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Hoshino N, Fukui Y, Hida K, Obama K. Similarities and differences between study designs in short- and long-term outcomes of laparoscopic versus open low anterior resection for rectal cancer: A systematic review and meta-analysis of randomized, case-matched, and cohort studies. Ann Gastroenterol Surg 2021; 5:183-193. [PMID: 33860138 PMCID: PMC8034685 DOI: 10.1002/ags3.12409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/17/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022] Open
Abstract
AIM Randomized controlled trials (RCT) are the gold standard in surgical research, and case-matched studies, such as studies with propensity score matching, are expected to serve as an alternative to RCT. Both study designs have been used to investigate the potential superiority of laparoscopic surgery to open surgery for rectal cancer, but it remains unclear whether there are any differences in the findings obtained using these study designs. We aimed to examine similarities and differences between findings from different study designs regarding laparoscopic surgery for rectal cancer. METHODS Systematic review and meta-analyses. A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane. RCT, case-matched studies, and cohort studies comparing laparoscopic low anterior resection and open low anterior resection for rectal cancer were included. In total, 8 short-term outcomes and 3 long-term outcomes were assessed. Meta-analysis was conducted stratified by study design using a random-effects model. RESULTS Thirty-five studies were included in this review. Findings did not differ between RCT and case-matched studies for most outcomes. However, the estimated treatment effect was largest in cohort studies, intermediate in case-matched studies, and smallest in RCT for overall postoperative complications and 3-year local recurrence. CONCLUSION Findings from case-matched studies were similar to those from RCT in laparoscopic low anterior resection for rectal cancer. However, findings from case-matched studies were sometimes intermediate between those of RCT and unadjusted cohort studies, and case-matched studies and cohort studies have a potential to overestimate the treatment effect compared with RCT.
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Affiliation(s)
- Nobuaki Hoshino
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Yudai Fukui
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Koya Hida
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Kazutaka Obama
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
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Tan HCL, Tan JH, Nur Dzainuddin NA, Chan KK. First Feasibility Study and Short-term Outcomes of Laparoscopic-Assisted Anterior Resection in Colorectal Cancer in Malaysia. Ann Coloproctol 2020; 36:94-101. [PMID: 32178501 PMCID: PMC7299566 DOI: 10.3393/ac.2019.05.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/10/2019] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The purpose of this study was to demonstrate the feasibility and safety of laparoscopic-assisted anterior resection (LAAR) for colorectal cancer in a local Asian population. METHODS This is a retrospective review of all patients with colorectal cancer operated from November 2017 to October 2018. Main variables of interest were demography, type and surgery, length of stay (LOS), and the involvement of proximal and distal doughnut. Postoperative complications were analysed using chi-square or Fisher exact and Mann-Whitney tests. RESULTS There were 23 patients with a mean age of 62.5 ± 12.2 years. The mean time from diagnosis to surgery was 97.1 ± 154.84 days. There were 12 patients in the LAAR group and 11 in the open anterior resection (OAR) group. Duration of surgery was shorter in OAR (129.58 ± 51.38 minutes) compared to LAAR (147.91 ± 39.37 minutes). Mean LOS was shorter in the LAAR group with 5±1.5 days compared to the OAR group of 7.42 ± 4.25 days. However, there was no significant P-value for both duration of surgery (P = 0.322) or LOS (P = 0.87). A total of 3 complications were recorded after OAR and 2 after LAAR. Both groups had clear proximal and distal margins with 16 (12-18.5) harvested lymph nodes in LAAR and 18 (16-22) in OAR, which were equal (P = 0.155). CONCLUSION This study reports a shorter LOS in the minimally invasive group of 2 days with similar oncologic resection outcomes. This shows that LAAR is feasible in Malaysia and has potential outcome benefits.
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Affiliation(s)
- Henry Chor Lip Tan
- Colorectal Unit, Department of Surgery, Hospital Sultanah Aminah, Johor Bahru, Malaysia.,Department of General Surgery, Faculty of Medicine, National University of Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Jih Huei Tan
- Colorectal Unit, Department of Surgery, Hospital Sultanah Aminah, Johor Bahru, Malaysia.,Department of General Surgery, Faculty of Medicine, National University of Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | | | - Koon Khee Chan
- Colorectal Unit, Department of Surgery, Hospital Sultanah Aminah, Johor Bahru, Malaysia
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Evolution of minimally invasive surgery for rectal cancer: update from the national cancer database. Surg Endosc 2020; 35:275-290. [PMID: 32112255 DOI: 10.1007/s00464-020-07393-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND As the use of minimally invasive techniques in colorectal surgery has become increasingly prevalent, concerns remain about the oncologic effectiveness and long-term outcomes of minimally invasive low anterior resection (MI-LAR) for the treatment of rectal cancer. STUDY DESIGN The 2010-2015 National Cancer Database (NCDB) Participant Data Use File was queried for patients undergoing elective open LAR (OLAR) or MI-LAR for rectal adenocarcinoma. A 1:1 propensity match was performed on the basis of demographics, comorbidity, and tumor characteristics. Outcomes were compared between groups and Cox proportional hazard modeling was performed to identify independent predictors of mortality. A subset analysis was performed on high-volume academic centers. RESULTS 35,809 patients undergoing LAR were identified of whom 18,265 (51.0%) underwent MI-LAR. After propensity matching, patients receiving MI-LAR were less likely to have a positive circumferential radial margin (CRM) (5.5% vs. 6.6%, p = 0.0094) or a positive distal margin (3.6% vs. 4.6%, p = 0.0022) and had decreased 90-day all-cause mortality (2.0% vs. 2.6%, p = 0.0238). MI-LAR resulted in decreased hospital length of stay (5 vs. 6 days, p < 0.0001) but a greater rate of 30-day readmission (7.6% vs. 6.5%, p = 0.0054). Long-term overall survival was improved with MI-LAR (79% vs. 76%, p < 0.0001). Cox proportional hazard modeling demonstrated a decreased risk of mortality with MI-LAR (HR 0.859, 95% CI 0.788-0.937). CONCLUSION MI-LAR is associated with improvement in CRM clearance and long-term survival. In the hands of experienced surgeons with advanced laparoscopy skills, MI-LAR appears safe and effective technique for the management of rectal cancer.
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An SB, Kim BC, Kim JY, Kim JW, Lee SJ. Results of Laparotomy and Laparoscopy for Perforated Colonic Diverticulitis. JSLS 2019; 23:JSLS.2019.00007. [PMID: 31431798 PMCID: PMC6687474 DOI: 10.4293/jsls.2019.00007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background and Objectives The applications of laparoscopic surgery are expanding, but there is still controversy about its application in patients with peritonitis resulting from diverticulitis perforation. This study aimed to investigate the factors affecting the postoperative mortality rate in patients undergoing surgery for perforated diverticulitis. Further, we compared the recovery courses of patients between open and laparoscopic surgeries. Methods We analyzed the medical records of adult patients with peritonitis caused by perforated diverticulitis from six hospitals of Hallym University Medical Center from January 2006 to December 2016. Results A total of 166 patients were identified. In the univariate analysis, the statistically significant factors associated with postoperative mortality were age ≥ 60 years, body mass index ≥ 23 kg/m2, American Society of Anesthesiologists score ≥ 3, hypertension, serum blood urea nitrogen ≥ 23 mg/dL, creatinine ≥ 1.2 mg/dL, albumin < 3.0 g/dL, modified Hinchey score ≥ grade III, formation of stoma, and laparoscopic surgery. In multivariate analysis, serum albumin < 3.0 g/dL was the only factor associated with mortality. After case-control matching, we compared postoperative hospital course and prognosis between open and laparoscopic surgery groups. There was no significant difference in the clinical course between the groups. No significant difference was observed in the complication rate, reoperation rate, readmission rate, and mortality. Conclusion Low preoperative serum albumin level (<3.0 g/dL) affects the mortality rate of patients after surgery. The hospital course and prognosis after laparoscopic surgery and conventional open surgery are comparable in patients with peritonitis caused by diverticulitis perforation.
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Affiliation(s)
- Sung Bak An
- Department Of Surgery, Hallym University Medical Center, Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Byung Chun Kim
- Department Of Surgery, Hallym University Medical Center, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jeong Yeon Kim
- Department Of Surgery, Hallym University Medical Center, Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jong Wan Kim
- Department Of Surgery, Hallym University Medical Center, Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Sang-Jeon Lee
- Department of Surgery, College of Medicine, Chungbuk National University and Hospital, Cheongju, Republic of Korea
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Standardised approach to laparoscopic total mesorectal excision for rectal cancer: a prospective multi-centre analysis. Langenbecks Arch Surg 2019; 404:547-555. [PMID: 31377857 DOI: 10.1007/s00423-019-01806-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/16/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high-quality surgery are equivalent to those achieved by open technique. We present short- and long-term post-operative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic TME for rectal cancer. We describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. METHODS Prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon at the minimally invasive colorectal unit in Portsmouth between 2006 and 2014 were analysed along with data acquired between 2010 and 2017 from surgeons at three further international centres. Endpoints were overall and disease-free survival at 5 years, and early post-operative clinical and pathological outcomes. RESULTS Two hundred sixty-three consecutive patients underwent laparoscopic TME surgery by the principal surgeon. At 5 years, overall survival was 82.9% (Dukes' A = 94.4%; B = 81.6%; C = 73.7%); disease-free survival was 84.0% (Dukes' A = 93.3%; B = 86.8%; C = 72.6%). Post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, major morbidity and 30-day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. CONCLUSION Laparoscopic TME produces excellent long-term survival outcomes for patients with rectal cancer. A standardised approach has the potential to improve outcomes by setting benchmarks for surgical quality, and providing a step-by-step method for surgical training.
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Hyde LZ, Baser O, Mehendale S, Guo D, Shah M, Kiran RP. Impact of surgical approach on short-term oncological outcomes and recovery following low anterior resection for rectal cancer. Colorectal Dis 2019; 21:932-942. [PMID: 31062521 DOI: 10.1111/codi.14677] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/08/2019] [Indexed: 12/11/2022]
Abstract
AIM The aim was to evaluate the influence of operative approach for low anterior resection (LAR) on oncological and postoperative outcomes. Minimally invasive surgical approaches are increasingly used for the treatment of rectal cancer with mixed outcomes. METHOD We compared patients undergoing LAR in the National Cancer Database between 2010 and 2015 by surgical approach. Multivariable regression was used to identify risk factors associated with conversion rate, prolonged length of stay (LOS) and 30-day unplanned readmission. RESULTS During the study period, 41 282 patients underwent LAR: 6035 robotic-assisted (RLAR) (14.6%), 13 826 laparoscopic (LLAR) (33.5%) and 21 421 open (OLAR) (51.9%). In propensity score matched analysis, RLAR compared to LLAR was associated with shorter LOS (6.3 vs 6.8 days, P < 0.0001), lower risk of prolonged LOS (22.1% vs 25.6%, P < 0.0001) and lower rate of conversion to open (7.5% vs 14.95%, P < 0.0001). Compared to OLAR, RLAR had shorter LOS (6.3 vs 7.8 days, P < 0.0001) and less prolonged LOS (14.1% vs. 20.9%, P < 0.0001). In multivariable analysis, for conversion to open, the laparoscopic approach was one of the risk factors; for prolonged LOS, conversion to open and non-robotic approaches (i.e. LLAR and OLAR) were risk factors; and for unplanned 30-day readmission, conversions and prolonged LOS were risk factors. CONCLUSIONS For patients with rectal cancer, RLAR shows recovery benefits over both open and laparoscopic LAR with reduced conversion to open compared with LLAR and less prolonged LOS compared with LLAR and OLAR. RLAR is associated with short-term oncological outcomes comparable to OLAR, supporting its use in minimally invasive surgery for rectal cancer.
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Affiliation(s)
- L Z Hyde
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York City, New York, USA
| | - O Baser
- Center for Innovation and Outcomes Research, Columbia University Medical Center, New York City, New York, USA
| | - S Mehendale
- Clinical Affairs, Intuitive Surgical, Sunnyvale, California, USA
| | - D Guo
- Clinical Affairs, Intuitive Surgical, Sunnyvale, California, USA
| | - M Shah
- Clinical Affairs, Intuitive Surgical, Sunnyvale, California, USA
| | - R P Kiran
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York City, New York, USA.,Center for Innovation and Outcomes Research, Columbia University Medical Center, New York City, New York, USA
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Schnitzbauer V, Gerken M, Benz S, Völkel V, Draeger T, Fürst A, Klinkhammer-Schalke M. Laparoscopic and open surgery in rectal cancer patients in Germany: short and long-term results of a large 10-year population-based cohort. Surg Endosc 2019; 34:1132-1141. [PMID: 31147825 PMCID: PMC7012798 DOI: 10.1007/s00464-019-06861-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 05/18/2019] [Indexed: 12/15/2022]
Abstract
Background Rectal cancer is frequent in Germany and worldwide. Several studies have assessed laparoscopic surgery as a treatment option and most have shown favorable results. However, long-term oncologic safety remains a controversial issue. Methods The current dataset derives from 30 clinical cancer registries in Germany and includes 16,378 patients diagnosed with rectal cancer between 2007 and 2016. Outcomes were 90-day mortality, overall survival (OS), local recurrence-free survival (RFS) and relative survival of patients treated with either open or laparoscopic surgery. Multivariable logistic regression was used to evaluate factors that affected the probability of a patient undergoing laparoscopic surgery as well as to evaluate short-term mortality. OS and RFS were analyzed by Kaplan–Meier plots and multivariable Cox regression conducted separately for UICC stages I–III, tumor location, and sex as well as by propensity score matching followed by univariable and multivariable survival analysis. Results Of 16,378 patients, 4540 (27.7%) underwent laparoscopic surgery, a trend which increased during the observation period. Patients undergoing laparoscopy attained better results for 90-day mortality (odds ratio, OR 0.658, 95% confidence interval, CI 0.526–0.822). The 5-year OS rate in the laparoscopic group was 82.6%, vs. 76.6% in the open surgery group, with a hazard ratio (HR) of 0.819 in multivariable Cox regression (95% CI 0.747–0.899, p < 0.001). The laparoscopic group showed a better 5-year RFS, with 81.8 vs. 74.3% and HR 0.770 (95% CI 0.705–0.842, p < 0.001). The 5-year relative survival rates were also in favor of laparoscopy, with 93.1 vs. 88.4% (p = 0.012). Conclusion Laparoscopic surgery for rectal cancer can be performed safely and, according to this study, is associated with an oncological outcome superior to that of the open procedure. Therefore, in the absence of individual contraindications, it should be considered as a standard approach.
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Affiliation(s)
- Valentin Schnitzbauer
- Faculty of Medicine — University Hospital Regensburg, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Michael Gerken
- Tumor Center Regensburg, Institute for Quality Assurance and Health Services Research, University of Regensburg, Am BioPark 9, 93053 Regensburg, Germany
| | - Stefan Benz
- Klinik für Allgemeine-,Viszeral- und Kinderchirurgie, Kliniken Böblingen, Bunsenstr. 120, 71032 Böblingen, Germany
| | - Vinzenz Völkel
- Tumor Center Regensburg, Institute for Quality Assurance and Health Services Research, University of Regensburg, Am BioPark 9, 93053 Regensburg, Germany
| | - Teresa Draeger
- Tumor Center Regensburg, Institute for Quality Assurance and Health Services Research, University of Regensburg, Am BioPark 9, 93053 Regensburg, Germany
| | - Alois Fürst
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Strasse 65, 93053 Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center Regensburg, Institute for Quality Assurance and Health Services Research, University of Regensburg, Am BioPark 9, 93053 Regensburg, Germany
- Arbeitsgemeinschaft Deutscher Tumorzentren e.V., Kuno-Fischer-Strasse 8, 14057 Berlin, Germany
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Draeger T, Völkel V, Schnitzbauer V, Gerken M, Benz S, Klinkhammer-Schalke M, Fürst A. Laparoscopic and open resection of rectal cancer-is age an effect modifier for short- and long-term survival? Int J Colorectal Dis 2019; 34:821-828. [PMID: 30778670 DOI: 10.1007/s00384-019-03265-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Rectal cancer is a frequently diagnosed tumor worldwide. Various studies have shown the noninferiority or even slight superiority of laparoscopic resection. However, there is no clear recommendation on whether age should influence the choice of surgical approach. MATERIALS AND METHODS This study compared outcomes of laparoscopic and open surgery in rectal cancer patients. Perioperative mortality and 5-year overall, relative, and recurrence-free survival rates were analyzed separately for three age groups. Data originate from 30 regional German cancer registries that cover approximately one quarter of the German population. All primary nonmetastatic rectal adenocarcinoma cases with surgery between 2005 and 2014 were eligible for inclusion. To compare survival rates, Kaplan-Meier analysis, a relative survival model, and multivariable Cox regression were used; a sensitivity analysis assessed bias by exclusion. RESULTS Ten thousand seven hundred fifty-four patients were included in the analysis. The mean laparoscopy rate was 23.0% and increased over time. Analysis of 30-day postoperative mortality rates revealed advantages for laparoscopically treated patients, although the significance level was not reached in any age group. Regarding 5-year overall survival, laparoscopy generally seems to be the superior approach, whereas for recurrence-free survival, an age-dependent gradient in effect size was observed: with a hazard ratio (HR) of 0.703 for laparoscopy, patients under 60 years benefitted more from the minimally invasive approach than older patients (septuagenarians, HR 0.923). CONCLUSION Laparoscopy shows similar results to the open approach in terms of postoperative survival in all age groups. Concerning long-term outcomes, younger patients benefitted most from the minimally invasive approach.
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Affiliation(s)
- Teresa Draeger
- Tumorzentrum Regensburg - Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Am BioPark 9, 93053, Regensburg, Germany.
| | - Vinzenz Völkel
- Tumorzentrum Regensburg - Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Am BioPark 9, 93053, Regensburg, Germany
| | | | - Michael Gerken
- Tumorzentrum Regensburg - Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Am BioPark 9, 93053, Regensburg, Germany
| | - Stefan Benz
- Klinik für Allgemeine-, Viszeral- und Kinderchirurgie, Kliniken Böblingen, Bunsenstr. 120, 71032, Böblingen, Germany
| | - Monika Klinkhammer-Schalke
- Tumorzentrum Regensburg - Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Am BioPark 9, 93053, Regensburg, Germany
| | - Alois Fürst
- Klinik für Allgemein-, Viszeral-, Thoraxchirurgie und Adipositasmedizin, Caritas Krankenhaus St. Josef Regensburg, Landshuter Str. 65, 93053, Regensburg, Germany
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de'Angelis N, Pigneur F, Martínez-Pérez A, Vitali GC, Landi F, Gómez-Abril SA, Assalino M, Espin E, Ris F, Luciani A, Brunetti F. Assessing surgical difficulty in locally advanced mid-low rectal cancer: the accuracy of two MRI-based predictive scores. Colorectal Dis 2019; 21:277-286. [PMID: 30428156 DOI: 10.1111/codi.14473] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/29/2018] [Indexed: 02/08/2023]
Abstract
AIM Predicting surgical difficulty is a critical factor in the management of locally advanced rectal cancer (LARC). This study evaluates the accuracy and external validity of a recently published morphometric score to predict surgical difficulty and additionally proposes a new score to identify preoperatively LARC patients with a high risk of having a difficult surgery. METHODS This is a retrospective study based on the European MRI and Rectal Cancer Surgery (EuMaRCS) database, including patients with mid/low LARC who were treated with neoadjuvant chemoradiation therapy and laparoscopic total mesorectal excision (L-TME) with primary anastomosis. For all patients, pretreatment and restaging MRI were available. Surgical difficulty was graded as high and low based upon a composite outcome, including operative (e.g. duration of surgery) and postoperative variables (e.g. hospital stay). Score accuracy was assessed by estimating sensitivity, specificity and area under the receiver operating characteristic curve (AROC). RESULTS In a total of 136 LARC patients, 17 (12.5%) were graded as high surgical difficulty. The previously published score (calculated on body mass index, intertuberous distance, mesorectal fat area, type of anastomosis) showed low predictive value (sensitivity 11.8%; specificity 92.4%; AROC 0.612). The new EuMaRCS score was developed using the following significant predictors of surgical difficulty: body mass index > 30, interspinous distance < 96.4 mm, ymrT stage ≥ T3b and male sex. It demonstrated high accuracy (AROC 0.802). CONCLUSION The EuMaRCS score was found to be more sensitive and specific than the previous score in predicting surgical difficulty in LARC patients who are candidates for L-TME. However, this score has yet to be externally validated.
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Affiliation(s)
- N de'Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - F Pigneur
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - A Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - G C Vitali
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - F Landi
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - S A Gómez-Abril
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - M Assalino
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - E Espin
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - F Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - A Luciani
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - F Brunetti
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
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Kelley KA, Tsikitis VL. Review of Colorectal Studies Using the National Cancer Database. Clin Colon Rectal Surg 2019; 32:69-74. [PMID: 30647548 DOI: 10.1055/s-0038-1673356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The National Cancer Database (NCDB) is a large clinical oncology database developed with data collected from Commission on Cancer (CoC)-accredited facilities. The CoC is managed under the American College of Surgeons, and is a multidisciplinary team that maintains standards in cancer care delivery in health care settings. This database has been used in multiple cancer-focused studies and reports on cancer diagnosis, hospital-level, and patient-related demographics. The focus of this review is to explore and discuss the use of NCDB in colorectal surgery research. Furthermore, our aim for this review is to formulate a guide for researchers who are interested in using the NCDB to complete colorectal research.
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Affiliation(s)
- Katherine A Kelley
- Division of Gastrointestinal and General Surgery, Department of General Surgery, Oregon Health and Science University Portland, Portland, OR
| | - V Liana Tsikitis
- Division of Gastrointestinal and General Surgery, Department of General Surgery, Oregon Health and Science University Portland, Portland, OR
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Laparoscopic Versus Conventional Open Rectum Amputation: a Clinical, Intraoperative, and Short-term Outcome Comparative Study. JOURNAL OF INTERDISCIPLINARY MEDICINE 2018. [DOI: 10.2478/jim-2018-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective: To evaluate and compare laparoscopic and conventional open rectum amputation procedures using clinical, intraoperative, postoperative, and oncological criteria.
Methods: Fifty-nine patients with lower rectal and anorectal cancer were included in a retrospective study, conducted between 2014 and 2017. Patients underwent open or laparoscopic rectum amputation surgery and were divided into two groups: group 1 – laparoscopic amputation group (LAG) and group 2 – open amputation group (OAG). The clinical, intraoperative, and postoperative outcomes and oncological results were compared between the two groups.
Results: We found a significantly smaller intraoperative blood loss (325 mL vs. 538.29 mL, p = 0.0002), earlier return of bowel motility (2.41 days vs. 3.10 days, p = 0.036), shorter hospital stays (10.08 days vs. 12.66 days, p = 0.03), and a higher number of lymph nodes removed during surgery (12.33 nodes for LAG vs. 9.98 nodes for OAG, p = 0.049). In the open surgery group we found shorter durations of surgery (199.58 minutes for LAG vs. 157.87 minutes for OAG, p = 0.0046).
Conclusion: Laparoscopic rectum amputation is a technically demanding procedure. The present study demonstrates the benefits and disadvantages of this surgery, with comparable clinical, intraoperative, postoperative, and oncological results compared to the conventional open rectum amputation procedure.
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Rubinkiewicz M, Nowakowski M, Wierdak M, Mizera M, Dembiński M, Pisarska M, Major P, Małczak P, Budzyński A, Pędziwiatr M. Transanal total mesorectal excision for low rectal cancer: a case-matched study comparing TaTME versus standard laparoscopic TME. Cancer Manag Res 2018; 10:5239-5245. [PMID: 30464621 PMCID: PMC6219401 DOI: 10.2147/cmar.s181214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Transanal total mesorectal excision (TaTME) is emerging as a novel alternative to laparoscopic total mesorectal excision (LaTME). The aim of this study was to compare clinical and pathological results from these two techniques in patients undergoing rectal resections because of low rectal cancer. Materials and methods Thirty-five patients undergoing TaTME were matched with 35 patients operated on using LaTME. Composite primary endpoint (complete TME, negative circumferential resection margin [pCRM], and distal resection margin [pDRM]) was used to assess pathological quality specimens. Secondary outcomes included operative and postoperative parameters (operative time, total blood loss, postoperative morbidity, length of stay, 30-day mortality). Results Composite primary endpoint was achieved by 85% of subjects in the TaTME group and 82% of subjects in the LaTME group (P=0.66). Mean pCRM was 1.1±1.29 vs 0.99±0.78 mm (P=0.25). Distal pDRM was 1.57±0.92 and 1.98±1.22 cm (P=0.15). In the TaTME and LaTME groups, respectively, complete mesorectal excision was achieved in 89% and 83% of subjects, while excision was nearly complete for the remaining 11% and 17% (P=0.23). Conclusion TaTME appears to be a noninferior alternative to laparoscopic surgery. TaTME allows for quality retrieval of surgical specimens with comparable clinical outcomes with LaTME.
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Affiliation(s)
- Mateusz Rubinkiewicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland,
| | - Michał Nowakowski
- Department of Medical Education, Jagiellonian University Medical College, Krakow, Poland,
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Magdalena Mizera
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland,
| | - Marcin Dembiński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland,
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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Cleary RK, Morris AM, Chang GJ, Halverson AL. Controversies in Surgical Oncology: Does the Minimally Invasive Approach for Rectal Cancer Provide Equivalent Oncologic Outcomes Compared with the Open Approach? Ann Surg Oncol 2018; 25:3587-3595. [DOI: 10.1245/s10434-018-6740-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/15/2022]
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14
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de’Angelis N, Pigneur F, Martínez-Pérez A, Vitali GC, Landi F, Torres-Sánchez T, Rodrigues V, Memeo R, Bianchi G, Brunetti F, Espin E, Ris F, Luciani A. Predictors of surgical outcomes and survival in rectal cancer patients undergoing laparoscopic total mesorectal excision after neoadjuvant chemoradiation therapy: the interest of pelvimetry and restaging magnetic resonance imaging studies. Oncotarget 2018; 9:25315-25331. [PMID: 29861874 PMCID: PMC5982752 DOI: 10.18632/oncotarget.25431] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Locally advanced rectal cancer (LARC) requires a multimodal therapy tailored to the patient and tumor characteristics. Pretreatment magnetic resonance imaging (MRI) is necessary to stage the primary tumor, while restaging MRI, which is not systematically performed, may be of interest to identify poor responders to neoadjuvant chemoradiation therapy (NCRT), and redefine therapeutic approach. The EuMaRCS study group aimed to investigate the role and accuracy of pretreatment (including pelvimetry) and restaging MRIs in predicting surgical difficulties and surgical outcomes in LARC therapy. METHODS Patients with mid or low LARC who were administered NCRT, who underwent laparoscopic total mesorectal excision, and for whom pretreatment and restaging MRIs were available, were included. RESULTS MRIs of 170 patients (median age: 61 years) were reanalyzed by the same radiologist. Pelvimetry differed significantly between males and females, but no gender difference was noted in the clinical and tumor characteristics. Tumor volume and tumor height assessed on the restaging MRI were associated, respectively, with operative time and estimated blood loss. Conversion was predicted by tumor volume, interischial distance and pubic tubercle height. The quality of the surgical resection was found to be a predictor of overall and disease-free survival. The sensitivity and specificity of tumor regression grade 1 to identify a pathologic complete response were 76.9% and 89.3%, respectively. CONCLUSIONS In LARC management, pelvimetry and restaging MRI may be useful to predict surgical difficulties and surgical outcomes. However, the main independent predictor of patient survival appears to be the achievement of a successful surgical resection.
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Affiliation(s)
- Nicola de’Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Frederic Pigneur
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Aleix Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Giulio Cesare Vitali
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Filippo Landi
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Teresa Torres-Sánchez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Victor Rodrigues
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Riccardo Memeo
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Giorgio Bianchi
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Francesco Brunetti
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Eloy Espin
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Frederic Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Alain Luciani
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
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15
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Montemurro S, Ammendola M, Gallo G, Romano R, Condoluci A, Curto L, De Franciscis S, Serra R, Sacco R, Sammarco G. Sphincter-saving proctectomy for rectal cancer with NO COIL® transanal tube and without ostoma. Clinical outcomes, cost effectiveness and quality of life in the elderly. MINERVA CHIR 2018; 74:19-25. [PMID: 29658682 DOI: 10.23736/s0026-4733.18.07755-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Colorectal cancer is one of the most common invasive cancers, and it is responsible for considerable physical and psychosocial morbidity specially in older patients. However, only few reports focused on quality of life, cost-effectiveness and clinical outcomes of rectal cancer patients undergone to surgery. This retrospective study compares short-term and long-term outcomes in rectal cancer patients with more and less than 75 years of age. METHODS Four hundred consecutive patients underwent radical surgery for rectal adenocarcinoma and they were collected in a prospective institutional database and divided into two groups: group 1 (≥75 years, N.=98); group 2 (<75 years, N.=302). Rectal anterior resection (RAR) with sphincter-saving restorative proctectomy and with application of silicone transanal tube NO COIL® 60-80 mm long, was the only procedure considered. Main clinical and pathological data were assessed and compared. RESULTS Statistically significant differences between the two groups were detected regard to comorbidities and the emergency presentation. Overall survival is lower in patients over 75 age, but cancer-related survival is not different between the two groups. CONCLUSIONS Although advanced age is associated with higher morbidity and mortality, in our experience, itself is not a contraindication for surgical sphincter-saving proctetomy in rectal cancer patients. The absence of a stoma also improved the cost effectiveness and patients' quality of life in both groups: psychological morbidity, sexuality, levels of anxiety and depression, body image.
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Affiliation(s)
- Severino Montemurro
- Unit of Surgery, Giovanni Paolo II Research Center, National Cancer Institute, Bari, Italy
| | - Michele Ammendola
- Unit of Surgery, Giovanni Paolo II Research Center, National Cancer Institute, Bari, Italy - .,Unit of Clinical Surgery, Department of Medical and Surgical Sciences, Magna Graecia University Medical School, Catanzaro, Italy
| | - Gaetano Gallo
- Unit of Clinical Surgery, Department of Medical and Surgical Sciences, Magna Graecia University Medical School, Catanzaro, Italy
| | - Roberto Romano
- Unit of Clinical Surgery, Department of Medical and Surgical Sciences, Magna Graecia University Medical School, Catanzaro, Italy
| | - Antonietta Condoluci
- Unit of Clinical Surgery, Department of Medical and Surgical Sciences, Magna Graecia University Medical School, Catanzaro, Italy
| | - Lucia Curto
- Unit of Clinical Surgery, Department of Medical and Surgical Sciences, Magna Graecia University Medical School, Catanzaro, Italy
| | - Stefano De Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Rosario Sacco
- Unit of Clinical Surgery, Department of Medical and Surgical Sciences, Magna Graecia University Medical School, Catanzaro, Italy
| | - Giuseppe Sammarco
- Unit of Clinical Surgery, Department of Medical and Surgical Sciences, Magna Graecia University Medical School, Catanzaro, Italy
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Long-term oncologic outcomes after laparoscopic versus open rectal cancer resection: a high-quality population-based analysis in a Southern German district. Surg Endosc 2018; 32:4096-4104. [PMID: 29611044 PMCID: PMC6132875 DOI: 10.1007/s00464-018-6148-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 03/21/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND An increasing number of rectal carcinoma resections in Germany and worldwide are performed laparoscopically. The recently published COLOR II trial demonstrated the oncologic safety of this surgical approach. It remains unclear whether these findings can be transferred to clinical practice. PATIENTS AND METHODS This population-based retrospective cohort study aimed to evaluate 5-year overall, relative, disease-free, and local recurrence-free survival of rectal cancer patients treated by open surgery and laparoscopy. Data from a southern German region of 1.1 million inhabitants were collected by an official clinical cancer registry. All primary non-metastatic rectal adenocarcinoma cases with surgery between 2004 and 2013 were eligible for inclusion. To compare survival rates, Kaplan-Meier analyses, relative survival models, and multivariate Cox regression were applied; a sensitivity analysis assessed bias by exclusion. RESULTS Finally, 1507 patients with a median follow-up time of 7.1 years were included. Of these patients, 28.4% underwent laparoscopic procedures, with an increasing rate over time. Patients with tumors of the upper or middle rectum, younger patients, and patients of specialized colorectal cancer centers were more likely to undergo laparoscopy. After 5 years, 80.4% of laparoscopy patients were still alive, compared to 68.6% in the open group (p < 0.001). Moreover, laparoscopy was associated with superior local recurrence-free survival rates. This advantage was also significant in multivariate analysis (HR 0.70, 95% CI 0.52-0.92). CONCLUSION Laparoscopic rectal cancer surgery can be considered safe in daily clinical practice. This should be confirmed by future studies outside the setting of randomized trials.
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Abstract
OBJECTIVE National examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS). BACKGROUND Surgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined. METHODS Retrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan-Meier analyses were used to estimate long-term OS. RESULTS Of 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02-1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.037). Kaplan-Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198). CONCLUSION In the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.
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18
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Factors Influencing Difficulty of Laparoscopic Abdominoperineal Resection for Ultra-Low Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2017; 27:104-109. [PMID: 28212258 PMCID: PMC5378004 DOI: 10.1097/sle.0000000000000378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Our current study was conducted to identify patients' anatomic, pathologic, and clinical factors to predict difficulty of performing laparoscopic abdominoperineal resection for ultra-low rectal cancer. MATERIALS AND METHODS Records of 117 consecutive patients with rectal cancer 2 to 5 cm from the anal verge were retrospectively reviewed. Using univariate and multivariate linear or logistic regression models, standardized operative time and blood loss, as well as postoperative morbidity were utilized as endpoints to screen patients' multiple variables to predict operative difficulty. RESULTS Multivariate linear regression analysis showed body mass index (BMI) (estimate=0.07, P=0.0056), interspinous distance (estimate=-0.02, P=0.0011), tumor distance from anal verge (estimate=-0.17, P=0.0355), prior abdominal surgery (estimate=0.51, P=0.0180), preoperative chemoradiotherapy (estimate=0.67, P=0.0146), and concurrent diseases (hypertension and/or diabetes mellitus) (estimate=0.49, P=0.0122) are predictors for standardized operative time. Age (estimate=0.02, P=0.0208) and concurrent diseases (estimate=0.43, P=0.0476) were factors related to standardized blood loss. BMI (estimate=0.15, P=0.0472) was the only predictor for postoperative morbidity based on logistic regression analysis. CONCLUSIONS Age, BMI, interspinous distance, tumor distance from anal verge, prior abdominal surgery, preoperative chemoradiotherapy, and concurrent diseases influence the difficulty of performing laparoscopic abdominoperineal resection for ultra-low rectal cancer. Standardized operative time allows researchers to amass samples by pooling data from all published studies, thus building reliable models to predict operative difficulty for clinical use.
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19
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Braunschmid T, Hartig N, Baumann L, Dauser B, Herbst F. Influence of multiple stapler firings used for rectal division on colorectal anastomotic leak rate. Surg Endosc 2017. [PMID: 28634627 DOI: 10.1007/s00464‐017‐5611‐0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anastomotic leakage following colorectal resection remains one of the most significant complications with relevant morbidity and mortality. There is evidence that a higher number of stapler firings for rectal division can affect the leak rate in double stapling anastomosis. However, there are no data concerning compression anastomosis. We present our institutional experience addressing this issue. DESIGN This is a retrospective review of a prospective institutional database of patients undergoing colonic and rectal resection for benign and malignant indications between January 2008 and December 2014 at the surgical department of the St. John of God Hospital, Vienna. Inclusion criteria were rectal division with linear stapling devices and construction of anastomosis to the rectal stump using a circular stapler or compression device. RESULTS Three hundred eighty two (196 female; 51.3%) patients were included. Mean age was 65.8 years (range: 18-95) Indications for the operation included diverticular disease (44.8%), colorectal carcinoma (51.6%), inflammatory bowel disease (1.8%), and adenoma (1.8%). A laparoscopic approach was employed in 334 cases (87.4%); in 170 patients (44.9%), a compression anastomosis was created. One, two, and three or more stapler cartridges were used for rectal division in 58.4, 33.5, and 8.1%, respectively. Male gender, neoadjuvant therapy, rectal cancer as an underlying disease, laparoscopic surgical approach, and duration of operation longer than 200 min are leading causes for the usage of more than one stapler cartridge. Overall leak rate was 4.7% (18/382). The only factor associated with the occurrence of leakage was the use of three or more stapler cartridges for the closure of the rectal stump (p = 0.002). CONCLUSION Our data support that multiple stapler firings for rectal division following colorectal resection has a major impact on anastomotic leak rate. Especially in laparoscopic surgery efforts should be made to minimize the number of stapler cartridges used.
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Affiliation(s)
- Tamara Braunschmid
- Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Nikolaus Hartig
- Department of Surgery, St. John of God Hospital, Vienna, Austria
| | - Lukas Baumann
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Bernhard Dauser
- Department of Surgery, St. John of God Hospital, Vienna, Austria
| | - Friedrich Herbst
- Department of Surgery, St. John of God Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
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20
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Braunschmid T, Hartig N, Baumann L, Dauser B, Herbst F. Influence of multiple stapler firings used for rectal division on colorectal anastomotic leak rate. Surg Endosc 2017. [PMID: 28634627 PMCID: PMC5715046 DOI: 10.1007/s00464-017-5611-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leakage following colorectal resection remains one of the most significant complications with relevant morbidity and mortality. There is evidence that a higher number of stapler firings for rectal division can affect the leak rate in double stapling anastomosis. However, there are no data concerning compression anastomosis. We present our institutional experience addressing this issue. DESIGN This is a retrospective review of a prospective institutional database of patients undergoing colonic and rectal resection for benign and malignant indications between January 2008 and December 2014 at the surgical department of the St. John of God Hospital, Vienna. Inclusion criteria were rectal division with linear stapling devices and construction of anastomosis to the rectal stump using a circular stapler or compression device. RESULTS Three hundred eighty two (196 female; 51.3%) patients were included. Mean age was 65.8 years (range: 18-95) Indications for the operation included diverticular disease (44.8%), colorectal carcinoma (51.6%), inflammatory bowel disease (1.8%), and adenoma (1.8%). A laparoscopic approach was employed in 334 cases (87.4%); in 170 patients (44.9%), a compression anastomosis was created. One, two, and three or more stapler cartridges were used for rectal division in 58.4, 33.5, and 8.1%, respectively. Male gender, neoadjuvant therapy, rectal cancer as an underlying disease, laparoscopic surgical approach, and duration of operation longer than 200 min are leading causes for the usage of more than one stapler cartridge. Overall leak rate was 4.7% (18/382). The only factor associated with the occurrence of leakage was the use of three or more stapler cartridges for the closure of the rectal stump (p = 0.002). CONCLUSION Our data support that multiple stapler firings for rectal division following colorectal resection has a major impact on anastomotic leak rate. Especially in laparoscopic surgery efforts should be made to minimize the number of stapler cartridges used.
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Affiliation(s)
- Tamara Braunschmid
- Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Nikolaus Hartig
- Department of Surgery, St. John of God Hospital, Vienna, Austria
| | - Lukas Baumann
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Bernhard Dauser
- Department of Surgery, St. John of God Hospital, Vienna, Austria
| | - Friedrich Herbst
- Department of Surgery, St. John of God Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
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Cao X, Zhao G, Yu T, An Q, Yang H, Xiao G. Preoperative Prognostic Nutritional Index Correlates with Severe Complications and Poor Survival in Patients with Colorectal Cancer Undergoing Curative Laparoscopic Surgery: A Retrospective Study in a Single Chinese Institution. Nutr Cancer 2017; 69:454-463. [PMID: 28287320 DOI: 10.1080/01635581.2017.1285038] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Xianglong Cao
- Department of General Surgery, Beijing Hospital, Beijing, China
| | - Gang Zhao
- Department of General Surgery, Beijing Hospital, Beijing, China
| | - Tao Yu
- Department of General Surgery, Beijing Hospital, Beijing, China
| | - Qi An
- Department of General Surgery, Beijing Hospital, Beijing, China
| | - Hua Yang
- Department of General Surgery, Beijing Hospital, Beijing, China
| | - Gang Xiao
- Department of General Surgery, Beijing Hospital, Beijing, China
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22
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Leo CA, Samaranayake S, Perry-Woodford ZL, Vitone L, Faiz O, Hodgkinson JD, Shaikh I, Warusavitarne J. Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery. Colorectal Dis 2016; 18:1162-1166. [PMID: 27110866 DOI: 10.1111/codi.13359] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/18/2016] [Indexed: 12/13/2022]
Abstract
AIM Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP). METHOD Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment. RESULTS The procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2 weeks postoperatively. CONCLUSION This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.
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Affiliation(s)
- C A Leo
- St Mark's Hospital Academic Institute, Harrow, UK
| | | | | | - L Vitone
- St Mark's Hospital Academic Institute, Harrow, UK
| | - O Faiz
- St Mark's Hospital Academic Institute, Harrow, UK
| | | | - I Shaikh
- St Mark's Hospital Academic Institute, Harrow, UK
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Multicentre propensity score-matched analysis of laparoscopic versus open surgery for T4 rectal cancer. Surg Endosc 2016; 31:3106-3121. [PMID: 27826780 DOI: 10.1007/s00464-016-5332-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The use of laparoscopy for advanced-stage rectal cancer remains controversial. This study aimed to compare the operative and oncologic outcomes of laparoscopic (LAR) versus open anterior rectal resection (OAR) for patients with pT4 rectal cancer. METHODS This is a multicenter propensity score matching (PSM) study of patients undergoing elective curative-intent LAR or OAR for pT4 rectal cancer (TNM stage II/III/IV) between 2005 and 2015. RESULTS In total, 137 patients were included in the analysis. After PSM, demographic, clinical and tumor characteristics were similar between the 52 LAR and the 52 OAR patients. Overall, 52 tumors were located in the high rectum, 25 in the mid-rectum and 27 in the low rectum. Multivisceral resection was performed in 26.9% of LAR and 30.8% of OAR patients (p = 0.829). Conversion was required in 11 LAR patients (21.2%). The LAR group showed significantly shorter time to flatus (3.13 vs. 4.97 days, p = 0.001), time to regular diet (3.59 vs. 6.36 days, p < 0.0001) and hospital stay (15.49 vs. 17.96 days, p = 0.002) compared to the OAR group. The 90-day morbidity and mortality were not different between groups. In the majority of patients (85.6%), R0 resection was achieved. A complete mesorectal excision was obtained in 82.7% of LAR and 78.8% of OAR patients (p = 0.855). The 1-, 2- and 3-year overall survival rates were, respectively, 95.6, 73.8 and 66.7% for the LAR group and 86.7, 66.9 and 64.1% for the OAR group (p = 0.219). The presence of synchronous metastases (hazard ratio 2.26), R1 resection (HR 2.71) and lymph node involvement (HR 2.24) were significant predictors of overall survival. CONCLUSION The present study suggests that LAR for pT4 rectal cancer can achieve good pathologic and oncologic outcomes similar to open surgery despite the risk of conversion. Moreover, laparoscopy offers the benefits of a faster recovery and a shorter hospital stay.
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Nakao T, Shimada M, Yoshikawa K, Higashijima J, Tokunaga T, Nishi M, Takasu C, Kashihara H, Suzuka I, Nishizaki T, Okitsu H, Yagi T, Miyake H, Miura M, Fukuyama M, Wada D, Bando Y. Propensity score-matched study of laparoscopic and open surgery for colorectal cancer in rural hospitals. J Gastroenterol Hepatol 2016; 31:1700-1704. [PMID: 26896303 DOI: 10.1111/jgh.13322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 02/12/2016] [Accepted: 02/14/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND AIM Various randomized clinical studies have suggested that short- and long-term outcomes of laparoscopic surgery (LAP) for colorectal cancer are comparable with those of open surgery (OP). However, these studies were performed in high-volume hospitals. The aim of the present study was to compare the outcomes of LAP versus OP for colorectal cancer in rural hospitals. METHODS This was a multicenter retrospective propensity score-matched case-control study of patients who underwent colorectal surgery from January 2004 to April 2009 in 10 hospitals in Japan. All patients underwent curative surgery for pathologically diagnosed stage II or III colorectal cancer. The primary end point was 5-year overall survival (OS). The secondary end points were disease-free survival (DFS) and postoperative complications. RESULTS In total, 319 patients who underwent LAP and 1020 patients who underwent OP were balanced to 261 pairs. There was no significant difference in the OS and DFS between two groups. The operation time was significantly shorter for OP than for LAP. Blood loss was significantly lower in LAP than in OP. There was no difference in intraoperative morbidity between the two groups. The postoperative morbidity was significantly lower in LAP than in OP. The hospital stay was significantly shorter in LAP than in OP. There was no significant difference in 90-day postoperative mortality. CONCLUSIONS Laparoscopic surgery may be a feasible option for colorectal cancer in rural hospitals.
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Affiliation(s)
- Toshihiro Nakao
- Department of Surgery, The University of Tokushima, Tokushima, Japan.
| | - Mitsuo Shimada
- Department of Surgery, The University of Tokushima, Tokushima, Japan
| | - Kozo Yoshikawa
- Department of Surgery, The University of Tokushima, Tokushima, Japan
| | - Jun Higashijima
- Department of Surgery, The University of Tokushima, Tokushima, Japan
| | - Takuya Tokunaga
- Department of Surgery, The University of Tokushima, Tokushima, Japan
| | - Masaaki Nishi
- Department of Surgery, The University of Tokushima, Tokushima, Japan
| | - Chie Takasu
- Department of Surgery, The University of Tokushima, Tokushima, Japan
| | - Hideya Kashihara
- Department of Surgery, The University of Tokushima, Tokushima, Japan
| | - Ichio Suzuka
- Department of Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Takashi Nishizaki
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Hiroshi Okitsu
- Department of Surgery, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Toshiyuki Yagi
- Department of Surgery, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Hidenori Miyake
- Department of Surgery, Tokushima Municipal Hospital, Tokushima, Japan
| | - Murato Miura
- Department of Surgery, Yoshinogawa Medical Center, Yoshinogawa, Japan
| | - Mitsutoshi Fukuyama
- Department of Surgery, National Hospital Organization Kochi National Hospital, Kochi, Japan
| | - Daisuke Wada
- Department of Surgery, Takamatsu Municipal Hospital, Takamatsu, Japan
| | - Yoshiaki Bando
- Department of Surgery, Tokushima Prefecture Naruto Hospital, Tokushima, Japan
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Chand M, Moran B, Wexner SD. Which technique to choose in the high-tech era of minimal-access rectal cancer surgery? Colorectal Dis 2016; 18:839-41. [PMID: 27120346 DOI: 10.1111/codi.13361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/29/2016] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Steve D Wexner
- Cleveland Clinic, Cleveland Clinic Boulevard, Weston, USA
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Characteristics of learning curve in minimally invasive ileal pouch-anal anastomosis in a single institution. Surg Endosc 2016; 31:1083-1092. [DOI: 10.1007/s00464-016-5068-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 06/20/2016] [Indexed: 02/07/2023]
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Chand M, Engledow AH. Does ‘open’ surgery remain the gold standard in rectal cancer surgery? COLORECTAL CANCER 2016. [DOI: 10.2217/crc-2016-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Manish Chand
- Department of GI Surgery, University College London Hospital, 235 Euston Road, London, UK
| | - Alec H Engledow
- Department of GI Surgery, University College London Hospital, 235 Euston Road, London, UK
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Abstract
BACKGROUND Transanal mesorectal resection has been developed to facilitate minimally invasive proctectomy for rectal cancer. OBJECTIVE The purpose of this study was to evaluate the evidence regarding technical parameters, oncological outcomes, morbidity, and mortality after transanal mesorectal resection. DATA SOURCES The Cochrane Library, PubMed, and MEDLINE databases were reviewed. STUDY SELECTION Systematic review of the literature from January 2005 to September 2015 was used for study selection. INTERVENTION Intervention included transanal mesorectal resection for rectal cancer. MAIN OUTCOME MEASURES Technical parameters, histological outcomes, morbidity, and mortality were the outcomes measured. RESULTS Fifteen predominately retrospective studies involving 449 patients were included (mean age, 64.3 years; 64.1% men). Different platforms were used. The operative mortality rate was 0.4% and the cumulative morbidity rate 35.5%. Circumferential resection margins were clear in 98%, and the resected mesorectum was grade III in 87% of patients. Median follow-up was 14.7 months. There were 4 local recurrences (1.5%) and 12 patients (5.6%) with metastatic disease. No study followed patients long enough to report on 5-year overall and disease-free survival rates. Functional outcome was only reported in 3 studies. LIMITATIONS A low number of procedures were performed by expert early adopters. There are no comparative or randomized data included in this study and inconsistent reporting of outcome variables. CONCLUSIONS Transanal mesorectal resection for rectal cancer may enhance negative circumferential margin rates with a reasonable safety profile. Contemporary randomized, controlled studies are required before there can be universal recommendation.
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Chen W, Li Q, Fan Y, Li D, Jiang L, Qiu P, Tang L. Factors Predicting Difficulty of Laparoscopic Low Anterior Resection for Rectal Cancer with Total Mesorectal Excision and Double Stapling Technique. PLoS One 2016; 11:e0151773. [PMID: 26992004 PMCID: PMC4798689 DOI: 10.1371/journal.pone.0151773] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 03/03/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Laparoscopic sphincter-preserving low anterior resection for rectal cancer is a surgery demanding great skill. Immense efforts have been devoted to identifying factors that can predict operative difficulty, but the results are inconsistent. OBJECTIVE Our study was conducted to screen patients' factors to build models for predicting the operative difficulty using well controlled data. METHOD We retrospectively reviewed records of 199 consecutive patients who had rectal cancers 5-8 cm from the anal verge. All underwent laparoscopic sphincter-preserving low anterior resections with total mesorectal excision (TME) and double stapling technique (DST). Data of 155 patients from one surgeon were utilized to build models to predict standardized endpoints (operative time, blood loss) and postoperative morbidity. Data of 44 patients from other surgeons were used to test the predictability of the built models. RESULTS Our results showed prior abdominal surgery, preoperative chemoradiotherapy, tumor distance to anal verge, interspinous distance, and BMI were predictors for the standardized operative times. Gender and tumor maximum diameter were related to the standardized blood loss. Temporary diversion and tumor diameter were predictors for postoperative morbidity. The model constructed for the operative time demonstrated excellent predictability for patients from different surgeons. CONCLUSIONS With a well-controlled patient population, we have built a predictable model to estimate operative difficulty. The standardized operative time will make it possible to significantly increase sample size and build more reliable models to predict operative difficulty for clinical use.
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Affiliation(s)
- Weiping Chen
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, China
- * E-mail:
| | - Qiken Li
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, China
| | - Yongtian Fan
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, China
| | - Dechuan Li
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, China
| | - Lai Jiang
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, China
| | - Pengnian Qiu
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, China
| | - Lilong Tang
- Department of Radiology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, China
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Robotic Low Anterior Resection for Rectal Cancer: A National Perspective on Short-term Oncologic Outcomes. Ann Surg 2016; 262:1040-5. [PMID: 25405559 DOI: 10.1097/sla.0000000000001017] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE This study examines short-term outcomes and pathologic surrogates of oncologic results among patients undergoing robotic versus laparoscopic low anterior resection for rectal cancer. A total of 6403 patients met inclusion criteria. Although the robotic approach required significantly fewer conversions to open, surrogates for proper oncologic surgery were nearly identical between the 2 approaches. BACKGROUND Although laparoscopic low anterior resection (LLAR) has gained popularity as an acceptable approach, the robotic low anterior resection (RLAR) remains largely unproven. We compared short-term oncologic outcomes between rectal cancer patients undergoing either RLAR or LLAR. STUDY DESIGN All patients with rectal cancer in the National Cancer Data Base undergoing RLAR or LLAR from 2010 to 2011 were included. Predictors of RLAR were modeled with multivariable logistic regression. Groups were matched on propensity to undergo RLAR. Primary endpoints included lymph node retrieval and margin status, whereas secondary 30-day outcomes were mortality, hospital length of stay (LOS), and unplanned readmission rates. RESULTS A total of 6403 patients met inclusion criteria, of which 956 (14.9%) underwent RLAR. RLAR patients were more likely to be treated at academic centers, receive neoadjuvant therapy, and have higher T-stage and longer time to surgery (all P < 0.001). Neoadjuvant therapy and treatment at an academic/research center remained the only significant predictors of robotic use after multivariable adjustment. After propensity matching, RLAR was associated with lower conversion (9.5 vs 16.4%, P < 0.001). There were no significant differences in lymph node retrieval, margin status, 30-day mortality, readmission, or hospital LOS. CONCLUSIONS In this largest series to date, we demonstrated equivalent perioperative safety and patient outcomes for robotic compared to LLAR in the setting of rectal cancer. Although the robotic approach required significantly fewer conversions to open, surrogates for proper oncologic surgery were nearly identical between the 2 approaches, suggesting that a robotic approach may be a suitable alternative. Further studies comparing long-term cancer recurrence and survival should be performed.
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