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Grass JK, Perez DR, Izbicki JR, Reeh M. Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery. Eur J Surg Oncol 2018; 45:498-509. [PMID: 30470529 DOI: 10.1016/j.ejso.2018.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 10/28/2018] [Accepted: 11/13/2018] [Indexed: 02/08/2023] Open
Abstract
Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.
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Affiliation(s)
- Julia K Grass
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Daniel R Perez
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany.
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
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Baukloh JK, Perez D, Reeh M, Biebl M, Izbicki JR, Pratschke J, Aigner F. Lower Gastrointestinal Surgery: Robotic Surgery versus Laparoscopic Procedures. Visc Med 2018; 34:16-22. [PMID: 29594165 DOI: 10.1159/000486008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction For a long time, the comprehensive application of minimally invasive techniques in lower gastrointestinal (GI) surgery was substantially impaired by inherent anatomical and technical complexities. Recently, several new techniques such as robotic operating platforms and transanal total mesorectal excision (taTME) have revolutionized the minimally invasive approach. This review aims to depict the current state of the art and evaluates the advantages and drawbacks in regard to perioperative outcome and quality of oncological resection. Methods A systematic literature search was performed using the search terms 'colorectal cancer', 'rectal cancer', 'minimally invasive surgery', 'laparoscopic surgery', and 'robotic' to identify relevant studies reporting on robotic surgery (RS) either alone or in comparison to laparoscopic surgery (LS). Publications on taTME were analyzed separately. Results 69 studies reporting on RS with a total of 20,872 patients, and 17 articles on taTME including 881 patients, were identified. Conclusion Both RS and taTME can facilitate a minimally invasive approach for lower GI surgery in an increasing number of patients. Furthermore, combining both techniques might become an auspicious approach in selected patients; further prospective and randomized trials are needed to verify its benefits over conventional laTME.
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Affiliation(s)
- Julia-Kristin Baukloh
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Perez
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Biebl
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Mitte and Virchow Klinikum, Berlin, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Mitte and Virchow Klinikum, Berlin, Germany
| | - Felix Aigner
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Mitte and Virchow Klinikum, Berlin, Germany
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Baukloh JK, Reeh M, Spinoglio G, Corratti A, Bartolini I, Mirasolo VM, Priora F, Izbicki JR, Gomez Fleitas M, Gomez Ruiz M, Perez DR. Evaluation of the robotic approach concerning pitfalls in rectal surgery. Eur J Surg Oncol 2017; 43:1304-1311. [PMID: 28189455 DOI: 10.1016/j.ejso.2016.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 11/26/2016] [Accepted: 12/07/2016] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The feasibility and advantages of robotic rectal surgery (RRS) in comparison to conventional open or laparoscopic rectal resections have been postulated in several reports. But well-known challenges and pitfalls of minimal invasive rectal surgery have not been evaluated by a prospective, multicenter setting so far. Aim of this study was to analyze the perioperative outcome of patients following RRS especially in regard to the pitfalls such as obesity, male patients and low tumors by a European multicenter setting. METHODS This prospective study included 348 patients undergoing robotic surgery due to rectal cancer in six major European centers. Clinicopathological parameters, morbidity, perioperative recovery and short-term outcome were analyzed. RESULTS A total of 283 restorative surgeries and 65 abdominoperineal resections were carried out. The conversion rate was 4.3%, mean blood loss was 191 ml, and mean operative time was 315 min. Postoperative complications with a Clavien-Dindo score >2 were observed in 13.5%. Obesity and low rectal tumors showed no significant higher rates of major complications or impaired oncological parameters. Male patients had significant higher rates of major complications and anastomotic leakage (p = 0.048 and p = 0.007, respectively). DISCUSSION RRS is a promising tool for improvement of rectal resections. The well-known pitfalls of minimal-invasive rectal surgery like obesity and low tumors were sufficiently managed by RRS. However, RRS showed significantly higher rates of major complications and anastomotic leakage in male patients, which has to be evaluated by future randomized trials.
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Affiliation(s)
- J K Baukloh
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - M Reeh
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - G Spinoglio
- Department of General Surgery, Azienda University Hospital, Novara, Italy
| | - A Corratti
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | - I Bartolini
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | - V M Mirasolo
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | - F Priora
- Department of General and Oncological Surgical, Azienda Ospedaliera SS Arrigo e Biagio e Cesare Arrigo, Alessandria, Italy
| | - J R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - M Gomez Fleitas
- Colorectal Division, Department of Surgery, Hospital Universitario "Marqués de Valdecilla", Santander, Spain
| | - M Gomez Ruiz
- Colorectal Division, Department of Surgery, Hospital Universitario "Marqués de Valdecilla", Santander, Spain
| | - D R Perez
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany.
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van der Linden YT, Boersma D, Bosscha K, Lips DJ, Prins HA. Use of a multi-instrument access device in abdominoperineal resections. J Minim Access Surg 2016; 12:248-53. [PMID: 27279397 PMCID: PMC4916752 DOI: 10.4103/0972-9941.181386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Laparoscopic colorectal surgery results in less post-operative pain, faster recovery, shorter length of stay and reduced morbidity compared with open procedures. Less or minimally invasive techniques have been developed to further minimise surgical trauma and to decrease the size and number of incisions. This study describes the safety and feasibility of using an umbilical multi-instrument access (MIA) port (Olympus TriPort+) device with the placement of just one 12-mm suprapubic trocar in laparoscopic (double-port) abdominoperineal resections (APRs) in rectal cancer patients. PATIENTS AND METHODS The study included 20 patients undergoing double-port APRs for rectal cancer between June 2011 and August 2013. Preoperative data were gathered in a prospective database, and post-operative data were collected retrospectively. RESULTS The 20 patients (30% female) had a median age of 67 years (range 46-80 years), and their median body mass index (BMI) was 26 kg/m2 (range 20-31 kg/m2). An additional third trocar was placed in 2 patients. No laparoscopic procedures were converted to an open procedure. Median operating time was 195 min (range 115-306 min). A radical resection (R0 resection) was achieved in all patients, with a median of 14 lymph nodes harvested. Median length of stay was 8 days (range 5-43 days). CONCLUSION Laparoscopic APR using a MIA trocar is a feasible and safe procedure. A MIA port might be of benefit as an extra option in the toolbox of the laparoscopic surgeon to further minimise surgical trauma.
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Affiliation(s)
| | - Doeke Boersma
- Department of Surgery, Jeroen Bosch Medical Center, 's-Hertogenbosch, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Medical Center, 's-Hertogenbosch, The Netherlands
| | - Daniel J Lips
- Department of Surgery, Jeroen Bosch Medical Center, 's-Hertogenbosch, The Netherlands
| | - Hubert A Prins
- Department of Surgery, Jeroen Bosch Medical Center, 's-Hertogenbosch, The Netherlands
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Hellan M, Ouellette J, Lagares-Garcia JA, Rauh SM, Kennedy HL, Nicholson JD, Nesbitt D, Johnson CS, Pigazzi A. Robotic Rectal Cancer Resection: A Retrospective Multicenter Analysis. Ann Surg Oncol 2014; 22:2151-8. [PMID: 25487966 DOI: 10.1245/s10434-014-4278-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Conventional laparoscopy has been applied to colorectal resections for more than 2 decades. However, laparoscopic rectal resection is technically demanding, especially when performing a tumor-specific mesorectal excision in a difficult pelvis. Robotic surgery is uniquely designed to overcome most of these technical limitations. The aim of this study was to confirm the feasibility of robotic rectal cancer surgery in a large multicenter study. METHODS Retrospective data of 425 patients who underwent robotic tumor-specific mesorectal excision for rectal lesions at seven institutions were collected. Outcome data were analyzed for the overall cohort and were stratified according to obese versus non-obese and low versus ultra-low resection patients. RESULTS Mean age was 60.9 years, and 57.9 % of patients were male. Overall, 51.3 % of patients underwent neoadjuvant therapy, while operative time was 240 min, mean blood loss 119 ml, and intraoperative complication rate 4.5 %. Mean number of lymph nodes was 17.4, with a positive circumferential margin rate of 0.9 %. Conversion rate to open was 5.9 %, anastomotic leak rate was 8.7 %, with a mean length of stay of 5.7 days. Operative times were significantly longer and re-admission rate higher for the obese population, with all other parameters comparable. Ultra-low resections also had longer operative times. CONCLUSION Robotic-assisted minimally invasive surgery for the treatment of rectal cancer is safe and can be performed according to current oncologic principles. BMI seems to play a minor role in influencing outcomes. Thus, robotics might be an excellent treatment option for the challenging patient undergoing resection for rectal cancer.
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Affiliation(s)
- Minia Hellan
- Division of Surgical Oncology, Department of Surgery, Wright State University, Dayton, OH, USA,
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Ghezzi TL, Luca F, Valvo M, Corleta OC, Zuccaro M, Cenciarelli S, Biffi R. Robotic versus open total mesorectal excision for rectal cancer: comparative study of short and long-term outcomes. Eur J Surg Oncol 2014; 40:1072-9. [PMID: 24646748 DOI: 10.1016/j.ejso.2014.02.235] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 01/27/2014] [Accepted: 02/17/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite the several series in which the short-term outcomes of robotic-assisted surgery were investigated, data concerning the long-term outcomes are still scarce. METHODS The prospectively collected records of 65 consecutive patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (RTME) were compared with those of 109 consecutive patients treated with open surgery (OTME). Patient characteristics, pathological findings, local and systemic recurrence rates and 5-year survival rates were compared. RESULTS There were no statistically significant differences in postoperative complications, reoperation and 30-day mortality. There were significant differences comparing groups: number of lymph nodes harvested (RTME: 20.1 vs. OTME: 14.1, P < 0.001), estimated blood loss (RTME: 0 vs. OTME: 150 ml, P = 0.003), operation time (RTME: 299.0 vs. OTME: 207.5 min, P < 0.001) and length of postoperative stay (RTME: 6 vs. OTME: 9 days, P < 0.001). The rate of circumferential resection margin involvement and distal resection margin were not statistically different between groups. There were no statistically significant differences at the 5-year follow-up: overall survival, disease-free survival and cancer-specific survival. The cumulative local recurrence rate was statistically lower in the robotic group (RTME: 3.4% vs. OTME: 16.1%, P = 0.024). CONCLUSION RTME showed a significant reduction in local recurrence rate and a higher, although not statistically significant, long-term cancer-specific survival with respect to OTME. Prospective randomized studies are needed to confirm or deny significantly better local control rates with robotic surgery.
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Affiliation(s)
- T L Ghezzi
- Division of Colorectal Surgery, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Ramiro Barcelos Street 2350, 90035-903 Porto Alegre, Brazil.
| | - F Luca
- Unit of Integrated Abdominal Surgery, Division of Abdominopelvic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy.
| | - M Valvo
- Unit of Integrated Abdominal Surgery, Division of Abdominopelvic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy
| | - O C Corleta
- Department of Surgery and General Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - M Zuccaro
- Division of Abdominopelvic Surgery, European Institute of Oncology, Milan, Italy
| | - S Cenciarelli
- Division of Abdominopelvic Surgery, European Institute of Oncology, Milan, Italy
| | - R Biffi
- Division of Abdominopelvic Surgery, European Institute of Oncology, Milan, Italy
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Matsuhashi N, Takahashi T, Nonaka K, Tanahashi T, Imai H, Sasaki Y, Tanaka Y, Okumura N, Yamaguchi K, Osada S, Yoshida K. Laparoscopic technique and safety experience with barbed suture closure for pelvic cavity after abdominoperineal resection. World J Surg Oncol 2013; 11:115. [PMID: 23705750 PMCID: PMC3685598 DOI: 10.1186/1477-7819-11-115] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 05/17/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Between April 2005 and December 2012, we performed laparoscopic colorectal resection with regional lymph node dissection on 273 cases of colorectal cancer patients. However, Laparoscopic rectal cancer surgery requires a high degree of skill. Any surgeon who is going to embark on these difficult resections should have at a minimum laparoscopic suturing skills in order to be able to close the peritoneal defect. METHODS In laparoscopic surgery for rectal cancer, the intracorporeal suture technique required to close the pelvic cavity is very difficult. Barbed sutures have recently been proposed to facilitate laparoscopic suturing. Two patients with rectal cancer who underwent laparoscopic abdominoperineal resection (APR) with intracorporeal closure of the pelvic cavity from September to October 2012 were enrolled in this study. RESULTS We present our initial experience of two consecutive cases of intracorporeal closure of the pelvic cavity by totally laparoscopic APR. After clinical follow-up, the two patients have no complaints and have shown no signs of recurrence. CONCLUSIONS We hypothesized that barbed sutures could potentially improve the efficiency of intracorporeal closure of the pelvic cavity after laparoscopic APR. Further, we expect that use of the V-Loc™ will reduce intra-operative stress on the endoscopic surgeon.
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Affiliation(s)
- Nobuhisa Matsuhashi
- Surgical Oncology, Gifu University School of Medicine, 1-1 Yanagido, Gifu City 501-1194, Japan
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Lujan J, Valero G, Biondo S, Espin E, Parrilla P, Ortiz H. Laparoscopic versus open surgery for rectal cancer: results of a prospective multicentre analysis of 4,970 patients. Surg Endosc 2012; 27:295-302. [PMID: 22736289 DOI: 10.1007/s00464-012-2444-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 06/07/2012] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare laparoscopic versus open surgery for rectal cancer and analyse the results of the multidisciplinary audited project on total mesorectal excision conducted in Spain. BACKGROUND The safety and therapeutic efficiency of laparoscopic surgery for rectal cancer are controversial due to the technical difficulties it involves. A deviation from the oncological principles of mesorectal excision would mean a potential increase in local recurrence and shorter survival. METHODS This prospective non-randomised multicentre study includes 4,970 patients with rectal cancer. The study compares perioperative, postoperative, anatomicopathological and survival variables. RESULTS Five hundred and sixty five patients were excluded. Of the remaining 4,405, 3,018 (68.51%) had open surgery (OS) and 1,387 (31.49%) laparoscopic surgery (LS). The rate of anterior resections was higher in the LS group. The rate of intraoperative tumour perforation, number of red blood cell concentrates transfused and length of hospital stay were greater in the OS group, whereas surgical time was longer in the LS group. The incidence of complications was 45.6% in the OS group and 38.3% in the LS group. Involvement of the circumferential and distal margin, as well as unsatisfactory and partially satisfactory quality of the mesorectum, were greater in the OS group. There were no differences for local recurrence and survival rates. CONCLUSIONS According to these results, laparoscopic surgery is the best option for the surgical treatment of rectal cancer, with similar rates of local recurrence and survival, although there are oncological indicators in this study to suggest that these results can be improved with laparoscopic surgery.
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Affiliation(s)
- J Lujan
- Department of Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain.
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Stottmeier S, Harling H, Wille-Jørgensen P, Balleby L, Kehlet H. Postoperative morbidity after fast-track laparoscopic resection of rectal cancer. Colorectal Dis 2012; 14:769-75. [PMID: 21848895 DOI: 10.1111/j.1463-1318.2011.02767.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
AIM Analysis was carried out of the nature and chronological order of early complications after fast-track laparoscopic rectal surgery with a view to optimizing the short-time outcome of rectal cancer surgery. METHOD A total of 102 consecutive patients who underwent elective fast-track laparoscopic rectal cancer surgery were analysed prospectively from the Danish Colorectal Cancer Database supplemented by data from the medical records. We studied in detail the nature and chronological order of postoperative morbidity and reason for prolonged stay (> 5 days). RESULTS Twenty-five patients (25%) had one or more complications. Surgical complications occurred in 19 patients, while six patients had medical complications as the primary event. Fifteen patients underwent reoperation, three died, and eight were readmitted within 30 days. The median length of stay was 5 days (range 2-42). CONCLUSION Postoperative morbidity remains a significant problem in the fast-track era, even in experienced surgical hands. Our results suggest that besides improvement of surgical technique further improvement of outcome lies in early recognition and proper treatment of complications and the perioperative optimization of organ function.
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Affiliation(s)
- S Stottmeier
- Department of Surgery K, Bispebjerg Hospital, Copenhagen, Denmark
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Laparoscopic ultralow anterior resection versus laparoscopic pull-through with coloanal anastomosis for rectal cancers: a comparative study. Am J Surg 2011; 202:291-7. [DOI: 10.1016/j.amjsurg.2010.09.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 09/09/2010] [Accepted: 09/14/2010] [Indexed: 12/18/2022]
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Hidalgo JMS, Targarona EM, Martinez C, Hernandez P, Balague C, Trias M. Laparoscopic rectal surgery: does immediate outcome differ in respect to sex? Dis Colon Rectum 2010; 53:438-44. [PMID: 20305444 DOI: 10.1007/dcr.0b013e3181bdbaa7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study analyzed the immediate postoperative outcome of the laparoscopic approach to the rectum in relation to the sex of the patient. METHODS Two hundred thirty-nine patients were included in our study. The inclusion criterion was rectal cancer <15 cm from the anal margin. Exclusion criteria were the presence of anesthetic contraindications for pneumoperitoneum, T4, pancolonic polyposis, and ulcerative colitis. The parameters analyzed included demographics, comorbidities, previous abdominal surgery, preoperative chemoradiotherapy, body mass index, operative time, type of operation, difficulty score, conversion, hospital stay, postoperative morbidity according to the Dindo classification, and histopathologic analysis. Analysis was performed on an intention-to-treat basis. Results are given as number of cases and percentages for categorical data, and as median and 95% confidence interval for quantitative variables. Data were analyzed by use of bivariate analysis, contingency tables, and chi or Fisher exact tests for categorical variables, and ANOVA or t test for quantitative variables. The statistical significance level was set at 5% (alpha = 0.05), and two-tailed tests were used throughout. RESULTS We did not find any statistical differences related to sex in the global series, pure laparoscopy, or converted patients in relation to mortality, conversion, anastomotic leakage, morbidity, reintervention, and morbidity classification according to Dindo (P > .05). We only observed a trend in relation to a longer duration of surgery in men. This was statistically significant in the low anterior resection subgroup (P = .02) and in the overall series (P = .002). Statistical analysis also showed that postoperative stay was longer in men after an anterior resection (P = .015). CONCLUSION We believe that no important differences exist in perioperative outcomes between men and women after a laparoscopic approach to rectum cancer.
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The Learning Curve for the Laparoscopic Approach to Conservative Mesorectal Excision for Rectal Cancer. Ann Surg 2010; 251:249-53. [DOI: 10.1097/sla.0b013e3181b7fdb0] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Milsom JW, de Oliveira O, Trencheva KI, Pandey S, Lee SW, Sonoda T. Long-term outcomes of patients undergoing curative laparoscopic surgery for mid and low rectal cancer. Dis Colon Rectum 2009; 52:1215-22. [PMID: 19571696 DOI: 10.1007/dcr0b013e3181a73e81] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The use of laparoscopy surgery in the management of rectal cancer is controversial, especially in the mid and low rectum. The aim of this study was to determine oncologic and long-term outcomes after laparoscopic and hand-assisted laparoscopic surgery for mid and low rectal cancer. METHODS Between January 1999 and December 2006, 185 patients had surgery for rectal cancer; 103 these patients had mid and low rectal cancer. The source of data was inpatient/outpatient medical records. Telephone interviews were conducted for all patients. Actuarial survival was calculated with use of the Kaplan-Meier method. RESULTS Hand-assisted laparoscopic surgery was performed in 58 (56.3%) patients, and pure laparoscopic surgery in 45 (43.7%) patients. Mean follow-up time was 42.1 months. The conversion rate was 2.9%. All specimen margins were negative. The anastomotic leak rate was 7.8% (n = 8). There was no 30-day mortality. Local recurrence rate was 5% at five years. Overall survival was 91% and disease-free survival was 73.1% at five years. CONCLUSION Laparoscopic surgical techniques for mid and low rectal cancer seem safe and feasible with acceptable oncologic and long-term outcomes. Further studies, comparing laparoscopic and open methods, are warranted.
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Affiliation(s)
- Jeffrey W Milsom
- New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA.
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Gouvas N, Tsiaoussis J, Pechlivanides G, Zervakis N, Tzortzinis A, Avgerinos C, Dervenis C, Xynos E. Laparoscopic or open surgery for the cancer of the middle and lower rectum short-term outcomes of a comparative non-randomised study. Int J Colorectal Dis 2009; 24:761-9. [PMID: 19221764 DOI: 10.1007/s00384-009-0671-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The study compares the short-term results of the laparoscopic and open approach for the surgical treatment of rectal cancer. Consecutive cases with rectal cancer operated upon with laparoscopy from 2004 to 2007 were compared to open rectal cancer cases. Total mesorectal excision (TME) was attempted in all cases. PATIENTS AND METHODS Forty-two cases were included in the OPEN and 45 in the LAP group and were matched for age, gender, disease stage and operation type. SURGICAL PROCEDURE Duration of surgery was longer and blood transfusion requirements were less in the LAP group. Higher blood loss was observed in patients with neoadjuvant treatment in both groups. Patients with neoadjuvant treatment in the OPEN group had higher operation time, but that was not the case in the LAP group. There were three conversions (7%). RESULTS Overall morbidity was higher in the OPEN group. LAP group patients were found to recover faster. R0 resection was achieved in 88% in the OPEN and 94% in the LAP group. DISCUSSION Less morbidity and faster recovery is offered after laparoscopic TME. Quality of surgery assessed by histopathology is similar between the approaches. Neoadjuvant chemoradiation seems to have significant impact on blood loss but results in longer operation times of the OPEN group.
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Li VKM, Wexner SD, Pulido N, Wang H, Jin HY, Weiss EG, Nogeuras JJ, Sands DR. Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc 2009; 23:2459-65. [DOI: 10.1007/s00464-009-0416-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 01/14/2009] [Accepted: 02/11/2009] [Indexed: 12/11/2022]
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Rosati R, Bona S, Romario UF, Elmore U, Furlan N. Laparoscopic total mesorectal excision after neoadjuvant chemoradiotherapy. Surg Oncol 2007; 16 Suppl 1:S83-9. [DOI: 10.1016/j.suronc.2007.10.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Bianchi PP, Rosati R, Bona S, Rottoli M, Elmore U, Ceriani C, Malesci A, Montorsi M. Laparoscopic surgery in rectal cancer: a prospective analysis of patient survival and outcomes. Dis Colon Rectum 2007; 50:2047-53. [PMID: 17906896 DOI: 10.1007/s10350-007-9055-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 03/24/2007] [Accepted: 05/23/2007] [Indexed: 12/13/2022]
Abstract
PURPOSE The role of laparoscopic resection in the management of rectal cancer is still controversial. We prospectively evaluated patient survival and outcomes in patients undergoing laparoscopic rectal resection for rectal cancer at a single institution. METHODS From November 1999 to November 2005, 107 patients with rectal cancer were treated by laparoscopy. Exclusion criteria were: metastatic disease, advanced disease with invasion of adjacent structures, clinical or radiologic involvement of the external anal sphincter, previous colonic resection, synchronous colonic adenocarcinoma, and contraindications to laparoscopy. All patients were followed prospectively for survival and complications. Survival was calculated by the Kaplan-Meier method. RESULTS A laparoscopic sphincter-saving procedure was performed in 104 patients, 2 patients had a laparoscopic Miles operation, and 1 underwent a laparoscopic Hartmann's procedure. Mean operating time was 278 (range, 135-430) minutes. Conversion to open surgery was required in 20 of 107 patients (18.7 percent). Overall morbidity was 27 percent, anastomotic leakage occurred in 14 of 104 patients (13.5 percent). There was no postoperative mortality. A mean of 18 (range, 1-49) lymph nodes was removed. Mean distance of distal margin from tumor was 2.6 (range, 0.5-10) cm; in two patients there was microscopic invasion of the distal margin. Mean hospital stay was nine (range, 4-43) days. Mean follow-up was 35.8 months. There was local recurrence in 1 of 107 patients (0.95 percent); there were no port site metastases. Actuarial five-year and disease-free survival rates are 81.4 and 79.8 percent, respectively. CONCLUSIONS Laparoscopic rectal surgery is feasible and oncologically radical but also technically demanding (conversion rate, 18.7 percent), time-consuming (mean operating time, 278 minutes), and associated with specific intraoperative complications. At present, the technique should only be performed in specialist centers by teams experienced in laparoscopic surgery.
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Affiliation(s)
- Paolo Pietro Bianchi
- Department of General Surgery, University of Milan, Istituto Clinico Humanitas IRCCS, Rozzano, Milano, Italy.
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Palanivelu C, Sendhilkumar K, Jani K, Rajan PS, Maheshkumar GS, Shetty R, Parthasarthi R. Laparoscopic anterior resection and total mesorectal excision for rectal cancer: a prospective nonrandomized study. Int J Colorectal Dis 2007; 22:367-72. [PMID: 16786316 DOI: 10.1007/s00384-006-0165-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to present our experience of laparoscopic total mesorectal resection, including ultralow resection and coloanal anastomosis. MATERIALS AND METHODS Between 1993 and 2005, patients fit for general anesthesia, with resectable cancers, and with lower edge of tumor beyond 5 cm of the anal verge were subjected to laparoscopic anterior resection with sphincter preservation. Double stapling technique is used to establish bowel continuity. RESULTS A total of 170 patients, 88 males and 82 females, were subjected to successful laparoscopic anterior resection, which included high anterior resection (n=90), low anterior resection (n=52), ultralow anterior resection (n=20), and coloanal anastomosis (n=8). The average age of patients was 58.4 years (12-90 years). Mean operating time was 130 min and mean hospital stay was 7 days. The morbidity was 13.5% with nil mortality. With an average follow-up of 49 months (range 9 years to 3 months), 9 patients developed local recurrence and 45 patients developed distant metastasis. CONCLUSION In selected cases, laparoscopic anterior resection is possible for all levels of rectal tumors, allowing sphincter preservation and maintaining oncological safety.
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Affiliation(s)
- C Palanivelu
- Gem Hospital, 45 A, Pankaja Mill Road, Coimbatore, Tamilnadu 641045, India
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Lelong B, Bege T, Esterni B, Guiramand J, Turrini O, Moutardier V, Magnin V, Monges G, Pernoud N, Blache JL, Giovannini M, Delpero JR. Short-term outcome after laparoscopic or open restorative mesorectal excision for rectal cancer: a comparative cohort study. Dis Colon Rectum 2007; 50:176-83. [PMID: 17180257 DOI: 10.1007/s10350-006-0751-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE The laparoscopic approach to rectal cancer is still a controversial procedure. A comparative cohort study was conducted to assess short-term results of laparoscopic restorative mesorectal excision. METHODS From January 1998 to December 2000, laparotomy was performed on all primary rectal cancer undergoing radical excision. From January 2002 to September 2004, all cases about to undergo radical excision were considered for laparoscopy. Patients with fixed tumor or T4, indications for synchronous hepatectomy, emergencies, and medical contraindications were not included. The study was based on the intention-to-treat principle. RESULTS Short-term outcome was compared between the laparoscopy group (n=104) and the laparotomy group (n=68). Demographic, general and tumor data, and rates of preoperative irradiation were comparable, as were surgical procedures and perioperative management. Hospital mortality (1 and 2.9 percent, P=0.33) and three-month overall morbidity (43.3 and 48.5 percent, P=0.49) were comparable between laparoscopy and laparotomy groups. Surgical complication rates were comparable (39.3 and 35.5 percent, P=0.58), but a significantly lower medical complication rate was observed in laparoscopy patients (8.7 and 20.6 percent, P=0.025), mainly because this group had fewer respiratory complications. Hospital stay was shorter in laparoscopy patients (10 and 14 days, P<0.001). Oncologic quality criteria were comparable, in terms of number of lymph nodes, lateral and distal margins, and delivery of postoperative chemotherapy. CONCLUSIONS The laparoscopic approach to restorative mesorectal excision for cancer does not increase postoperative morbidity or reduce oncologic quality. Our results suggest that the short-term outcome is probably improved with this procedure.
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Affiliation(s)
- Bernard Lelong
- Department of Surgical Oncology, Paoli Calmettes Institute, Comprehensive Cancer Center, Marseille, France.
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Abstract
A recent major advance in the surgical treatment of colorectal cancer has been the introduction of laparoscopic surgery. Laparoscopic colectomy is associated with decreased postoperative pain, faster ileus resolution, shorter hospital stay, improved cosmesis, and decreased morbidity when compared with open colectomy. However, early reports of high rates of laparoscopic wound metastases gave rise to questions regarding the adequacy of the laparoscopic technique for curative resection of malignancies. These concerns over oncologic outcomes are addressed by several single and multi-institutional randomized trials in the United States and throughout the world that have compared laparoscopic-assisted colectomy with conventional open colectomy. These studies have established both the short- and long-term safety and oncologic efficacy of laparoscopic colectomy for cancer. To ensure successful outcomes, surgeons performing laparoscopic colectomy should be adequately experienced. Limitations include the technical requirements of advanced laparoscopic skills and training, increased operative time, and equipment costs. Despite these limitations, patient recovery benefits may offset the increased operative costs and result in improved outcome overall.
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Affiliation(s)
- George J Chang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, TX 77030-4009, USA.
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Person B, Vivas DA, Wexner SD. Totally laparoscopic low anterior resection with transperineal handsewn colonic J-pouch anal anastomosis for low rectal cancer. Surg Endosc 2006; 20:700-2. [PMID: 16508809 DOI: 10.1007/s00464-005-0581-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Accepted: 11/15/2005] [Indexed: 12/21/2022]
Affiliation(s)
- B Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Stocchi L, Nelson H. Minimally Invasive Surgery for Colorectal Carcinoma. Ann Surg Oncol 2005; 12:960-70. [PMID: 16244804 DOI: 10.1245/aso.2005.02.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Accepted: 07/17/2005] [Indexed: 01/29/2023]
Affiliation(s)
- Luca Stocchi
- Division of Colon and Rectal Surgery, Gonda 9S, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
Minimally invasive surgical techniques are preferred for a variety of surgical disorders and result in improved outcomes. Laparoscopic colectomy is associated with decreased postoperative pain, faster ileus resolution, shorter hospitalization, and improved cosmesis when compared with open colectomy. The laparoscopic technique is now often preferred for benign disease, but concerns over oncologic adequacy have limited its availability for cancer. The Clinical Outcomes of Surgical Therapy randomized trial of laparoscopic versus open colectomy for cancer recently validated the efficacy of laparoscopy for colon cancer. Limitations include the technical requirements of advanced laparoscopic skills and training, increased operative time, and equipment costs. Surgeons performing laparoscopic colectomy should be adequately experienced and certified to ensure successful outcomes. Despite these limitations, patient recovery benefits may offset the increased operative costs and result in improved cost-effectiveness overall.
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Affiliation(s)
- George J Chang
- Division of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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