Oncologic outcomes following laparoscopic colon cancer resection for T4 lesions: a case-control analysis of 7-years' experience

PD-1 blockade enhances the effect of targeted chemotherapy on locally advanced pMMR/MSS colorectal cancer

BACKGROUND

Patients with DNA mismatch repair-proficient/microsatellite stable (pMMR/MSS) colorectal cancer (CRC), which accounts for 85% of all CRC cases, display a poor respond to immune checkpoint inhibitors (i.e., anti-PD-1 antibodies). pMMR/MSS CRC patients with locally advanced cancers need effective combined therapies.

METHODS

In this pilot study, we administered six preoperative doses of each 2-week cycle of the anti-PD-1 antibody sintilimab (at a fixed dose of 200 mg), oxaliplatin, and 5-FU/CF (mFOLFOX6) combined with five doses of bevacizumab (the number of doses was reduced to prevent surgical delays) to patients with cT4NxM0 colon or upper rectal cancers. And radical surgery was performed approximately 2 weeks after the last dose of neoadjuvant therapy. The primary endpoint was a pathologic complete response (pCR). We also evaluated major pathologic response (MPR, ≤10% residual viable tumor), radiological and pathological regression, safety, and tumor mutation burden (TMB), and tumor microenvironment (TME) characteristics.

RESULTS

By the cutoff date (September 2023), 22 patients with cT4NxM0 pMMR/MSS colon or upper rectal cancers were enrolled and the median follow-up was 24.7 months (IQR: 21.1-26.1). All patients underwent R0 surgical resection without treatment-related surgical delays. pCR occurred in 12 of 22 resected tumors (54.5%) and MPR occurred in 18 of 22 (81.8%) patients. At the cutoff date, all patients were alive, and 21/22 were recurrence-free. Treatment-related adverse events of grade 3 or higher occurred in of 2/22 (9.1%) patients. Among the pCR tumors, two were found to harbor POLE mutations. The degree of pathological regression was significantly greater than that of radiological regression (p = 1.35 × 10-8). The number of CD3+/CD4+ cells in the tumor and stroma in pretreated biopsied tissues was markedly lower in pCR tumors than in non-pCR tumors (p = 0.038 and p = 0.015, respectively).

CONCLUSIONS

Neoadjuvant sintilimab combined with bevacizumab and mFOLFOX6 was associated with few side effects, did not delay surgery, and led to pCR and non-pCR in 54.5% and 81.8% of the cases, respectively. Downregulation of CD3/CD4 expression in the tumor and stroma is related to pCR. However, the molecular mechanisms underlying PD-1 blockade-enhanced targeted chemotherapy require further investigation.

Effect of minimally invasive versus open surgery in hepatectomy on postoperative wound complications in patients with hepatocellular carcinoma: A meta-analysis

In a meta-analysis, we assessed the impact of different surgical approaches on the outcome of hepatectomy with hepatocellular carcinoma. Four databases, including PubMed, Embase, Cochrane Library, and the Web of Science, have been critically reviewed through the full literature through June 2023. Eleven related trials were examined once they had met the trial's classification and exclusion criteria, as well as the assessment of the quality. A random effects approach was applied to analysis of operative organ infections, and a fixed-effect model was applied to determine the 95% CI and OR. Analysis of the data was done with RevMan 5.3. Our findings indicated that patients undergoing minimally invasive liver cancer surgery had significantly lower risks of surgical organ infection (OR, 0.35; 95% CI, 0.16-0.77; p = 0.009) and wound infection (OR, 0.19; 95% CI, 0.13-0.28; p < 0.001) compared to those undergoing open surgery. There was no heterogeneity observed between the two groups (I2  = 0) in wound infection. Nevertheless, because of the limited number of randomised controlled trials in this meta-analysis, care should be taken and carefully considered in the treatment of these values. Further high-quality studies involving a large number of samples are needed to validate and reinforce the results.

Laparoscopic and robotic multivisceral resection in colorectal cancer: A case series and systematic review

PURPOSE

Multivisceral resection (MVR) with open approach is the standard surgical treatment for locally advanced colorectal cancer. However, the medical literature concerning the practice of minimally invasive MVR in order to reduce postoperative complications and hospital stay has been growing exponentially over the last years. The present study aimed to examine our experience and to provide a systematic review about the results and complications of minimally invasive MVR.

METHODS

Data of patients that underwent minimally invasive MVR for locally advanced colorectal cancer from 2015 to 2021 were retrospectively reviewed. The literature was searched for studies concerning minimally invasive MVR for colorectal cancer.

RESULTS

A total of 39 laparoscopic MVR were performed in our department. Complications occurred in 14 patients (35.9%) with major complications in five patients (18.82%) according to Clavien-Dindo classification. Conversion was required in one case (2.56%) with subsequent mortality (2.56%). Pathologic adjacent organs or structures invasion was observed in 30 patients (76.9%) and positive resection margin occurred in two cases (5.2%). Twenty-two studies including 1055 patients were identified after literature search. In these studies, laparoscopic surgery and robotic surgery were performed in 90.15% and 9.85% of the patients, respectively. R0 resection was established in 95% of cases, conversion rate varied between 0% and 41.7%, and postoperative mortality ranged between 0% and 7.7% in the included articles.

CONCLUSION

Minimally invasive approach may be a safe option for patients requiring MVR for locally advanced colorectal cancer, with equivalent oncological results and could result in better early postoperative outcomes to open approach. However, further studies on this topic are needed to confirm the results of the current study.

Post-operative outcomes in patients with locally advanced colon cancer: a comparison of operative approach

INTRODUCTION

Surgeons may choose an open approach to locally advanced colon cancer (LACC) because of the elevated conversion rate (minimally invasive to open) in these patients (resulting in part from a judgment of the technical feasibility of a minimally invasive approach). Poorer outcomes have been suggested in those requiring conversion from a minimal access to an open approach; however, the influence of conversion has not been studied in LACC. We sought to compare perioperative outcomes in patients with T4aN2 colon cancer undergoing minimally invasive surgery (MIS), planned open (PO), and converted (CN) procedures to evaluate the influence of conversion in this subgroup.

METHODS

A retrospective cohort study was conducted using the NSQIP database. Patients with T4aN2 colon cancer undergoing elective resection were included; rectal/unknown tumor location, and T4b disease were excluded (to ensure homogeneity in surgical management). Patients were divided into cohorts based on approach: PO, MIS, and CN. Summary statistics were compared between groups. Multivariable analysis was conducted for mortality and morbidity outcomes.

RESULTS

1286 cases were included (313 PO, 842 MIS, 131 CN); 10.2% underwent conversion. Those undergoing MIS had a shorter length of stay than those undergoing PO or CN (p < 0.0001). On univariable analysis, CN resulted in increased rates of any complication (p < 0.0001). CN also had a greater rate of anastomotic leak (p = 0.0046) and death (p = 0.05). On multivariable analysis, significant predictors of any complication included age, ASA class, M stage, and approach; however, CN did not increase the risk of complication compared with MIS, whereas PO nearly doubled the risk of complication (OR = 1.98, p = 0.0083). The only significant predictor of mortality on multivariable analysis was age (HR = 1.09, p = 0.0002)-approach was not associated with mortality.

CONCLUSION

PO confers the greatest risk of suffering any complication. Surgical approach was not associated with death. Results of our study challenge the notion that conversion is associated with the worst perioperative outcomes and an MIS approach should be considered in patients with LACC.

Laparoscopic versus open colectomy for locally advanced T4 colonic cancer: meta-analysis of clinical and oncological outcomes

BACKGROUND

The aim of this study was to review the early postoperative and oncological outcomes after laparoscopic colectomy for T4 cancer compared with open surgery.

METHOD

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for any relevant clinical study comparing laparoscopic and open colectomy as treatment for T4 colonic cancer. The risk ratio (RR) with 95 per cent c.i. was calculated for dichotomous variables, and the mean difference (m.d.) with 95 per cent confidence interval for continuous variables. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was implemented for assessing quality of evidence (QoE).

RESULTS

Twenty-four observational studies (21 retrospective and 3 prospective cohort studies) were included, analysing a total of 18 123 patients: 9024 received laparoscopic colectomy and 9099 underwent open surgery. Laparoscopic colectomy was associated with lower rates of mortality (RR 0.48, 95 per cent c.i. 0.41 to 0.56; P < 0.001; I2 = 0 per cent, fixed-effect model; QoE moderate) and complications (RR 0.61, 0.49 to 0.76; P < 0.001; I2 = 20 per cent, random-effects model; QoE very low) compared with an open procedure. No differences in R0 resection rate (RR 1.01, 1.00 to 1.03; P = 0.12; I2 = 37 per cent, random-effects model; QoE very low) and recurrence rate (RR 0.98, 0.84 to 1.14; P = 0.81; I2 = 0 per cent, fixed-effect model; QoE very low) were found.

CONCLUSION

Laparoscopic colectomy for T4 colonic cancer is safe, and is associated with better clinical outcomes than open surgery and similar oncological outcomes.

Lymph Node Status and Long-Term Oncologic Outcomes After Colon Resection in Locally Advanced Colon Cancer

Locally advanced colon cancer is associated with poor prognosis. The aim of this report was to examine the association between the lymph node status and prognosis of locally advanced colon cancer. Perioperative and oncologic outcomes were studied in patients who had undergone colectomy for colon cancer between June 2004 and December 2018. Locally advanced colon cancer was defined as stage T4a/T4b cancer. The long-term oncologic results were investigated in patients with non-metastatic locally advanced colon cancer. Of 195 patients operated for locally advanced colon cancer, 83 (42.6%), 43 (22.1%), and 69 (35.3%) had pN0, pN1, and pN2 disease, respectively. Preoperative serum levels of CEA and CA 19-9, as well as incidence of distant metastases were significantly higher in patients with pN2 compared to those with pN0 and pN1. In non-metastatic setting, a trend towards higher incidence of recurrence was observed in node-positive patients. Nodal stage was a significant predictor for survival in the univariable analysis but non-significant after adjusting for confounders. Subgroup analyses among the patients with T4a and T4b cancer did not demonstrate any association between the nodal stage and survival. Preoperative CA 19-9 > 37 U/ml and adjuvant chemotherapy were the only prognostic factors in T4a and T4b colon cancer, respectively. Although a trend towards higher incidence of recurrence was observed in node-positive locally advanced colon cancer, nodal stage was not associated with survival. Adjuvant chemotherapy should be strongly considered in T4b stage colon cancer.

Fluorescence ureteral navigation during laparoscopic surgery for clinically suspected stage T4 colorectal cancer: A cohort study

BACKGROUND

Approximately 15% of patients with colorectal cancer present with locally advanced tumors (T4 stage). Laparoscopic surgery for stage T4 disease has not yet been established. The near-infrared ray catheter fluorescent ureteral catheter (NIRFUC) is a new device that uses near-infrared fluorescence resin. We examined the utility of fluorescence ureteral navigation (FUN) with the NIRFUC during laparoscopic surgery for stage T4 colorectal cancer.

MATERIALS AND METHODS

Patients with stage T4 colorectal cancer (n = 143, from January 2017 to March 2021) were divided into a T4FUN + group, in which the NIRFUC was used (n = 21), and a T4FUN- group, in which the NIRFUC was not used (n = 122). Short-term outcomes were compared between the groups. Next, the laparoscopic surgery rate and incidence of ureteral injury from January 2017 to March 2021 were compared between the T4FUN- group and the non-stage T4FUN- group (n = 434, from January 2017 to March 2021), in which fluorescence ureter navigation was not used.

RESULTS

Rectal cancer, stage T4b disease, and invasion into the urinary tract were observed more often in the T4FUN + group than in the T4FUN- group. In the comparisons of the T4FUN + versus T4FUN- groups, the operative time was 398 (161-1090) vs. 256 (93-839) minutes, the blood loss was 10 (1-710) vs. 25 (0-1360) ml, and the ratio of laparoscopic surgery to open surgery was 21:0 vs. 79:43. Postoperative complications (Clavien-Dindo grade ≥ III) were present in 2 (10%; 0 ureteral injury) patients in the T4FUN + group and 13 (11%; 2 ureteral injury) patients in the T4FUN- group. In the T4FUN + group, the operative time was longer (p < 0.0001), but the laparoscopic ratio was higher (p = 0.0002), and the blood loss volume and incidence of ureteral injury tended to be lower. In the comparisons of the T4FUN- versus non-stage T4FUN- groups, the ratio of laparoscopic surgery to open surgery was 79:43 vs. 384:50, the incidence of open conversion was 8 (6.6%) vs. 15 (3.5%), and the incidence of ureteral injury was 2 (1.6%) vs. 0 (0%). In the T4FUN- group, the open surgery rate (<0.0001), open conversion rate (p = 0.0205) and incidence of ureteral injury (p = 0.0478) were high, with a significant difference observed between the groups.

CONCLUSION

Patients with stage T4 disease have an increased risk of ureteral injury and are more likely to be converted to open surgery. FUN can help to safely increase the laparoscopic surgery rate while safely visualizing the ureter. FUN is recommended for laparoscopic surgery in patients with stage T4 colorectal cancer.

CLINICAL TRIAL REGISTRATION

Examination of fluorescence navigation for laparoscopic colorectal cancer surgery; Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinical research-r02.pdf.

Feasibility and outcomes of ERAS protocol in elective cT4 colorectal cancer patients: results from a single-center retrospective cohort study

BACKGROUND

Programs of Enhanced Recovery After Surgery reduces morbidity and shorten recovery in patients undergoing colorectal resections for cancer. Patients presenting with more advanced disease such as T4 cancers are frequently excluded from undergoing ERAS programs due to the difficulty in applying established protocols. The primary aim of this investigation was to evaluate the possibility of applying a validated ERAS protocol in patients undergoing colorectal resection for T4 colon and rectal cancer and to evaluate the short-term outcome.

METHODS

Single-center, retrospective cohort study. All patients with a clinical diagnosis of stage T4 colorectal cancer undergoing surgery between November 2016 and January 2020 were treated following the institutional fast track protocol without exclusion. Short-term postoperative outcomes were compared to those of a control group treated with conventional care and that underwent surgical resection for T4 colorectal cancer at the same institution from January 2010 to October 2016. Data from both groups were collected retrospectively from a prospectively maintained database.

RESULTS

Eighty-two patients were diagnosed with T4 cancer, 49 patients were included in the ERAS cohort and 33 in the historical conventional care cohort. Both, the mean time of tolerance to solid food diet and postoperative length of stay were significantly shorter in the ERAS group than in the control group (3.14 ± 1.76 vs 4.8 ± 1.52; p < 0.0001 and 6.93 ± 3.76 vs 9.50 ± 4.83; p = 0.0084 respectively). No differences in perioperative complications were observed.

CONCLUSIONS

Results from this cohort study from a single-center registry support the thesis that the adoption of the ERAS protocol is effective and applicable in patients with colorectal cancer clinically staged T4, reducing significantly their length of stay and time of tolerance to solid food diet, without affecting surgical postoperative outcomes.

Minimally Invasive Surgical Approaches Are Safe and Appropriate in N2 Colorectal Cancer

BACKGROUND

There is emerging evidence of the oncological safety of minimally invasive surgery in T4 colorectal cancer; however, such support is lacking in N2 disease.

OBJECTIVE

This study aimed to compare oncological and perioperative outcomes of surgical resection for N2 colorectal cancer using an open versus minimally invasive approach.

DESIGN

We conducted a retrospective cohort study using the National Surgical Quality Improvement Program's generic and targeted colectomy data sets.

SETTINGS

Data about surgery for N2 colorectal cancer were obtained regarding North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

PATIENTS

All patients undergoing elective surgical resection for N2 colorectal cancer in participating hospitals between 2014 and 2018 were selected.

INTERVENTIONS

Surgical resection of N2 colorectal cancer was performed.

MAIN OUTCOME MEASURES

Our primary outcome was nodal yield. Secondary outcomes included perioperative complications and mortality.

RESULTS

A total of 1837 patients underwent open and 3907 patients underwent minimally invasive surgery colectomies for N2 colorectal cancer (n = 5744). Median nodal yield was 20 (interquartile range, 15-27) in the open group and 21 (interquartile range, 16-28) in the minimally invasive group (p < 0.0001); however, nodal harvest between the 2 groups was not significantly different on multivariate analysis. Perioperative complications were higher on univariate analysis in the open surgery group, with respect to key outcomes including anastomotic leak and death (p < 0.001).

LIMITATIONS

This study is limited by its retrospective design and by the fact that the staging data collected by the National Surgical Quality Improvement Program are pathological rather than clinical; however, prior studies found a 97% concordance between pathological and clinical N2 determination.

CONCLUSIONS

Minimally invasive surgery approaches to colorectal cancer with N2 disease result in equivalent nodal harvests compared with open approaches. Our group supports the use of a minimally invasive approach in advanced nodal stage colorectal cancer in the appropriately selected patient. See Video Abstract at http://links.lww.com/DCR/B417.

LOS ABORDAJES QUIRRGICOS MNIMAMENTE INVASIVOS SON SEGUROS Y APROPIADOS EN EL CNCER COLORRECTAL N

ANTECEDENTES:Existe evidencia emergente de la seguridad oncológica de la cirugía mínimamente invasiva en el cáncer colorrectal T4; sin embargo, semenjante apoyo falta en la enfermedad N2.OBJETIVO:comparar los resultados oncológicos y perioperatorios de la resección quirúrgica para el cáncer colorrectal N2 utilizando un abordaje abierto versus mínimamente invasivo.DISEÑO:Realizamos un estudio de cohorte retrospectivo utilizando los conjuntos de datos de colectomía genéricos y específicos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica.AJUSTE:Hospitales de Norte America que participan en el Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes sometidos a resección quirúrgica electiva por cáncer colorrectal N2 en los hospitales participantes entre 2014 y 2018.INTERVENCIONES:Resección quirúrgica de cáncer colorrectal N2.PRINCIPALES MEDIDAS DE VOLORACION:Nuestro resultado principal fue el rendimiento nodal. Los resultados secundarios incluyeron complicaciones perioperatorias y mortalidad.RESULTADOS:1837 pacientes fueron sometidos a cirugía abierta y 3907 pacientes fueron sometidos a colectomías de cirugía mínimamente invasiva por cáncer colorrectal N2 (n = 5744). La mediana del rendimiento nodal fue 20 (IQR 15-27) en el grupo abierto y 21 (IQR 16-28) en el grupo mínimamente invasivo (p <0,0001); sin embargo, el rendimiento nodal entre los dos grupos no fue significativamente diferente en el análisis multivariado. Las complicaciones perioperatorias fueron mayores en el análisis univariado en el grupo de cirugía abierta, con respecto a los resultados clave, incluida la fuga anastomótica y la muerte (p <0,001).LIMITACIONES:Este estudio está limitado por su diseño retrospectivo y por el hecho de que los datos de estadificación recopilados por NSQIP son patológicos más que clínicos; sin embargo, estudios previos encontraron una concordancia del 97% entre la determinación patológica y clínica de N2.CONCLUSIONES:Los enfoques de cirugía mínimamente invasiva para el cáncer colorrectal con enfermedad N2 dan rendimientos nodales equivalentes a abordajes abiertos. Nuestro grupo apoya el uso de abordaje mínimamente invasivo en el cáncer colorrectal avanzado en estadio ganglionar en el paciente adecuadamente seleccionado. Consulte Video Resumenhttp://links.lww.com/DCR/B417.

Laparoscopic segmental resection for tumours of the Angle of Treitz: a challenging but feasible surgical option. Results from a retrospective case-series analysis

Tumours of the small intestine are rare and account for about 5% of gastrointestinal tract neoplasms. The angle of Treitz (AT) could be defined as the intestinal loop comprised between the third duodenal portion and the first 10 cm of jejunum. A gold standard surgical treatment for AT neoplasm has not yet been well defined. This paper is focused on a very rare disease and at the best of our knowledge this is the largest case series in the literature about the Laparoscopic Segmental Resection (LSR) of AT tumours. Using a prospectively collected database, all data of consecutive patients, from January 2007 to May 2019, who underwent LSR for AT tumours at two different institutions were analysed. Patients' demographics, intra and post-operative data, 30-day mortality and overall survival were collected. A total of 16 patients were retrieved from our database. The mean operative time was 206,5 ± 79 min. Conversion to open surgery was needed in two cases due to tumor size and, respectively, invasion of the transverse colon which required a multivisceral resection. The mean distal and proximal resection margins were 7.4 ± 2.2 and 3.9 ± 1.2 cm. The median number of harvested nodes was 9 ± 3. Pathological diagnosis was GIST in 11 cases, adenocarcinoma in 4 and sarcoma in 1 case. In conclusion, in experienced hands, LSR appears to be a safe and effective treatment option for tumours of the AT. Prospective studies are needed to confirm these findings.

Laparoscopic approach for T4 colon cancer can be associated with poor prognosis in right-sided T4b tumours

INTRODUCTION

Although recent studies have demonstrated the safety of laparoscopic surgery in T4 colon cancer, some patients could have poor prognosis. In this study, we aimed to analyse the risk factors affecting oncologic outcome of laparoscopic surgery.

MATERIALS AND METHODS

Among the 1033 T4 colon cancer patients collected from a multicentre database (2004-2017), 584 patients (458 T4a and 126 T4b) underwent laparoscopic approach for radical surgery. Risk factors associated with 3-year disease-free survival (DFS) and overall survival (OS) were evaluated through multivariate analysis. In addition, subgroups were classified using a combination of risk factors, and the survival rate was evaluated.

RESULTS

During this period, 188 (32.2%) had recurrence, and 151 (25.9%) died. In the multivariate analysis for oncologic outcome, elevated carcinoembryonic antigen level (hazard ratio [HR] 1.37) and absence of adjuvant chemotherapy (HR 1.60) were associated with poor DFS. T4b (HR 1.56, 1.46), right-sided location (HR 1.52, 1.42), and open conversion (HR 2.70, 2.12) were independently associated with both poor DFS and OS. When four subgroups were analysed through the combination of tumour location and T stage, the DFS and OS rates were significantly lower in patients with right-sided T4b cancer than in other groups (log-rank p < 0.001).

CONCLUSION

Right-sided T4b colon cancer for laparoscopic surgery may lead to poor oncologic outcome. This approach could be a caution in suspected cases preoperatively.

Applicability of minimally invasive surgery for clinically T4 colorectal cancer

The role of minimally invasive surgery (MIS) to treat clinically T4 (cT4) colorectal cancer (CRC) remains uncertain and deserves further investigation. A retrospective cohort study was conducted between September 2006 and March 2019 recruiting patients diagnosed as cT4 CRC and undergoing MIS at a university hospital and its branch. Patients’ demography, clinicopathology, surgical and oncological outcomes, and radicality were analyzed. A total of 128 patients were recruited with an average follow-up period of 33.8 months. The median time to soft diet was 6 days, and the median postoperative hospitalization periods was 11 days. The conversion and complication (Clavien–Dindo classification ≥ II) rates were 7.8% and 27.3%, respectively. The 30-day mortality was 0.78%. R0 resection rate was 92.2% for cT4M0 and 88.6% for pT4M0 patients. For cT4 CRC patients, the disease-free survival and 3-year overall survival were 86.1% and 86.8% for stage II, 54.1% and 57.9% for stage III, and 10.8% and 17.8% for stage IV. With acceptable conversion, complication and mortality rate, MIS may achieve satisfactory R0 resection rate and thus lead to good oncological outcomes for selected patients with cT4 CRC.

Outcomes of Laparoscopic Surgery for Mucinous Colorectal Adenocarcinoma

Background: Mucinous colorectal adenocarcinoma (MAC) has a higher incidence of local extension, leading to lower overall resection rates. Few studies have investigated the outcomes of laparoscopic surgery for MACs to date. Therefore, we aimed to elucidate the validity of laparoscopic surgery for mucinous adenocarcinoma (MAC). Methods: This study analyzed short-term and long-term outcomes between laparoscopic and open surgery for MACs from 2008 to 2018. Multivariate analyses were used to define prognostic factors of overall survival (OS) and disease-free survival (DFS). Results: Patients in the laparoscopy (LAP) group had significantly less blood loss, fewer days to first flatus and to diet, and shorter length of hospital stay. The 3-year and 5-year DFS rates for all stages combined were 65.7% and 62.5% in the LAP group compared with 60.5% and 57.6% in the open (OPEN) surgery group (P = .521). The 3-year and 5-year OS rates for all stages combined were 72.3% and 67.3% in the LAP group compared with 72.6% and 67.8% in the OPEN group (P = .934). OS and DFS in stage II, stage III, and pathological T4 (pT4) stage patients who underwent laparoscopic surgery did not differ from patients who underwent open surgery. Multivariate analysis showed that stage pT4, pN2, and carcinoembryonic antigen (CEA) were significant predictors of OS. Independent factors, including intraoperative blood transfusion, stage pT4, pN2, CEA, and CA19-9, carbohydrate antigen 19-9, have a great effect on DFS. Conclusions: Laparoscopic surgery is a safe and feasible option for mucinous colorectal AC, which provides faster postoperative recovery and less intraoperative blood loss.

Outcomes of laparoscopic surgery for pathological T4 colon cancer

PURPOSE

The surgical indication of laparoscopic surgery for pT4 colon cancer remains to be established because only a few studies have investigated the short- and long-term outcomes of laparoscopic surgery for them to date. Therefore, we aimed to elucidate the validity of laparoscopic surgery for them.

METHODS

We retrospectively analyzed 81 patients with pT4 colon cancer who underwent surgical resection with a curative intent at Kobe University Hospital from January 2007 to December 2015. The short- and long-term outcomes were compared between the propensity score-matched patients who underwent laparoscopic colectomy (LAP group, n = 25) and those who underwent open colectomy (OP group, n = 25).

RESULTS

Intraoperative blood loss was significantly less in the LAP group than in the OP group (p = 0.029). Operative time, R0 resection rate, and morbidity did not significantly differ between the two groups. The 5-year overall survival (OS) and the 5-year recurrence-free survival (RFS) did not significantly differ between the propensity score-matched groups. Univariate and multivariate analyses of the entire cohort showed the surgical approach (LAP vs OP) selected was not a significant prognostic factor for OS or RFS.

CONCLUSIONS

The short and the long-term outcomes were similar between the LAP and OP groups. Laparoscopic surgery might be a safe and feasible option for pT4 colon cancer patients.

Resection of the urinary bladder for locally advanced colorectal cancer: a retrospective comparison of partial versus total cystectomy

Background

The postoperative and survival outcomes of patients with primary advanced colorectal cancer who undergo partial versus total cystectomy have not been adequately compared, as studies of this topic are rare and comprise relatively small cohorts. This study aimed to investigate the short- and long-term outcomes of patients who underwent en bloc partial or total cystectomy for primary advanced colorectal cancer that was suspected of adhering to or invading the urinary bladder.

Methods

The study included 90 patients who underwent various degrees of cystectomy between 1993 and 2013 to treat locally advanced primary colorectal cancer that was suspected of involving the urinary bladder. Patients in whom total cystectomy was performed solely because of prostate-invading lower rectal cancer were excluded. Data on patient characteristics and their short- and long-term outcomes were collected retrospectively to evaluate differences between partial cystectomy (the P group; n = 72) and total cystectomy (the T group; n = 18). Postoperative and oncologic outcomes were also analyzed.

Results

The T group had significantly greater operating times than the P group (median, 572 vs. 346 min); blood loss volume was also greater in the T group (median, 3092 vs. 1112 mL). The postoperative overall complication rate was significantly greater in the T group than in the P group (94.4% vs. 51.4%). With a median follow-up duration of 62 months, local recurrences were observed in 22.2 and 6.9% of patients in the T and P groups, respectively. On multivariate Cox regression analyses using partial cystectomy as the reference, total cystectomy was independently associated with poorer local recurrence-free survival (hazard ratio [HR], 4.0 95% confidence interval [CI], 1.1–15.0), relapse-free survival (HR, 2.9; 95% CI, 1.2–6.9), and overall survival (HR, 2.1; 95% CI, 1.0–4.3).

Conclusions

Patients who undergo en bloc total cystectomy for locally advanced colorectal cancers have worse postoperative and oncologic outcomes than those who undergo partial cystectomy.

Laparoscopic surgery in patients diagnosed with clinical N2 colon cancer

PURPOSE

The benefits of laparoscopic surgery for colorectal cancer have been well established. Several randomized controlled trials have demonstrated similar oncological outcomes between laparoscopic and open surgery for colon cancer. However, whether or not laparoscopic surgery is acceptable in patients with clinical N2 colon cancer is unclear. Therefore, the present study aimed to evaluate the safety and oncological outcomes of laparoscopic surgery for clinical N2 colon cancer.

METHODS

This retrospective study assessed a prospective database and identified 262 consecutive patients with clinical N2 colon cancer who underwent either laparoscopic or open primary resection between 2000 and 2016. After propensity-score matching, 162 patients were analyzed. The primary outcome of interest was the 3-year recurrence-free survival rate, and the secondary outcome of interest was the postoperative complication rate.

RESULTS

The 3-year recurrence-free survival rate did not differ markedly between the laparoscopic and open surgery groups (77.4% vs. 76.5%, p = 0.620). In addition, the incidence of postoperative complications did not differ markedly between the laparoscopic and open surgery groups (16.6% vs. 24.0%, p = 0.317).

CONCLUSIONS

Our findings suggest that laparoscopic surgery is safe and effective for clinical N2 colon cancer. Laparoscopic resection can be considered in patients diagnosed with clinical N2 colon cancer.

Laparoscopic approach for left-sided T4 colon cancer is a safe and feasible procedure, compared to open surgery

BACKGROUND

A laparoscopic approach can be attempted for pathologic T4 (pT4) colon cancer. Our aim was to evaluate the clinico-oncologic outcomes following laparoscopic versus open surgery for right and left-sided pT4 colon cancer.

METHODS

From a multicentric collaborative database, we enrolled 245 patients with right-sided colon cancer (RCC, 128 laparoscopy and 117 open) and 338 with left-sided colon cancer (LCC, 176 laparoscopy and 162 open). All patients underwent intended curative surgery for histologically proven T4 adenocarcinoma, between 2004 and 2013. The primary end-point of our analysis was the oncologic outcome, including the 5-year disease-free survival (5 year-DFS) and the 5-year overall survival (5 year-OS). The secondary end-points included the R0 resection rate and postoperative complications.

RESULTS

Our study group included 224 T4N0 and 359 T4N+ tumors. The median follow-up was 53 months. For patients with RCC, the rate of postoperative morbidities was lower for the laparoscopy than that for the open surgery group (12.5 vs. 22.2%, p = 0.044). There was no difference in the R0 resection rate (94.5 vs. 96.6%, p = 0.425) between the groups. The 5 year-DFS and 5 year-OS rates were lower for the laparoscopy than that in the open group (48.9% vs. 59.2%, p = 0.093; 60.0% vs. 70.0%, p = 0.284, respectively), but this difference was not statistically significant. Among patients with LCC, there were no differences in the rate of postoperative complication and R0 resection (15.3 vs. 21.0%, p = 0.307; 96.0 vs. 95.7%, p = 0.875, respectively). Both groups had comparable 5 year-DFS and 5 year-OS rates (62.7% vs. 61.1%, p = 0.552; 72.0% vs. 71.8%, p = 0.611, respectively).

CONCLUSIONS

Laparoscopic surgery appears to be a safe procedure for patients with pT4 LCC, but requires careful consideration for patients with pT4 RCC.

Impact of postoperative complications on long-term survival following surgery for T4 colorectal cancer

BACKGROUND

Postoperative complications (POCs) after the resection of locally advanced colorectal cancer (CRC) may influence adjuvant treatment timing, outcomes, and survival. This study aimed to evaluate the impact of POCs on long-term outcomes in patients surgically treated for T4 CRC.

METHODS

All consecutive patients who underwent the resection of T4 CRC at a single centre from 2004 to 2013 were retrospectively analysed from a prospectively maintained database. POCs were assessed using the Clavien-Dindo classification. Patients who developed POCs were compared with those who did not in terms of recurrence-free survival (RFS) and overall survival (OS).

RESULTS

The study population comprised 106 patients, including 79 (74.5%) with synchronous distant metastases. Overall, 46 patients (43%) developed at least one POC during the hospital stay, and of those patients, 9 (20%) had severe complications (Clavien-Dindo ≥ grade III). POCs were not associated with OS (65% with POCs vs. 69% without POCs; p = 0.72) or RFS (58% with POCs vs. 70% without POCs; p = 0.37). Similarly, POCs did not affect OS or RFS in patients who had synchronous metastases at diagnosis compared with those who did not.

CONCLUSIONS

POCs do not affect the oncological course of patients subjected to the resection of T4 CRC, even in cases of synchronous metastases.

Clinical Efficacy of Laparoscopic Surgery for T4 Colon Cancer Compared with Open Surgery: A Single Center's Experience

BACKGROUND

Laparoscopic surgery for T4 colon cancer remains controversial according to many colorectal cancer guidelines. The aim of this study was to compare short- and long-term outcomes in patients who underwent T4 colon cancer resection by laparoscopy versus open surgery.

METHODS

Patients who underwent T4 colon cancer resection either by laparoscopy or by open surgery between January 2012 and January 2017 were included and used to perform a retrospective cohort analysis. Demographics, patient characteristics, short-term outcomes, and long-term oncological outcomes were compared between two groups. Multivariate analyses were used to define prognostic factors of overall survival.

RESULTS

Groups were comparable in terms of preoperative characteristics and demographics. Intraoperative blood loss (127.3 versus 226.1 mL, P = .001) and hospital stay (11.6 versus 14.8 days, P = .001) were significantly reduced in the laparoscopic group compared with the open group. Operative time, bowel movement, time to soft diet, and lymph nodes harvested did not significantly differ between the two groups. R0 resection achieved 100% in both the groups. Similarly, the overall survival rate and disease-free survival rate in stage II and stage III disease showed no significant differences. Multivariate analyses showed that intraoperative blood loss was a significantly independent factor related to a poor prognosis.

CONCLUSIONS

This study suggests that laparoscopy for T4 colon cancer can be safely performed with superior short-term outcomes, such as less intraoperative blood loss and shorter time of hospital stay compared with open surgery, and with similar long-term oncological outcomes. Therefore, laparoscopic procedure could be a viable option in selected patients.

Meta-analysis of short- and long-term outcomes after pure laparoscopic versus open liver surgery in hepatocellular carcinoma patients

Background

The advantages of laparoscopy are widely known. Nevertheless, its legitimacy in liver surgery is often questioned because of the uncertain value associated with minimally invasive methods. Our main goal was to compare the outcomes of pure laparoscopic (LLR) and open liver resection (OLR) in patients with hepatocellular carcinoma.

Methods

We searched EMBASE, MEDLINE, Web of Science, and The Cochrane Library databases to find eligible studies. The most recent search was performed on December 1, 2017. Studies were regarded as suitable if they reported morbidity in patients undergoing LLR versus OLR. Extracted data were pooled and subsequently used in a meta-analysis with a random-effects model. Clinical applicability of results was evaluated using predictive intervals. Review was reported following the PRISMA guidelines.

Results

From 2085 articles, forty-three studies (N = 5100 patients) were included in the meta-analysis. Our findings showed that LLR had lower overall morbidity than OLR (15.59% vs. 29.88%, p < 0.001). Moreover, major morbidity was reduced in the LLR group (3.78% vs. 8.69%, p < 0.001). There were no differences between groups in terms of mortality (1.58% vs. 2.96%, p = 0.05) and both 3- and 5-year overall survival (68.97% vs. 68.12%, p = 0.41) and disease-free survival (46.57% vs. 44.84%, p = 0.46).

Conclusions

The meta-analysis showed that LLR is beneficial in terms of overall morbidity and non-procedure-specific complications. That being said, these results are based on non-randomized trials. For these reasons, we are calling for randomization in upcoming studies. Systematic review registration: PROSPERO registration number CRD42018084576.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6431-6) contains supplementary material, which is available to authorized users.

Oncological outcomes of laparoscopic versus open surgery in pT4 colon cancers: A systematic review and meta-analysis

BACKGROUND

Widespread adoption of minimally invasive surgery for colon cancer has achieved improved short-term benefits and better long-term oncological outcomes compared with open surgery. However, it is still controversial whether laparoscopic surgery is suitable for patients with stage T4 colon cancer. The aim of this meta-analysis was to compare short- and long-term oncological outcomes associated with laparoscopic and conventional open surgery for pT4 colon cancer.

METHODS

Published studies from 2003 to 2018 comparing oncological outcomes following laparoscopic and open surgery for pT4 colon cancer were systematically searched. Data on conversion rate, R0 resection rate, number of harvested lymph nodes, morbidity and mortality, and overall survival (OS) and disease-free survival (DFS) were subjected to meta-analysis using fixed-effect and random-effect models.

RESULTS

Twelve observational studies met the inclusion criteria with a total of 2396 cases (1250 laparoscopic and 1146 open). There was no significant difference in R0 resection rate [relative risk (RR) = 1.007; 95% confidence interval (CI) = 0.935-1.085; P = 0.850], number of harvested lymph nodes (MD = 0.004; 95% CI = -0.139 to 0.148; P = 0.951), mortality (RR = 0.509; 95% CI = 0.176-1.470; P = 0.212), and 3-year OS (RR = 1.056; 95% CI = 0.939-1.188; P = 0.360), 5-year OS (RR = 1.003; 95% CI = 0.883-1.139; P = 0.966), 3-year DFS (RR = 1.032; 95% CI = 0.903-1.179; P = 0.642), and 5-year DFS (RR = 0.995; 95% CI = 0.868-1.140; P = 0.973) between the groups. The rate of conversion from laparoscopic to open procedures was 10.7% (95% CI = 0.090-0.124). There was a significant difference in incidence of complications within 30 postoperative days between laparoscopic and open surgery (RR = 0.703; 95% CI = 0.564-0.876; P = 0.002).

CONCLUSION

Laparoscopic surgery is safe and feasible in pT4 colon cancer, oncological outcomes are similar, and more importantly, there are fewer postoperative complications compared with open surgery.

A rare case of ascending colon adenocarcinoma incarcerated in an inguinoscrotal hernia: case report and literature review

Background

Inguinal hernias and colorectal cancers are common conditions, but the presentation of a loop of bowel containing cancer within a hernia is rare. Principles of surgery include oncological resection of the involved colonic segment as well as lymphatic drainage. Based on case reports of the last several decades, there have been no reports of a case where the reduction of an inguinoscrotal hernia and oncological colectomy were performed completely laparoscopically. We present the first instance of a completely laparoscopically assisted resection and hernia repair on a patient with T4 ascending colon cancer. A literature search on recent case reports over the last 30 years has also been presented with a focus on trends in treatment.

Case presentation

An 83-year-old man presented for further investigation of his iron deficiency anaemia and was diagnosed with adenocarcinoma of the ascending colon. This was demonstrated radiologically to be found within a large right inguinoscrotal hernia. He underwent a laparoscopically assisted right hemicolectomy and laparoscopic closure of the internal ring and recovered well.

Conclusions

Colorectal cancers within inguinal hernias are rare and can often present with complications such as perforation. As such, treatment has mostly involved an open operation. The last few years have shown feasibility of a laparoscopic approach and can be attempted safely when indicated.

Short- and long-term outcomes following laparoscopic vs open surgery for pathological T4 colorectal cancer: 10 years of experience in a single center

AIM

To evaluate the short-term and long-term outcomes following laparoscopic vs open surgery for pathological T4 (pT4) colorectal cancer.

METHODS

We retrospectively analyzed the short- and long-term outcomes of proven pT4 colorectal cancer patients who underwent complete resection by laparoscopic or open surgery from 2006 to 2015 at Guangdong General Hospital.

RESULTS

A total of 211 pT4 colorectal cancer patients were included in this analysis, including 101 cases in the laparoscopy (LAP) group and 110 cases in the open surgery (OPEN) group [including 15 (12.9%) cases of conversion to open surgery]. Clinical information (age, gender, body mass index, comorbidities, American Society of Anesthesiologists score, etc.) did not differ between the two groups. In terms of blood loss, postoperative complications and rate of recovery, the LAP group performed significantly more favorably (P < 0.05). With regard to pT4a/b and combined organ resection, there were significantly more cases in the OPEN group (P < 0.05). The 3- and 5-year overall survival rates were 74.9% and 60.5%, respectively, for the LAP group and 62.4% and 46.5%, respectively, for the OPEN group (P = 0.060). The 3- and 5-year disease-free survival rates were 68.0% and 57.3%, respectively, for the LAP group and 55.8% and 39.8%, respectively, for the OPEN group (P = 0.053). Multivariate analysis showed that IIIB/IIIC stage, lymph node status, and CA19-9 were significant predictors of overall survival. PT4a/b, IIIC stage, histological subtypes, CA19-9, and adjuvant chemotherapy were independent factors affecting disease-free survival.

CONCLUSION

Laparoscopy is safely used in the treatment of pT4 colorectal cancer while offering advantages of minimal invasiveness and faster recovery. Laparoscopy is able to achieve good oncologic outcomes similar to those of open surgery. We recommend that laparoscopy be carried out in experienced centers. It is still required to screen the appropriate cases for laparoscopic surgery, optimize the preoperative diagnosis process, and reduce the conversion rate. Multi-center, prospective, and large-sample studies are required to assess these issues.