Clinical feasibility of laparoscopic lateral pelvic lymph node dissection following total mesorectal excision for advanced rectal cancer

Evaluation of Short-Term Postoperative Outcomes of Lateral Lymph Node Dissection After Neoadjuvant Radiotherapy for Rectal Cancer Patients: The Early Learning Phase After Surgical Training in the Netherlands

BACKGROUND

Distal, locally advanced rectal cancer might spread to lateral lymph nodes (LLNs), posing a risk of lateral local recurrence (LLR). This study evaluated quality-controlled implementation of lateral lymph node dissection (LLND) in the Netherlands.

METHODS

This retrospective multicenter cohort study included consecutively treated rectal cancer patients who underwent neoadjuvant therapy, total mesorectal excision (TME) surgery, and nerve-sparing minimally invasive LLND by trained surgeons across 10 Dutch hospitals. Training involved cadaver sessions, monthly video meetings, and proctoring. Outcome measures included intra- and postoperative complications, urogenital dysfunction and 18-month LLR, local recurrence (LR), and disease-free survival (DFS).

RESULTS

The study comprised 41 patients (median follow-up period, 16 months; interquartile range, IQR, 8-21 months) with advanced tumors (27% cT4, 49% cN2, 7% cM1), and a mean LLN size of 11 mm on primary-staging MRI. Abdominoperineal resection was performed for 29 patients (70%). A beyond TME procedure was performed for 11 patients (28%). The median blood-loss was 250 ml (IQR, 100-400 ml), with obturator nerve injury reported in one patient. Malignant LLNs were found in 41% of the LLND specimens. Complications occurred for 22 patients (54%), 21% (9/41) of which were grade 3 or higher. Nine patients (22%, four of whom underwent beyond TME surgery) had a Foley or intermittent urinary catheter at the end of the follow-up period. Sexual dysfunction of three patients was reported. No ipsilateral LLRs occurred. The 18-month LR rate was 14%, and the DFS was 55%.

CONCLUSION

Minimally invasive nerve-sparing LLND by trained Dutch surgeons showed acceptable complication rates and good oncologic control of the lateral compartment to date.

Comparison of robotic and laparoscopic approaches in short- and long-term outcomes of lateral pelvic lymph node dissection for advanced rectal cancer: a Japanese multicenter study

BACKGROUND

Lateral pelvic lymph node dissection (LPND) is a challenging surgical technique with complex anatomy and narrow pelvic manipulation. The outcomes of robotic and laparoscopic surgery for LPND are still unclear.

METHODS

We retrospectively reviewed 169 consecutive patients who underwent rectal cancer surgery with LPND between 2016 and 2023. Patients were divided into two groups according to whether LPND was performed by robotic surgery (R group, n = 40) or laparoscopic surgery (L group, n = 129). Clinicopathological feature and outcomes were compared between groups.

RESULTS

Frequency of surgery with combined resection of adjacent structures (5.0% vs. 19.4%, p = 0.023), frequency of patients with distant metastasis (5.0% vs. 19.4%, p = 0.028), and estimated blood loss from bilateral LPND (74 mL vs. 132 mL, p = 0.013) were all lower in the R group than in the L group. Type of surgical approach did not correlate with postoperative complications. Median follow-up was 31.0 months (range, 1.0-69.0 months). No patients in the R group experienced local recurrence, compared to 4.6% in the L group. Multivariate analysis revealed laparoscopic surgery (odds ratio 3.687, 95% confidence interval 1.505-6.033; p = 0.004) as an independent predictor of poor relapse-free survival.

CONCLUSIONS

Robotic surgery for LPND appears to have good prognostic value in some, but not all, oncologic cases. However, large prospective studies are desirable to validate these findings.

Comparison of short-term outcomes of laparoscopic surgery, robot-assisted laparoscopic surgery, and open surgery for lateral lymph-node dissection for rectal cancer: a network meta-analysis

This study attempted to compare short-term outcomes of laparoscopic surgery (LS), robot-assisted laparoscopic surgery (RS), and open surgery (OS) for lateral lymph-node dissection (LLND) in treatment of rectal cancer through network meta-analysis. Embase, Web of Science, PubMed, and The Cochrane Library databases were searched to collect cohort studies on outcomes of LS, RS, and OS for LLND for rectal cancer. Newcastle-Ottawa Scale (NOS) was utilized to evaluate the quality of cohort studies. Primary outcomes should at least include one of the following clinical outcome measures: operative time, blood loss, total lymph-node harvest, positive resection margin rate, postoperative complications, and postoperative hospital stay. A network meta-analysis was conducted using STATA software. Fourteen cohort studies including 8612 patients were eligible for inclusion. The network meta-analysis results showed that, in terms of intraoperative outcomes, the RS group had the longest operative time, while the OS group had the shortest; the LS and RS groups had significantly less blood loss than the OS group. In terms of histological outcomes, there were no significant differences in the total number of lymph nodes harvested and the positive margin rate among the LS, RS, and OS groups (P > 0.05). Regarding postoperative outcomes, the OS group had the highest probability of postoperative complications and the longest hospital stay, followed by the LS group, with the RS group being the lowest. RS was the best method in blood loss, postoperative complication rate, and postoperative hospital stay, followed by LS. OS had the shortest operative time and the highest blood loss.

Robotic versus laparoscopic pelvic lateral lymph node dissection in locally advanced rectal cancer: a systemic review and meta-analysis

BACKGROUND

There are few available studies that compare the feasibility, efficacy, and safety of robotic pelvic lateral lymph node dissection compared to laparoscopic pelvic lateral lymph node dissection (LPLND) in advanced rectal cancer. This meta-analysis aims to compare perioperative outcomes between robotic and LPLND.

METHODS

We performed a systemic literature review of PubMed, Embase, and Web of Science databases. Perioperative parameters were extracted and pooled for analysis. This meta-analysis provided an analysis of heterogeneity and prediction intervals.

RESULTS

Five studies were included: 567 patients divided between 266 robotic and 301 LPLND. Overall operation time was longer in the robotic group than laparoscopic group (difference in means = 67.11, 95% CI [30.80, 103.42], p < 0.001) but the difference in the pelvic lateral lymph dissection time was not statistically significant (difference in means =  - 1.212, 95% CI [ - 11.594, 9.171], p = 0.819). There were fewer overall complications in the robotic than in the laparoscopic group (OR = 1.589, 95% CI [1.009, 2.503], p = 0.046), especially with respect to urinary retention (OR = 2.23, 95% CI [1.277, 3.894], p = 0.005). More pelvic lateral lymph nodes were harvested by robotic surgery than by laparoscopy (differences in means =  - 1.992, 95% CI [ - 2.421, 1.563], p < 0.001).

CONCLUSIONS

In this meta-analysis, robotic pelvic lateral lymph node dissection was associated with more pelvic lateral lymph nodes harvested and lower overall complications, especially urinary retention when compared to LPLND. Further studies are needed to reinforce these findings.

Comparison of laparoscopic lateral lymph node dissection for rectal cancer with and without routine resection of the visceral branches of internal iliac artery

PURPOSE

This study aimed to explore the safety and feasibility of the modified lateral lymph node dissection (LLND) with routine resection of the visceral branches of internal iliac vessels (IIVs) for mid-low-lying rectal cancer.

MATERIALS AND METHOD

Consecutive patients undergoing LLND for rectal cancer were divided into the routine visceral branches of the IIVs resection group (RVR group) and the NRVR group (without routine resection). The main outcomes were postoperative complications and the number of lateral lymph nodes harvested.

RESULTS

From 2012 to 2021, a total of 75 and 57 patients were included in the RVR and NRVR group, respectively. The operative time was reduced in the RVR group (p = 0.020). No significant difference was observed between the two groups for the incidence of total, major, or minor postoperative complications. Pathologically confirmed LLNM were 24 (32%) patients in the RVR group and 12 (21.1%) in the NRVR group (p = 0.162). The number of lateral lymph nodes harvested had no significant difference between two groups (11 vs. 12, p = 0.329).

CONCLUSION

LLND with routine resection of visceral branches of IIVs is safe and feasible, which brings no major complication or long-term urinary disorder.

Risk factors for lateral pelvic lymph node metastasis in patients with lower rectal cancer: a systematic review and meta-analysis

Background and objective

Lateral pelvic lymph node (LPLN) metastasis is one of the prominent reasons for local recurrence (LR) in patients with rectal cancer (RC). The evaluation criteria of lateral lymph node dissection (LLND) for patients in eastern (mainly in Japan) and western countries have been controversial. The aim of this study was to analyse the risk factors for LPLN metastasis in order to guide surgical methods.

Methods

We searched relevant databases (Embase (Ovid), Medline (Ovid), PubMed, Cochrane Library, and Web of Science) for articles published between 1 January 2000 and 05 October 2022 to evaluate the risk factors for LPLN metastasis in patients with RC in this meta-analysis.

Results

A total of 24 articles with 5843 patients were included in this study. The overall results showed that female sex, age <60 years, pretherapeutic CEA level >5 ng/ml, clinical T4 stage (cT4), clinical M1 stage (cM1), distance of the tumour from the anal verge (AV) <50 mm, tumour centre located below the peritoneal reflection (Rb), short axis (SA) of LPLN ≥8 mm before nCRT, short axis (SA) of LPLN ≥5 mm after nCRT, border irregularity of LPLN, tumour size ≥50 mm, pathological T3-4 stage (pT3-4), pathological N2 stage (pN2), mesorectal lymph node metastasis (MLNM), lymphatic invasion (LI), venous invasion (VI), CRM (+) and poor differentiation were significant risk factors for LPLN metastasis (P <0.05).

Conclusion

This study summarized almost all potential risk factors of LPLN metastasis and expected to provide effective treatment strategies for patients with LRC. According to the risk factors of lateral lymph node metastasis, we can adopt different comprehensive treatment strategies. High-risk patients can perform lateral lymph node dissection to effectively reduce local recurrence; In low-risk patients, we can avoid overtreatment, reduce complications and trauma caused by lateral lymph node dissection, and maximize patient survival and quality of life.

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.

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

Analysis of Prevention and Treatment of Anastomotic Leakage after Sphincter-Preserving Surgery for Middle- and Low-Grade Rectal Cancer under Laparoscopy

BACKGROUND

Anastomotic leakage is one of the most serious complications that can occur after laparoscopic-assistedsphincter-preserving surgery for middle- and low-grade rectal cancer.

OBJECTIVES

To explore the cause, prevention, and treatment of anastomotic leakage after sphincter-preserving surgery for middle- and low-grade rectal cancer under laparoscopy.

METHODS

The clinical data from patients with mid- and low-grade rectal cancer who underwent laparoscopic-assistedanus-preserving surgery in the anorectal surgery department of our hospital have been analyzed. Patients with a definite diagnosis, indications for laparoscopic surgery, and sphincter-preserving surgery were included in the analysis, and patients with a protective loop ileostomy and laparotomy were excluded.

RESULTS

Among the 126 patients with middle- and low-grade rectal cancer undergoing sphincter-preserving surgery under laparoscopy. There were 75 male patients and 51 female patients, ranging in age from 37 to 89 years old, with an average age of 60.2 ± 6.7. The distance from the lower edge of the rectal tumor to the anal edge was ≤10 cm. 6 developed anastomotic leakage after the operation (leakage rate of 4.7%). Moreover, turbid purulent fluid was drained from the abdominal drainage tube in three patients on the third and fourth days after the operation, and the abdominal drainage tube drained serous drainage in three more patients on the fifth and sixth days, with signs of peritonitis appearing locally. All patients received continuous flushing and negative pressure drainage with a self-made double cannula and symptomatic treatment, and all were cured and discharged.

CONCLUSION

Many factors can cause anastomotic leakage after this operation, and adequate perioperative preparation, meticulous operation during surgery, and careful postoperative management are key factors in preventing it.

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.

Long-term clinical outcomes of total mesorectal excision and selective lateral pelvic lymph node dissection for advanced low rectal cancer: a comparative study of a robotic versus laparoscopic approach

BACKGROUND

The long-term outcomes of minimally invasive lateral pelvic lymph node dissection (LPND) are not completely known. The aim of this study was to compare long-term outcomes between robotic and laparoscopic LPND in low rectal cancer patients with suspected lymph node metastasis in the pelvic sidewall.

METHODS

We retrospectively reviewed the records of all rectal cancer patients who had laparoscopic or robotic total mesorectal excision (TME) with LPND between March 2006 and June 2016. Stage IV patients were excluded. The outcomes of patients who had laparoscopic and robotic TME with LPND were compared.

RESULTS

Twenty-nine patients had laparoscopic LPND and 70 had robotic LPND. No significant differences in patient characteristics were observed between the two groups. The urinary retention rate was lower in the robotic group than in the laparoscopic group (7.1% vs. 24.1%; p = 0.043). During a median follow-up of 44.3 months, the overall recurrence rates were 48.3% and 31.4% in the laparoscopic and robotic groups, respectively (p = 0.175). The 5-year disease-free survival rates were 50.4% and 67.0% in the laparoscopic and robotic groups, respectively (p = 0.227). The 5-year overall survival rates were 65.0% and 92.2% in the laparoscopic and robotic groups, respectively (p = 0.017).

CONCLUSIONS

Robotic TME with LPND is safe and feasible. In particular, it is associated with lower urinary retention. Robotic TME with LPND might yield a similar local recurrence rate and 5-year disease-free survival, but favorable long-term overall survival as compared to the laparoscopic approach. However, considering the retrospective nature and both major variables of TME and LPND involved together, this should be cautiously interpreted.

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.

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.

Short-term outcomes of laparoscopic lateral pelvic node dissection for advanced lower rectal cancer

BACKGROUND

The laparoscopic magnified visual effects and evolution of the laparoscopic camera system have recently enabled us to observe details in the deep pelvic floor. Indications of laparoscopic surgery for colorectal cancer have been expanded, and laparoscopic (Lap) lateral pelvic node dissection (LLND) has been introduced in some institutions. We investigated the feasibility of Lap LLND in patients with locally advanced rectal cancer (LARC).

METHODS

Lap LLND was performed in 38 patients diagnosed with cT3-4 or cN1-2 cancer during 2014-2018. We retrospectively analyzed their surgical and short-term outcomes.

RESULTS

Laparoscopic surgery was performed in all patients. cStages II/III/IV were found in 6/31/1 patients, respectively. Among them, 25 patients underwent neoadjuvant chemotherapy without radiotherapy. Lap unilateral LLND was performed in 6 patients and Lap bilateral LLND was performed 32 patients. The number of harvested lymph nodes (LNs) were 4 in the unilateral group and 15 in the bilateral group. Operation time was 531 min, and blood loss was 105 ml. Oral intake has started on postoperative day (POD) 3, and pelvic drain was removed on POD 7. Hospital stay was 18.5 days. Seven patients developed a neurogenic bladder (all Clavien-Dindo grade (CD) II and all occured in the bilateral LLND group), one patient developed abdominal bleeding (CD IIIb) and one patient developed anastomotic leakage (CD IIIb). Pathological results revealed 2/5/16/14/1 patients with pStages 0/I/II/III/IV, respectively. Four patients had histopathologically verified lateral pelvic lymph node metastases. There were no local recurrences after curative surgery (median follow-up 24.2 months).

CONCLUSION

Although the median follow-up period is relatively short and further follow-up is necessary, oncologically, especially in the point of local control rate, Lap LLND appears to have acceptable in the treatment of LARC without radiotherapy in experienced centers. Further investigations focusing on indications and the Lap LLND procedural technique are required.

Laparoscopic dissection for pelvic lymph node recurrence of thymic carcinoma: A case report

Thymic carcinoma, a rare mediastinal neoplasm, is characterized by extensive local invasion and distant metastasis. To our knowledge, this is the first case report demonstrating the efficacy of laparoscopic dissection for pelvic lymph node metastases from thymic carcinoma. A 64-year-old man was found to have a mediastinal mass by CT and underwent radical resection. Six months after resection of his thymic carcinoma, follow-up CT revealed a gluteal tumor and enlarged pelvic lymph nodes. The gluteal tumor was resected percutaneously. Two months after this procedure, PET showed that the three pelvic lymph nodes had abnormal uptake of ¹⁸ F-fluorodeoxyglucose and had enlarged further. The patient accordingly underwent laparoscopic dissection of these lymph nodes. Pathological examination of all resected specimens showed metastatic thymic carcinoma. We recommend laparoscopic dissection of pelvic lymph node metastases because it provides a clear intraoperative view and is minimally invasive.

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.

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.

Repeated laparoscopic resection of extra-regional lymph node metastasis after laparoscopic radical resection for rectal cancer

Here, we report a case of repeated laparoscopic resection of extra-regional lymph node metastases in a patient after laparoscopic surgery for rectal cancer. A 72-year-old woman was diagnosed with upper rectal cancer and underwent laparoscopic low anterior resection and D3 dissection. The pathological stage was considered as T3, N2b, M0, Stage IIIC. Six months after the operation, positron emission tomography-computed tomography (PET-CT) showed fluorodeoxyglucose (FDG) accumulation in the infra-renal para-aortic lymph nodes (PALNs). Systemic chemotherapy was administered; however, chemotherapy was discontinued due to hemoptysis related to her pulmonary disease. Therefore, we performed laparoscopic PALN resection. Pathologically, one lymph node was diagnosed with a metastasis. Three months after the second operation, PET-CT identified FDG accumulation in the left lateral pelvic lymph nodes (LPLNs) and a PALN. Laparoscopic LPLN dissection and PALN resection through minilaparotomy were performed. Pathologically, lymph node metastases were diagnosed in both fields. Sixteen months after the 3^rd operation, there is no recurrence.

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.

New Application of Old Material: Chinese Traditional Ink for Photothermal Therapy of Metastatic Lymph Nodes

Finding a simple and effective strategy to eliminate tumor metastatic lymph nodes is highly desired in clinical tumor treatment. Herein, we reported a Chinese traditional ink (Hu-ink)-based treatment for photothermal therapy (PTT) of tumor metastatic lymph nodes. By simple dilution, stable Chinese traditional ink dispersion was obtained, which presents excellent photothermal effect because of its high absorption in near-infrared (NIR) region. Meanwhile, as revealed by staining and photoacoustic imaging, Hu-ink could transfer to nearby lymph nodes after directly injected into the primary tumors. Under the guidance of dual-modality mapping, the metastatic sentinel lymph nodes could be subsequently eliminated by NIR irradiation. The good biocompatibility of Hu-ink has also been verified by a series of experiments. Therefore, the Hu-ink-based treatment exhibits great potential for PTT of tumor metastatic lymph nodes in future clinical practice.

Single-incision Plus One Port Laparoscopic Total Mesorectal Excision and Bilateral Pelvic Node Dissection for Advanced Rectal Cancer--A Medial Umbilical Ligament Approach

We prove the safety and feasibility of single-incision plus 1 port (SILS+1) laparoscopic total mesorectal excision (TME) + lateral pelvic lymph node dissection (LPLD) via a medial umbilical approach for rectal cancer. Only a few reports have been published about single-incision multiport laparoscopic low anterior resection with LPLD. Recently, minimally invasive surgery such as single-incision plus 1 port (SILS + 1) for advanced rectal cancer has been reported as safe and feasible. To our knowledge, this is the first reported case of SILS + 1 used for LPLD. A wound protector was inserted through a 30-mm transumbilical incision. Next, a single-port access device was mounted to the wound protector and 3 ports (5 mm each) were placed. A 12-mm port was inserted in the right lower quadrant. Super-low anterior resection of the rectum and bilateral LPLD and temporary ileostomy were performed with SILS + 1, with a blood loss of 50 mL and a total surgical time of 525 minutes. The time for right lateral dissection was 74 minutes; the time for left lateral dissection was 118 minutes. The total number of dissected lymph nodes was 57 and the number of lateral lymph nodes dissected was 21 (8 left pelvic lymph nodes, 13 right pelvic lymph nodes). No postoperative anastomotic insufficiency or voiding dysfunction was observed. We have documented the safety and feasibility of SILS + 1-TME + LPLD via a medial umbilical approach for rectal cancer.

The short-term outcomes of induction SOX (S-1 + oxaliplatin) ± cetuximab chemotherapy followed by short-course chemoradiotherapy in patients with poor-risk locally advanced rectal cancer

PURPOSE

To evaluate the safety and efficacy of induction SOX (S-1 + oxaliplatin) ± cetuximab chemotherapy followed by short-course chemoradiotherapy and surgery in patients with poor-risk locally advanced rectal cancer.

METHODS

We enrolled eligible patients with poor-risk rectal cancer defined as T3 lower rectal cancer with mesorectal fascia involvement, T4a or T4b tumors or cases with lateral lymph node swelling. The primary endpoint was a pathological complete response (pCR), and the secondary endpoints were the objective response rate (ORR) and the pathological high response rate (Grade 2 plus 3).

RESULTS

Twenty eligible patients were enrolled. The majority (75.0 %, 15/20) of the patients completed four cycles of induction chemotherapy, and all patients completed the radiotherapy (25 Gy/10 fractions/5 days). The global rate of Grade 3-4 toxicities was 30.0 % (6/20 patients). The ORRs were 85.0 % (17/20) and 95.0 % (19/20) in the patients who underwent R0 and R1 resection, respectively. The pathological high response rate was 70.0 % (14/20) and the pCR was 10.0 % (2/20).

CONCLUSION

The regimen of induction SOX (S-1 + oxaliplatin) ± cetuximab chemotherapy followed by short-course chemoradiotherapy is safe and is associated with good tumor regression in patients with poor-risk locally advanced rectal cancer.

Therapeutic Importance of Endoscopic Pathology Versus Magnetic Resonance Imaging Findings for T1 Rectal Cancer: A Case Report

Preoperative image-based diagnosis is important for the treatment of rare cases of T1 lower rectal cancers with lateral pelvic lymph node (LLN) metastasis. We report a case of LLN metastasis in T1 lower rectal cancer diagnosed preoperatively via magnetic resonance imaging (MRI). A 65-year-old woman was admitted to our hospital because of abdominal pain. An endoscopic examination revealed a large laterally spreading tumor in the lower rectum, which was en bloc resected using endoscopic submucosal dissection. Pathologic examination of the resected specimen showed deep invasion of the cancer cells into the submucosal layer and lymphovascular invasion. MRI revealed swollen perirectal lymph nodes (≥5 mm) and a left LLN approximately 8 mm long. Laparoscopic abdominoperineal resection (Lap-APR) with left lateral pelvic lymph node dissection (LLND) was performed. Cancer cells were not seen in the resected material; however, 7 perirectal lymph nodes and 1 LLN of 47 lymph nodes contained metastatic cancer cells. We show that LLN metastasis in T1 lower rectal cancer can be preoperatively detected via MRI and successfully and safely treated via Lap-APR with left LLND.

Meta-analysis of application of lateral lymph node dissection for low rectal cancer in China

AIM: To assess the value of the application of lateral lymph node dissection (LLND) for low rectal cancer in China.

METHODS: By meta-analysis we made a comprehensive analysis of the application of LLND for low rectal cancer based on 11 articles published in China between January 2005 and September 2015.

RESULTS: Operative time was significantly longer in the LLND group than in the non-LLND (NLLND) group [weighted mean difference (WMD) = 47.79 min, P < 0.00001]. Intra-operative blood loss was significantly greater in the LLND group than in the NLLND group (WMD = 27.84, P < 0.0001). Five-year survival rate was significantly higher in the LLND group than in the NLLND group (59.38% vs 51.3%, P = 0.02). Three-year survival rate was also significantly higher in the LLND group than in the NLLND group (81.6% vs 63.5%, P < 0.00001). Local recurrence rate for the NLLND group (16.9%) was significantly higher than that of the LLND group (8.4%) (P = 0.0003). Local recurrence rate showed no statistical difference between the LLND group and the NLLND group for stage I or IIA low rectal cancer, but was significantly lower in the LLND group than in the NLLND group for stage Ⅲ rectal cancer (14.5% vs 22.1%, P = 0.01).

CONCLUSION: Lateral lymph node dissection in Chinese patients with low rectal cancer can effectively prolong the 5-year survival rate and 3-year survival rate, decrease the local recurrence rate (especially in stage Ⅲ low rectal cancer) and improve the patient's prognosis, but it increases the operative time and the amount of bleeding.

Prognostic significance of a preoperative magnetic resonance imaging assessment of the distance of mesorectal extension in clinical T3 lower rectal cancer

PURPOSES

The aim of this study was to evaluate the association between the mesorectal extensions on high-resolution magnetic resonance imaging (MRI) and the prognosis of patients with clinical T3 lower rectal cancer.

METHODS

Fifty-eight patients with clinical T3 lower rectal cancer were investigated using high-resolution MRI. One radiologist who was blinded to the clinicopathological findings retrospectively examined the MRI-predicted circumferential resection margin (mrCRM) and the distance of mesorectal extension (mrDME) on the scans. If the imaging showed a tumor ≤1 mm from the mesorectal fascia, then the mrCRM involvement was defined as potentially present. The tumors were divided into two groups: mrDME ≤4 mm and mrDME >4 mm.

RESULTS

A survival analysis showed that mrCRM-positive patients had a significantly poorer prognosis in the RFS (p < 0.01) and LRFS (p < 0.01). Patients with mrDME >4 mm revealed a significantly poorer prognosis than those with mrDME ≤4 mm in the OS (p = 0.04), RFS (p < 0.01), and LRFS (p = 0.04). A multivariate analysis revealed that both mrCRM and mrDME on MRI had a significant impact on the RFS (p = 0.01 and 0.03, respectively).

CONCLUSION

The mrDME, as well as the mrCRM, may be an important preoperative prognostic factor for patients with clinical T3 lower rectal cancer.

Technical feasibility of laparoscopic extended surgery beyond total mesorectal excision for primary or recurrent rectal cancer

Relatively little is known about the oncologic safety of laparoscopic surgery for advanced rectal cancer. Recently, large randomized clinical trials showed that laparoscopic surgery was not inferior to open surgery, as evidenced by survival and local control rates. However, patients with T4 tumors were excluded from these trials. Technological advances in the instrumentation and techniques used by laparoscopic surgery have increased the use of laparoscopic surgery for advanced rectal cancer. High-definition, illuminated, and magnified images obtained by laparoscopy may enable more precise laparoscopic surgery than open techniques, even during extended surgery for T4 or locally recurrent rectal cancer. To date, the quality of evidence regarding the usefulness of laparoscopy for extended surgery beyond total mesorectal excision has been low because most studies have been uncontrolled series, with small sample sizes, and long-term data are lacking. Nevertheless, laparoscopic extended surgery for rectal cancer, when performed by specialized laparoscopic colorectal surgeons, has been reported safe in selected patients, with significant advantages, including a clear visual field and less blood loss. This review summarizes current knowledge on laparoscopic extended surgery beyond total mesorectal excision for primary or locally recurrent rectal cancer.

The feasibility of laparoscopic extended pelvic surgery for rectal cancer

PURPOSE

The present study aimed to assess the safety and feasibility of laparoscopic extended pelvic surgery for primary or recurrent rectal cancer.

METHODS

The data on 77 patients, who underwent extended pelvic surgery between February 2008 and June 2014, were retrospectively analyzed. The patients were divided, based on their treatment history, into an open surgery (OS) group (n = 41) and a laparoscopic surgery (LS) group (n = 36).

RESULTS

The operative time in the LS group was significantly longer than that in the OS group (766 vs. 561 min; p < 0.001). In contrast, the LS group was associated with a significantly lower volume of intraoperative blood loss (195 vs. 923 ml; p < 0.001), fluid balance (5.38 vs. 8.23 ml/kg/h; p < 0.001) and rate of complications (40.0 vs. 68.3 %; p = 0.035), and a significantly shorter postoperative hospital stay. The postoperative levels of colloid osmotic pressure and albumin were significantly higher in the LS group.

CONCLUSION

The operative time of the LS group was longer than that of the OS group; however, the LS group experienced less blood loss and fewer complications. Moreover, LS was associated with a reduction in intraoperative infusions and a reduced fluid balance, which maintained homeostasis.

Laparoscopic lymphadenectomy around the left renal vein (16a2lat) by tunneling under the pancreas for advanced Siewert type II adenocarcinoma

The para-aortic lymph nodes around the left renal vein (16a2lat) are now considered important to target in the treatment of advanced adenocarcinoma of the esophagogastric junction. We describe a laparoscopic approach for resecting these nodes. This new tunneling approach starts from the ligament of Treitz and then enters the retroperitoneal space. The left renal vein and left adrenal vein are dissected to identify the anatomy of the 16a2lat area. After this dissection, the 16a2lat nodes are retrieved through the suprapancreatic area. Six patients with advanced type II junctional cancer underwent laparoscopic 16a2lat lymph node dissection. The median operative time and estimated blood loss were 479 (390-750) min and 250 (130-500) ml, respectively. The median hospital stay was 22 (17-54) days and there were no deaths or serious complications. Although this series was relatively small, our technique proved effective and feasible.

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

BACKGROUND

Laparoscopic lateral pelvic lymph node dissection (LPLD) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. This study assessed potential risk factors for lateral pelvic lymph node metastasis (LPLM) and evaluated the feasibility and oncological safety of laparoscopic LPLD compared with the conventional open approach.

METHODS

We retrospectively reviewed the clinical records of 90 patients with advanced low rectal cancer who underwent LPLD following total mesorectal excision at Kyushu University Hospital between January 2001 and July 2014. We compared the clinicopathological features between the patients with and without LPLM and the surgical outcomes between patients who underwent laparoscopic LPLD (LL) and open LPLD (OL).

RESULTS

Fourteen (15.6 %) patients had LPLM. Univariate analysis revealed that undifferentiated cancer, positive lymphatic invasion, >50 % circumferential cancer extent, mesorectal lymph node metastases (MLM), and distant metastasis were associated with LPLM. In the multivariate analysis, MLM was the only independent risk factor for LPLM. Forty-six (51.1 %) patients underwent LL, and 44 (48.9 %) patients underwent OL. The mean surgical duration was longer in the LL group than in the OL group (641.0 vs. 312.0 min, P < 0.001). The LL group also had less hemorrhage (252.0 vs. 815.0 mL, P < 0.001) and a shorter hospital stay (22.9 vs. 29.1 days, P = 0.04) than the OL group. The mean number of harvested lateral pelvic lymph nodes was larger in the LL group than in the OL group (19.5 vs. 15.8, P < 0.05). The morbidity rate and overall survival (3-year OS: 94.7 vs. 82.9 %, P = 0.25) did not differ between the two groups.

CONCLUSIONS

Patients with advanced low rectal cancer presenting MLM are good candidates for LPLD. Laparoscopic LPLD enables retrieval of more lymph nodes and may be acceptable for the treatment of advanced low rectal cancer.

Robotic-assisted laparoscopic versus open lateral lymph node dissection for advanced lower rectal cancer

BACKGROUND

The aim of the present study was to clarify the advantages of robotic-assisted laparoscopic lateral lymph node dissection (RALLD) for rectal cancer by comparing its short-term outcomes with those of open lateral lymph node dissection (OLLD) in a large series from a single center. In terms of RALLD for advanced lower rectal cancer, there are only a few reports with a small number of cases in retrospective, non-comparative studies.

METHODS

From April 2010 to July 2014, a total of 177 patients underwent rectal cancer surgery with lateral lymph node dissection. Four patients who underwent conventional laparoscopic lateral lymph node dissection were excluded. Thus, 173 patients were enrolled, with 85 RALLD and 88 OLLD cases. Perioperative outcomes, postoperative complications, and pathological results were compared between the groups.

RESULTS

No conversion to open surgery was necessary in the RALLD group. The rate of sphincter-preserving procedure was significantly higher in the RALLD group than in the OLLD group (p = 0.007). Operative time was significantly longer in the RALLD group than in the OLLD group (p = 0.007). Blood loss was significantly less in the RALLD group than in the OLLD group (p < 0.001). The rates of wound infection, small bowel obstruction, anastomotic leakage, and urinary retention were significantly lower in the RALLD group than in the OLLD group. Numbers of harvested lymph nodes and positive resection margin rates showed no significant differences.

CONCLUSIONS

The short-term outcomes of RALLD may be superior to those of OLLD for advanced lower rectal cancer.