incision (5 cm vs. 20 cm, p < 0.01), less intraoperative blood loss (80 mL vs. 100 mL, p = 0.02), and shorter time to postoperative liquid diet (72 h vs. 96 h, p = 0.05). There were no significant differences in both early and late postoperative complications. The 3-year overall survival was 85.9% in the laparoscopic group and 76.9% in the open group (p = 0.75), respectively. The 3-year disease-free survival was 70.6% in the laparoscopic group and 74.1% in the open group (p = 0.83), respectively.

CONCLUSION

Laparoscopic LLND had comparable oncological outcomes to open LLND. Moreover, laparoscopic LLND had postoperative recovery advantages over open LLND.

Is prophylactic lateral lymph node dissection needed for lower rectal cancer? A single-center retrospective study

Background

The effectiveness of prophylactic lateral lymph node dissection (LLND) in treating patients with lower rectal cancer remains controversial and has not been clearly established. Therefore, we aimed to retrospectively analyze the survival impact of prophylactic LLND in patients with lower rectal cancer.

Methods

Data of 301 patients with lower rectal cancer (tumor’s lower edge on the anal side of the peritoneal reflexion) with clinical T3 disease and negative preoperative lateral lymph node metastasis, who underwent radical resection (R0) at our hospital between April 2007 and March 2017, were included in this study. Patients who received preoperative chemotherapy or radiotherapy were excluded. The relapse-free survival (RFS) and overall survival (OS) rates were compared between the dissection (prophylactic LLND, n = 37) and non-dissection (no prophylactic LLND, n = 264) groups.

Results

Significantly fewer men and younger patients were noted in the dissection group than in the non-dissection group. Post-surgery 3- and 5-year RFS rates were 69.6% and 66.8% in the dissection group and 75.1% and 72.5% in the non-dissection group, respectively (5-year post-surgery RFS, p = 0.58). In the dissection and non-dissection groups, the 5-year OS rates were 86.5% and 79.7%, respectively (p = 0.29), and the 5-year cancer-specific survival rates were 88.9% and 86.0%, respectively (p = 0.29), with no significant differences. Lateral lymph node recurrence was observed in one (2.7%) and 10 patients (3.8%) in the dissection and non-dissection groups, respectively, and there was no significant difference between the groups.

Conclusions

In this study, the effectiveness of prophylactic LLND was limited in patients with > T3 lower rectal cancer with no evidence of preoperative lymph node metastasis. Prophylactic LLND may not be necessary if there is no preoperative lymph node metastasis, even if the invasion depth is T3 or higher.

Long-term effects of laparoscopic lateral pelvic lymph node dissection on urinary retention in rectal cancer

BACKGROUND

The addition of lateral pelvic lymph node dissection (LPLND) in rectal cancer surgery has been reported to increase the incidence of post-operative urinary retention. Here, we assessed the predictive factors and long-term outcomes of urinary retention following laparoscopic LPLND (L-LPLND) with total mesorectal excision (TME) for advanced lower rectal cancer.

METHODS

This retrospective single-institutional study reviewed post-operative urinary retention in 71 patients with lower rectal cancer who underwent L-LPLND with TME. Patients with preoperative urinary dysfunction or who underwent unilateral LPLND were excluded. Detailed information regarding patient clinicopathologic characteristics, post-void residual urine volume, and the presence or absence of urinary retention over time was collected from clinical and histopathologic reports and telephone surveys. Urinary retention was defined as residual urine > 100 mL and the need for further treatment.

RESULTS

Post-operative urinary retention was observed in 25/71 patients (35.2%). Multivariate analysis revealed that blood loss ≥ 400 mL [odds ratio (OR) 4.52; 95% confidence interval (CI) 1.24-16.43; p = 0.018] and inferior vesical artery (IVA) resection (OR 8.28; 95% CI 2.46-27.81; p < 0.001) were independently correlated with the incidence of urinary retention. Furthermore, bilateral IVA resection caused urinary retention in more patients than unilateral IVA resection (88.9% vs 47.1%, respectively; p = 0.049). Although urinary retention associated with unilateral IVA resection improved relatively quickly, urinary retention associated with bilateral IVA resection tended to persist over 1 year.

CONCLUSION

We identified the predictive factors of urinary retention following L-LPLND with TME, including increased blood loss (≥ 400 mL) and IVA resection. Urinary retention associated with unilateral IVA resection improved relatively quickly. L-LPLND with unilateral IVA resection is a feasible and safe procedure to improve oncological curability. However, if oncological curability is guaranteed, bilateral IVA resection should be avoided to prevent irreversible urinary retention.

Robotic lateral pelvic lymph node dissection after chemoradiation for rectal cancer: a Western perspective

AIM

There are limited outcome data for lateral pelvic lymph node dissection (LPLND) following neoadjuvant chemoradiotherapy (nCRT), particularly in the West. Our aim was to evaluate the short-term perioperative and oncological outcomes of robotic LPLND at a single cancer centre.

METHOD

A retrospective analysis of a prospective database of consecutive patients undergoing robotic LPLND for rectal cancer between November 2012 and February 2020 was performed. The main outcomes were short-term perioperative and oncological outcomes. Major morbidity was defined as Clavien-Dindo grade 3 or above.

RESULTS

Forty patients underwent robotic LPLND during the study period. The mean age was 54 years (SD ± 15 years) and 13 (31.0%) were female. The median body mass index was 28.6 kg/m² (IQR 25.5-32.6 kg/m² ). Neoadjuvant CRT was performed in all patients. Resection of the primary rectal cancer and concurrent LPLND occurred in 36 (90.0%) patients, whilst the remaining 4 (10.0%) patients had subsequent LPLND after prior rectal resection. The median operating time was 420 min (IQR 313-540 min), estimated blood loss was 150 ml (IQR 55-200 ml) and length of hospital stay was 4 days (IQR 3-6 days). The major morbidity rate was 10.0% (n = 4). The median lymph node harvest from the LPLND was 6 (IQR 3-9) and 13 (32.5%) patients had one or more positive LPLNs. The median follow-up was 16 months (IQR 5-33 months), with 1 (2.5%) local central recurrence and 7 (17.5%) patients developing distant disease, resulting in 3 (7.5%) deaths.

CONCLUSION

Robotic LPLND for rectal cancer can be performed in Western patients to completely resect extra-mesorectal LPLNs and is associated with acceptable perioperative morbidity.

Feasibility and safety of laparoscopic lateral pelvic lymph node dissection for locally recurrent rectal cancer and risk factors for re-recurrence

INTRODUCTION

Lateral pelvic lymph node (LPLN) metastasis is considered a distant metastasis. It is often treated by systemic chemotherapy and/or radiation therapy, but complete radical resection of LPLN metastasis can sometimes achieve cure. However, the safety and efficacy of radical resection for recurrent LPLN after curative rectal surgery have not been well elucidated. Therefore, we evaluated the feasibility of laparoscopic radical surgery for recurrent LPLN compared with the conventional open approach and assessed oncological outcomes between patients with and without re-recurrence.

METHODS

We retrospectively reviewed 17 cases (4 open, 13 laparoscopic) who underwent radical resection for LPLN metastasis after curative rectal surgery between July 2012 and August 2016 at the National Hospital Organization Osaka National Hospital. Operative factors and short-term outcomes were compared. Oncological outcome was evaluated based on the pathologic response to preoperative adjuvant therapy.

RESULTS

The laparoscopic group's median blood loss and C-reactive protein elevation were lower than that of the open group on postoperative day 3. The laparoscopic group also had a shorter postoperative hospital stay. The median operative time, R0 resection rate, and morbidity rate were similar between the two groups. Local re-recurrence after LPLN resection occurred more frequently in pathologic non-responders than responders.

CONCLUSION

Laparoscopic surgery for LPLN metastasis is feasible and less invasive than open surgery. Laparoscopic radical resection of LPLN may be justified for curative intent. Patients with incomplete pathologic response to neoadjuvant therapy have a greater risk of re-recurrence.

Short-term outcomes of robotic-assisted laparoscopic versus laparoscopic lateral lymph node dissection for advanced lower rectal cancer

BACKGROUND

Therapeutic strategies to suppress local recurrence, including lateral lymph node metastasis, are important to improve the curability of rectal cancer. The aim of the present study was to clarify the advantages of robotic-assisted laparoscopic lateral lymph node dissection (RALLD), comparing its short-term outcomes with those of laparoscopic lateral lymph node dissection (LLLD). There are some retrospective reports comparing RALLD or LLLD and open lateral lymph node dissection (OLLD), but few reports comparing RALLD and LLND to each other.

METHODS

From November 2014 to August 2020, we compared the short-term outcomes in 40 patients who underwent RALLD and 55 patients who underwent LLLD.

RESULTS

The total operative time was significantly longer in the RALLD group than in the LLLD group (p < 0.001). However, lateral dissection time was not significantly different between the groups (p = 0.661). The postoperative hospital time was shorter in the RALLD group than in the LLLD group (p < 0.048). No significant differences were identified in the rates of postoperative bleeding, incisional surgical site infection (SSI), organ/space SSI, urinary disfunction, urinary infection, or small bowel obstruction between the groups. However, anastomotic leakage was significantly lower in the RALLD group than in the LLLD group (p = 0.031).

CONCLUSIONS

The short-term outcomes of RALLD indicate it is feasible, and RALLD may be a useful modality for lower rectal cancer.

Short- and long-term outcomes of laparoscopic versus open lateral lymph node dissection for locally advanced middle/lower rectal cancer using a propensity score-matched analysis

BACKGROUND

There are few reports on large-scale trials for the long-term outcomes regarding laparoscopic lateral lymph node dissection (LLND). We evaluated the short- and long-term outcomes of laparoscopic versus open LLND for locally advanced middle/lower rectal cancer using a propensity score-matched analysis.

METHODS

From January 2005 to December 2016, consecutive clinical stage II to III middle/lower rectal cancer patients who underwent total mesorectal excision (TME) plus LLND were retrospectively collected at three institutions. Laparoscopic LLND was compared with open LLND for the surgical and oncological outcomes, including the long-term survival, using a propensity score-matched analysis.

RESULTS

A total of 325 patients were collected. There were 142 patients who underwent open TME plus LLND (open group) and 183 patients who underwent laparoscopic TME plus LLND (laparoscopic group). A total of 93 patients each were matched to each group. Compared to the open group, the laparoscopic group had a significantly longer operative time (327 vs. 377 min; p = 0.002) but significantly less blood loss (540 vs. 50 ml; p < 0.001), fewer Clavian-Dindo grade ≥ 2 postoperative complications (49.5% vs. 34.4%; p = 0.037) and shorter postoperative hospital stay (18 vs. 14 days; p = 0.008). Furthermore, the rate of urinary retention was significantly lower in the laparoscopic group than in the open group (16.1% vs. 6.5%; p = 0.037). The estimated 3-year overall survival, relapse-free survival, and cumulative incidence of local recurrence were 91.4%, 73.1%, and 3.4% in the open group and 90.3%, 74.2%, and 4.3% in the laparoscopic group (p = 0.879, 0.893, 0.999), respectively.

CONCLUSIONS

This study showed that laparoscopic LLND had advantages over an open approach, such as less blood loss, fewer postoperative complications, and a shorter postoperative hospital stay, and the oncologic outcomes were similar to the open approach. Laparoscopic LLND could be a viable standard approach to LLND for advanced middle/lower rectal cancer surgery.

Postoperative morbidity and mortality after mesorectal excision with laparoscopic versus conventional open lateral lymph node dissection for advanced rectal cancer: A meta-analysis

Lateral lymph node dissection (LLND) is a challenging procedure due to its technical difficulty and higher incidence of surgical morbidity, thus the purpose of this study is to compare the postoperative morbidity and mortality between laparoscopic and conventional open LLND after mesorectal excision (ME) for advanced rectal cancer. A comprehensive search was conducted in August 2019 based on data from PubMed, Embase, Cochrane Library, CNKI and Wanfang Data to identify relevant studies, and studies comparing laparoscopic with conventional open LLND were included. Seven studies with 335 cases in the laparoscopic LLND group and 841 cases in the conventional open LLND group were finally included. Compared with the conventional open LLND group, the laparoscopic LLND group enjoys a lower postoperative morbidity (OR = 0.47,95% CI [0.23, 0.97], P = 0.04), same postoperative mortality (Postoperative mortality in both groups was zero), shorter length of postoperative hospitalization (WMD = -5.30, 95% CI [-8.42, -2.18], P = 0.0009), less wound infection (OR = 0.40,95% CI [0.21, 0.77], P = 0.006), less intestinal obstruction (OR = 0.50,95% CI [0.29, 0.84], P = 0.009), and less urinary retention (OR = 0.61,95% CI [0.38, 0.97], P = 0.04). There were no significant differences in the incidence of anastomotic leakage, abdominal pelvic abscess and urinary tract infection between the two groups (P > 0.05). But in the sensitivity analysis, there was a significant change of urinary tract infection (OR = 0.22, 95%CI [0.06, 0.89], P = 0.03), and the degree of between-study heterogeneity decreased greatly. In conclusion, laparoscopic LLND may be a better alternative to conventional open LLND for advanced rectal cancer with lower postoperative morbidity and shorter postoperative hospital stay.

Laparoscopic versus open selective lateral pelvic lymph node dissection following total mesorectal excision for locally advanced low rectal cancer

PURPOSES

Lateral pelvic lymph node (LPLN) dissection represents a technically challenging procedure with a high potential risk of surgical morbidity. The purpose of this study was to compare the technical feasibility, safety, and oncological efficacy of laparoscopic LPLN dissection (LPLD) following total mesorectal excision (TME) with open LPLD for locally advanced low rectal cancer (LALRC).

METHODS

Between January 2010 and December 2016, consecutive patients with LALRC and swollen LPLNs who underwent laparoscopic or open TME with LPLD at our institution were enrolled in this retrospective observational study. Data regarding patient demographics, perioperative characteristics, and oncological outcomes were analyzed and compared.

RESULTS

A total of 64 patients met the inclusion criteria. Thirty-four patients underwent open procedure, and 30 underwent laparoscopic procedure. The mean blood loss volume was significantly less in the laparoscopic group than in the open group (165 vs. 422 mL; P = 0.012). The mean operative time was not significantly different between the laparoscopic and the open groups (354 ± 91 vs. 315 ± 78 min; P = 0.522). The overall postoperative complication rates were 30.0% and 35.3% for the laparoscopic and open groups (P = 0.428), respectively. Postoperative urinary retention was significantly less in the laparoscopic group than in the open group (14.7 vs. 0%; P = 0.036).The duration of postoperative hospital stay was significantly shorter in the laparoscopic group (8.5 ± 3.8 vs. 13.6 ± 6.5 days; P = 0.025). The numbers of harvested lymph nodes and positive resection margin rates showed no significant differences. Pathological LPLN metastases were confirmed in 10 patients (29.4%) in the open group and 11 (36.7%) in the laparoscopic group (P = 0.537). The median follow-up duration was 41.5 months (range 3-98). The laparoscopic and open groups also showed a similar 3-year overall survival rate (88.2% vs. 85.3%; P = 0.577), relapse-free survival rate (73.3% vs. 67.6%; P = 0.889), and local recurrence rate (3.3 vs. 5.9%; P = 0.653).

CONCLUSIONS

Laparoscopic TME with LPLD is technically feasible and safe in selected patients with LALRC and is associated with similar oncological outcomes as open approach.

Is laparoscopic selective lateral lymph node dissection for locally advanced rectal cancer after neoadjuvant chemoradiotherapy safe?

BACKGROUND

This study aimed to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic total mesorectal excision (TME) with selective lateral lymph node (LLN) dissection (sLLND) in patients with locally advanced rectal cancer (LARC) and clinically suspected swollen LLNs treated with preoperative neoadjuvant chemoradiotherapy (nCRT).

METHODS

Consecutive patients with LARC and swollen LLNs who underwent laparoscopic TME and sLLND following nCRT between October 2012 and October 2018 were reviewed from the prospectively collected database. Patient demographics, operation safety, perioperative complications and oncological outcomes were analysed.

RESULTS

A total of 43 patients were identified. All procedures were completed under laparoscopy without conversion to open surgery. The median operation time was 313 min (range 170-570 min). The median blood loss was 80 mL (range 30-450 mL). The median number of LLNs harvested was 11 (range 1-29). LLN metastasis was found in 12 patients (27.9%). Major post-operative complications were found in four patients (9.3%). The median hospital stay was 7 days (range 4-27 days). The median time to tolerance to liquid food was 72 h (range 36-120 h). The post-operative 30-day mortality rate was 0%. Over the median follow-up of 24 months, no lateral pelvic recurrence developed. For the whole group of patients, the 2-year cumulative overall survival and disease-free survival were 90.5% and 78.1%, respectively.

CONCLUSION

With the advantages of a minimally invasive approach, laparoscopic TME and sLLND following preoperative nCRT in patients with LARC and swollen LLNs is safe and feasible. This procedure provides acceptable perioperative and oncological outcomes.

Application of indocyanine green-enhanced near-infrared fluorescence-guided imaging in laparoscopic lateral pelvic lymph node dissection for middle-low rectal cancer

BACKGROUND

As one effective treatment for lateral pelvic lymph node (LPLN) metastasis (LPNM), laparoscopic LPLN dissection (LPND) is limited due to the complicated anatomy of the pelvic sidewall and various complications after surgery. With regard to improving the accuracy and completeness of LPND as well as safety, we tried an innovative method using indocyanine green (ICG) visualized with a near-infrared (NIR) camera system to guide the detection of LPLNs in patients with middle-low rectal cancer.

AIM

To investigate whether ICG-enhanced NIR fluorescence-guided imaging is a better technique for LPND in patients with rectal cancer.

METHODS

A total of 42 middle-low rectal cancer patients with clinical LPNM who underwent total mesorectal excision (TME) and LPND between October 2017 and March 2019 at our institution were assessed and divided into an ICG group and a non-ICG group. Clinical characteristics, operative outcomes, pathological outcomes, and postoperative complication information were compared and analysed between the two groups.

RESULTS

Compared to the non-ICG group, the ICG group had significantly lower intraoperative blood loss (55.8 ± 37.5 mL vs 108.0 ± 52.7 mL, P = 0.003) and a significantly larger number of LPLNs harvested (11.5 ± 5.9 vs 7.1 ± 4.8, P = 0.017). The LPLNs of two patients in the non-IVG group were residual during LPND. In addition, no significant difference was found in terms of LPND, LPNM, operative time, conversion to laparotomy, preoperative complication, or hospital stay (P > 0.05).

CONCLUSION

ICG-enhanced NIR fluorescence-guided imaging could be a feasible and convenient technique to guide LPND because it could bring specific advantages regarding the accuracy and completeness of surgery as well as safety.

Risk factors and prognostic significance of lateral pelvic lymph node metastasis in advanced rectal cancer

BACKGROUND

The aim of this study was to elucidate the risk factors for and prognostic value of lateral pelvic lymph node (LPLN) metastasis in advanced rectal cancer patients, including those with stage IV disease.

METHODS

The treatment outcomes of 78 patients with advanced rectal cancer, the lower margin of which was located at or below the peritoneal reflection, who underwent curative-intent surgery with bilateral LPLN dissection from 2005 to 2018 were retrospectively analyzed.

RESULTS

In total, 78 rectal cancer patients, including 13 patients with stage IV tumors, 9 patients (11.5%) had LPLN metastasis. A multivariate analysis to identify preoperative clinical factors associated with LPLN metastasis showed that tumor location (below the peritoneal reflection: Rb), LPLN metastasis on preoperative imaging and distant metastasis were independent predictors of LPLN metastasis. In addition, metastasis at the regional lymph nodes in the mesorectum was significantly associated with LPLN metastasis. Both the disease-free survival (DFS) and cancer-specific survival (CSS) of patients with LPLN metastasis were significantly worse in comparison to patients without LPLN metastasis, and the CSS of stage IV patients with LPLN metastasis was significantly worse in comparison to stage IV patients without LPLN metastasis.

CONCLUSIONS

Tumor location (Rb), LPLN metastasis on preoperative imaging and distant metastasis were risk factors for LPLN metastasis. The prognosis of rectal cancer patients with LPLN metastasis is poor. There may not be the indication of LPLN dissection in stage IV lower rectal cancer except cases having complaints due to LPLN metastasis.

Laparoscopic versus Open Surgery in Lateral Lymph Node Dissection for Advanced Rectal Cancer: A Meta-Analysis

Aim

To compare the clinical efficacies between laparoscopic and conventional open surgery in lateral lymph node dissection (LLND) for advanced rectal cancer.

Methods

We comprehensively searched PubMed, Embase, Cochrane Library, CNKI, and Wanfang Data and performed a cumulative meta-analysis. According to inclusion criteria and exclusion criteria, all eligible randomized controlled trials (RCTs) or retrospective or prospective comparative studies assessing the two techniques were included, and then a meta-analysis was performed by using RevMan 5.3 software to assess the difference in clinical and oncological outcomes between the two treatment approaches.

Results

Eight studies involving a total of 892 patients were finally selected, with 394 cases in the laparoscopic surgery group and 498 cases in the traditional open surgery group. Compared with the traditional open group, the laparoscopic group had a longer operative time (WMD = 81.56, 95% CI (2.09, 142.03), P = 0.008), but less intraoperative blood loss (WMD = −452.18, 95% CI (-652.23, -252.13), P < 0.00001), shorter postoperative hospital stay (WMD = −5.30, 95% CI (-8.42, -2.18), P = 0.0009), and higher R0 resection rate (OR = 2.17, 95% CI (1.14, 4.15), P = 0.02). There was no significant difference in the incidence of surgical complications between the two groups (OR = 0.52, 95% CI (0.26, 1.07), P = 0.08). Lateral lymph node harvest, lateral lymph node metastasis, local recurrence, 3-year overall survival, and 3-year disease-free survival did not differ significantly between the two approaches (P > 0.05).

Conclusion

Laparoscopic LLND has a similar efficacy in oncological outcomes and postoperative complications to the conventional open surgery, with the advantages of reduced intraoperative blood loss, shorter postoperative hospital stay, and higher R0 resection rate, and tumor radical cure is similar to traditional open surgery. Laparoscopic LLND is a safe and feasible surgical approach, and it may be used as a standard procedure in LLND for advanced rectal cancer.

Predictive factors of pathological lateral pelvic lymph node metastasis in patients without clinical lateral pelvic lymph node metastasis (clinical stage II/III): The analysis of data from the clinical trial (JCOG0212)

BACKGROUND

Mesorectal excision (ME) is the standard surgical procedure for lower rectal cancer. However, in Japan, total or tumor-specific ME with lateral pelvic lymph node dissection (LLND) is the standard surgical procedure for patients with clinical stages II or III lower rectal cancer, because lateral pelvic lymph node metastasis occasionally occurs in these patients. The aim of study was to elucidate the predictive factors of pathological lateral pelvic lymph node metastasis in patients without clinical lateral pelvic lymph node metastasis.

METHODS

Data form the clinical trial (JCOG0212) was analyzed. The JCOG0212 was a randomized controlled trial to confirm the non-inferiority of mesorectal excision alone to mesorectal excision with lateral lymph node dissection for clinical stage II/III patients who don't have clinical lateral pelvic lymph node metastasis in terms of relapse free survival. This study was conducted at a multitude of institution33 major hospitals in Japan. Among the 351 patients who underwent lateral lymph node dissection in the JCOG0212 study, 328 patients were included in this study. Associations between pathological lateral pelvic lymph node metastasis and preoperative and postoperative factors were investigated. The preoperative factors were age, sex, clinical stage, tumor location, distance from anal verge, tumor size, and short-axis diameter of lateral pelvic lymph node on computed tomography and the postoperative factors were pathological T, pathological N, and histological grade.

RESULTS

Among the 328 patients, 24 (7.3%) had pathological lateral pelvic lymph node metastasis. In multivariable analysis of the preoperative factors, patient age (p = 0.067), tumor location (p = 0.025), and short-axis diameter of lateral pelvic lymph node (p = 0.002) were significantly associated with pathological lateral pelvic lymph node metastasis.

CONCLUSIONS

Patient age, tumor location, and short-axis diameter of lateral pelvic lymph node were predictive factors of pathological lateral pelvic lymph node metastasis.

Utility of preoperative 3-D simulation of laparoscopic lateral pelvic lymph node dissection for advanced rectal cancer: Surgical outcomes of 10 initial cases

INTRODUCTION

Laparoscopic lateral pelvic lymph node dissection (LPLD) is technically challenging because of the complicated anatomy of the pelvic wall. To overcome this difficulty, we introduced preoperative 3-D simulation. The aim of the study is to investigate the usefulness of preoperative 3-D simulation for the safe conduct of laparoscopic LPLD for rectal cancer.

METHODS

After undergoing colonoscopy, patients were brought to the radiology suite where multi-detector row CT was performed. Three-dimensional images were constructed at a workstation and showed branches of the iliac artery and vein, ureter, urinary bladder, and enlarged lymph nodes. All members of the surgical team participated in preoperative simulation using the 3-D images.

RESULTS

A total of 10 patients with advanced lower rectal cancer and enlarged lateral pelvic lymph nodes underwent laparoscopic unilateral LPLD after total mesorectal excision, tumor-specific mesorectal excision, or total proctocolectomy. Four of the 10 patients (40%) had variations in pelvic vascular anatomy. The median operative time for unilateral LPLD was 91 min (range, 66-142 min) and gradually declined, suggesting a good learning curve. The median number of lateral pelvic lymph nodes harvested was nine (range, 3-16). The median estimated blood loss was 13 mL (range, 10-160 mL). No conversion to open surgery or intraoperative complications occurred. No patient had major postoperative complications.

CONCLUSION

Preoperative 3-D simulation may be useful for the safe conduct of laparoscopic LPLD, especially for surgeons with limited prior experience.

Lateral Lymph Node Dissection With the Focus on Indications, Functional Outcomes, and Minimally Invasive Surgery

The lateral lymph node dissection (LLND) is still a subject of great debate as to the appropriate treatment for patients with mid to low advanced rectal cancer. The guidelines of the Japanese Society for Cancer of the Colon and Rectum recommend a LLND for patients with T3/4 rectal cancer below the peritoneal reflection. However, in most Western countries, a routine LLND is not recommended unless a node or nodes are clinically suspicious for metastasis. Even after preoperative chemoradiotherapy (CRT), an 8% to 12% lateral pelvic recurrence was noted. The size of the lateral lymph node and responsiveness to preoperative CRT should be the main factors for selecting appropriate patients to undergo a LLND. In addition, from the recent literature, a laparoscopic LLND is safe and oncologically feasible and might have some advantages in short-term outcomes.

Feasibility of Extended Dissection of Lateral Pelvic Lymph Nodes During Laparoscopic Total Mesorectal Excision in Patients with Locally Advanced Lower Rectal Cancer: A Single-Center Pilot Study After Neoadjuvant Chemotherapy

BACKGROUND The feasibility of additional dissection of the lateral pelvic lymph nodes (LPLNs) in patients undergoing total mesorectal excision (TME) combined with neoadjuvant chemotherapy (NAC) for locally advanced rectal cancer (LARC) is controversial. The use of laparoscopic surgery is also debated. In the present study, we evaluated the utility of laparoscopic dissection of LPLNs during TME for patients with LARC and metastatic LPLNs after NAC, based on our experience with 19 cases. MATERIAL AND METHODS Twenty-five patients with LARC with swollen LPLNs who underwent laparoscopic TME and LPLN dissection were enrolled in this pilot study. The patients were divided into 2 groups: those patients with NAC (n=19) and without NAC (n=6). Our NAC regimen involved 4 to 6 courses of FOLFOX plus panitumumab, cetuximab, or bevacizumab. RESULTS The operative duration was significantly longer in the NAC group than in the non-NAC group (648 vs. 558 minutes, respectively; P=0.022). The rate of major complications, defined as grade ≥3 according to the Clavien-Dindo classification, was similar between the 2 groups (15.8% vs. 33.3%, respectively; P=0.4016). No conversion to conventional laparotomy occurred in either group. In the NAC group, a histopathological complete response was obtained in 2 patients (10.5%), and a nearly complete response (Tis N0 M0) was observed in one patient (5.3%). Although the operation time was prolonged in the NAC group, the other perioperative factors showed no differences between the 2 groups. CONCLUSIONS Laparoscopic LPLN dissection is feasible in patients with LARC and clinically swollen LPLNs, even after NAC.

Oncological outcomes of robotic-assisted laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer

BACKGROUND

The long-term outcomes of robotic-assisted laparoscopic lateral lymph node dissection (RALLD) have not been fully investigated. This study aimed to assess the oncological and long-term outcomes of RALLD for rectal cancer through comparison with those of open lateral lymph node dissection (OLLD) in a retrospective study.

METHODS

Between September 2002 and October 2014, the medical data of 426 patients who underwent total mesorectal excision with lateral lymph node dissection for primary rectal cancer were collected. Of these, 115 patients were excluded after data collection (stage IV, n = 61; total pelvic exenteration, n = 31; multiple cancer, n = 20; conventional laparoscopic surgery, n = 3). Before matching, 311 patients with clinical stage II/III were analyzed. Using exact matching, patients were stratified into RALLD (n = 78) and OLLD (n = 78) groups. Pathological findings and long-term outcomes were compared between the groups.

RESULTS

The pathological stage and number of harvested lymph nodes showed no significant differences between the groups. The rate of positive resection margin in the RALLD group tended to be lower compared with that of the OLLD group (p = 0.059). The median follow-up duration was 54.0 months in 156 patients. The 5-year overall survival rate was 95.4 and 87.8% in the RALLD and OLLD groups, respectively (p = 0.106). The 5-year relapse-free survival rate was 79.1 and 69.9% in the RALLD and OLLD groups, respectively (p = 0.157). The 5-year local relapse-free survival rate was 98.6 and 90.9% in the RALLD and OLLD groups, respectively (p = 0.029).

CONCLUSIONS

The short- and long-term outcomes indicated that RALLD may be a useful modality for locally advanced low rectal cancer.

Laparoscopic pelvic lymph node dissection for malignant foot melanoma

A 39 year-old woman with malignant foot melanoma underwent wide excision of the primary tumor with a safety margin and sentinel lymph node biopsy (SLNB) for the right inguinal lymph node. SLNB was positive and a computed tomography (CT) scan revealed right iliac lymph node swelling. Positron emission tomography computed tomography (PET-CT) scan of the lymph nodes revealed abnormal uptake of fluorodeoxyglucose (FDG). We performed a laparoscopic pelvic lymph node obturator, iliac lymph node) dissection. During the operation, several black lymph nodes were observed in the iliac lymph node. Pathologically, the iliac lymph node consisted of metastasized atypical melanocytes. This surgical method for pelvic lymph node dissection is not a standard procedure among institutions. There have been no reported cases of malignant melanoma with pelvic lymph node metastasis treated by laparoscopic surgery. However, due to the minimally invasive technique, this method is worth considering to be used for pelvic lymph node dissection in malignant melanoma as well as other cancers in the field of urology or gynecology.

Feasibility of Laparoscopic Total Mesorectal Excision with Extended Lateral Pelvic Lymph Node Dissection for Advanced Lower Rectal Cancer after Preoperative Chemoradiotherapy

BACKGROUND

The feasibility of additional lateral pelvic lymph node dissection (LPLND) compared with total mesorectal excision (TME) alone in patients treated with preoperative chemoradiotherapy (CRT) is controversial, especially in laparoscopic surgery. This study was performed to evaluate the feasibility of adding laparoscopic LPLND to TME in patients with advanced lower rectal cancer and swollen LPLNs treated with preoperative CRT.

METHODS

We reviewed 327 patients with lower rectal cancer without distant metastasis who underwent preoperative CRT followed by laparoscopic TME. Laparoscopic LPLND was added in patients with swollen LPLNs before CRT. Outcomes were compared between patients with (n = 107) and without (n = 220) LPLND.

RESULTS

LPLN metastasis was found in 26 patients (24.3 %) in the LPLND group. The operation time was significantly longer, and total blood loss was significantly greater in the LPLND than TME group (461 vs. 298 min and 115 vs. 30 mL, respectively; P < 0.0001). The major complication rate was similar in the LPLND and TME groups (9.3 vs. 5.5 %, respectively; P = 0.188), and there were no conversions to open surgery. The LPLND and TME groups also showed a similar 3-year relapse-free survival rate (84.7 vs. 82.0 %, respectively; P = 0.536) and local recurrence rate (3.2 vs. 5.2 %, respectively; P = 0.569) despite significantly more patients with pathological lymph node metastasis in the LPLND than TME group (37.4 vs. 22.3 %, respectively; P < 0.0001).

CONCLUSIONS

Additional laparoscopic LPLND is feasible in patients with advanced lower rectal cancer and clinically swollen LPLNs treated with preoperative CRT, with no significant increase in major complications compared with TME alone.

Laparoscopic Versus Open Lateral Lymph Node Dissection for Locally Advanced Low Rectal Cancer: A Subgroup Analysis of a Large Multicenter Cohort Study in Japan

BACKGROUND

Mesorectal excision with lateral lymph node dissection is the standard treatment for locally advanced low rectal cancer in Japan. However, the safety and feasibility of laparoscopic lateral lymph node dissection remain to be determined.

OBJECTIVE

The purpose of this study was to evaluate the safety and feasibility of laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer.

DESIGN

This was a retrospective cohort study using an exact matching method.

SETTING

We conducted a multicenter study of 69 specialized centers in Japan.

PATIENTS

Patients with consecutive midrectal or low rectal adenocarcinoma cancer stage II to III who underwent mesorectal excision with curative intent between 2010 and 2011 were recruited.

MAIN OUTCOME MEASURES

Short-term and oncological outcomes were compared between the laparoscopic and open-surgery groups.

RESULTS

Of the 1500 eligible patients, 676 patients who underwent lateral lymph node dissection were analyzed, including 137 patients who were treated laparoscopically and 539 patients who were treated with open surgery. After matching, the patients were stratified into laparoscopic (n = 118) and open-surgery (n = 118) groups. Operative times in the overall cohort were significantly longer (461 vs 372 min) in the laparoscopic versus the open-surgery group. In the laparoscopic group, the blood loss volume was significantly smaller (193 vs 722 mL), with fewer instances of blood transfusion (7.3% vs 25.5%) compared with the open-surgery group. The postoperative complication rates were 35.8% and 43.6% for the laparoscopic and open-surgery groups (p = 0.10). The 3-year relapse-free survival rates were 80.3% and 72.6% for the laparoscopic and open-surgery groups (p = 0.07).

LIMITATIONS

The study was limited by its retrospective design and potential selection bias.

CONCLUSIONS

Laparoscopic lateral lymph node dissection is safe and feasible for cancer stage II to III low rectal cancer and is associated with similar oncological outcomes as open lateral lymph node dissection. See Video Abstract at http://links.lww.com/DCR/A334.

Laparoscopic Extirpation of a Schwannoma in the Lateral Pelvic Space

Schwannomas in the lateral pelvic space are very rare. Here, we report the case of a 48-year-old woman who had a tumor detected in her abdomen by abdominal ultrasonography. Abdominal computed tomography and magnetic resonance imaging revealed a well-defined solid tumor of 65 mm in diameter in the right lateral pelvic space. We performed laparoscopic surgery under a diagnosis of a gastrointestinal tumor or neurogenic tumor. The tumor was safely dissected and freed from the surrounding tissues using sharp and blunt maneuvers. The tumor originated from the right sciatic nerve. Complete laparoscopic extirpation was performed with preservation of the right sciatic nerve. Pathological examination suggested schwannoma. The patient recovered well but had remaining sciatic nerve palsy in her right foot. Laparoscopic extirpation for a schwannoma in the lateral pelvic space was safe and feasible due to the magnified surgical field afforded by laparoscopy.

Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery

AIM

Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP).

METHOD

Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment.

RESULTS

The procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2 weeks postoperatively.

CONCLUSION

This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.