1
|
Gachabayov M, Lee H, Kajmolli A, Felsenreich DM, Bergamaschi R. Impact of robotic total mesorectal excision upon pathology metrics in overweight males with low rectal cancer: a pooled analysis of 836 cases. Updates Surg 2024; 76:505-512. [PMID: 38147292 DOI: 10.1007/s13304-023-01733-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/12/2023] [Indexed: 12/27/2023]
Abstract
The aim of this pooled analysis was to evaluate the impact of robotic total mesorectal excision (TME) on pathology metrics in Male Overweight patients with Low rectal cancer (MOL). This was a multicenter retrospective pooled analysis of data. Two groups were defined: MOL (Male, Overweight, Low rectal cancer) and non-MOL. Overweight was defined as BMI ≥ 25 kg/m2. Low rectal cancer was defined as cancer within 6 cm from the anal verge. The primary endpoints of this study were histopathological metrics, namely circumferential resection margin (CRM) (mm), CRM involvement rate (%), and the quality of TME. Circumferential resection margin (CRM) was involved if < 1 mm. 836 (106 MOL and 730 non-MOL) patients that underwent robotic TME by six surgeons over 3 years were compared. No significant differences in demographics and perioperative variables were found, except for operating time, distal margin, and number of lymph nodes harvested. CRM involvement rate did not significantly differ (7.5% vs. 5.5%, p = 0.395). Mean CRM was statistically significantly narrower in MOL patients (6.6 vs. 7.7 mm, p = 0.04). Quality of TME did not differ. Distance of tumor from the anal verge was the only independent predictor of CRM involvement. Robotic TME may provide optimal pathology metrics in overweight males with low rectal cancer. Although CRM was a few millimeters narrower in MOL, the values were within the range of uninvolved margins making the difference statistically significant, but not clinically. Being MOL was not a risk factor for involvement of circumferential resection margin.
Collapse
Affiliation(s)
- Mahir Gachabayov
- Section of Colorectal Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Hanjoo Lee
- Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrence, CA, USA
| | - Agon Kajmolli
- Section of Colorectal Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Daniel M Felsenreich
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Roberto Bergamaschi
- Section of Colorectal Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA.
| |
Collapse
|
2
|
Barzola E, Cornejo L, Gómez N, Pigem A, Julià D, Ortega N, Delisau O, Bobb KA, Farrés R, Planellas P. Comparative analysis of short-term outcomes and oncological results between robotic-assisted and laparoscopic surgery for rectal cancer by multiple surgeon implementation: a propensity score-matched analysis. J Robot Surg 2023; 17:3013-3023. [PMID: 37924415 DOI: 10.1007/s11701-023-01736-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/26/2023] [Indexed: 11/06/2023]
Abstract
Robotic-assisted surgery (RAS) is becoming increasingly common for the surgical treatment of rectal cancer. However, the use and implementation of robotic surgery remains controversial. This study aimed to compare the short-term outcomes of robotic surgery, focusing on pathological results and disease-free survival (DFS), in our cohort with initial robotic experience by multiple surgeon implementation. This retrospective study enrolled 571 patients diagnosed with rectal cancer, who were treated with chemoradiotherapy and surgery between January 2015 and December 2021. Surgical outcomes after RAS and laparoscopic surgery (LS) were compared using a propensity score-matching (PSM) analysis. After matching, 200 patients (100 in each group) were included. The median operative time was significantly longer in the RAS group than in the LS group (p < 0.001). The conversion and morbidity rates were similar between the groups. A significantly higher rate of complete mesorectal excision (92% vs. 72%; p = 0.001) and number of lymph nodes harvested (p = 0.009) was observed in the RAS group. There were no statistically significant differences between the groups regarding circumferential and distal resection margin involvement. The 3-year overall and disease-free survival rate was similar between the two groups (p = 0.849 and p = 0.582, respectively). Two patients in the LS group developed local recurrence and 27 patients (15.4%) developed metastatic disease. Multivariate analysis showed that tumor stage III was the only factor associated with disease-free survival (HR, 9.34; (95% CI 1.13-77.1), p = 0.038). RAS and LS showed similar outcomes in terms of perioperative, anatomopathological, and disease-free survival, after multiple surgeon implementations.
Collapse
Affiliation(s)
- E Barzola
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - L Cornejo
- Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Gómez
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - A Pigem
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - D Julià
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Ortega
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - O Delisau
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - K A Bobb
- Department of Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies-St. Augustine, Eric Williams Medical Sciences Complex, Mount Hope, Trinidad, West Indies, Trinidad and Tobago
| | - R Farrés
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - P Planellas
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain.
| |
Collapse
|
3
|
Flynn J, Larach JT, Kong JCH, Rahme J, Waters PS, Warrier SK, Heriot A. Operative and oncological outcomes after robotic rectal resection compared with laparoscopy: a systematic review and meta-analysis. ANZ J Surg 2023; 93:510-521. [PMID: 36214098 DOI: 10.1111/ans.18075] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most studies comparing robotic and laparoscopic surgery, show little difference in clinical outcomes to justify the expense. We systematically reviewed and pooled evidence from studies comparing robotic and laparoscopic rectal resection. METHOD Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), and Cochrane databases were searched for studies between 1996 and 2021 comparing clinical outcomes between laparoscopic and robotic rectal surgeries involving total mesorectal excision. Outcome measures included operative times, conversions to open, complications, recurrence and survival rates. RESULTS Fifty eligible studies compared outcomes between robotic and laparoscopic rectal resections; three were randomized trials. Pooled results showed significantly longer operating times for robotic surgery but lower conversion and complications rates, shorter lengths of stay in hospital, better rates of complete mesorectal resection and better three-year overall survival. However, the low number of randomized studies makes most data subject to bias. CONCLUSION Available evidence supports the safety and ongoing use of robotic rectal cancer surgery, while further high-quality evidence is sought to justify the expense.
Collapse
Affiliation(s)
- Julie Flynn
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jose T Larach
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Departamento de Cirugía Digestiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joseph C H Kong
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jessica Rahme
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- General Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Peadar S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| |
Collapse
|
4
|
Somashekhar SP, Saklani A, Dixit J, Kothari J, Nayak S, Sudheer OV, Dabas S, Goud J, Munikrishnan V, Sugoor P, Penumadu P, Ramachandra C, Mehendale S, Dahiya A. Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer. Front Oncol 2022; 12:1002530. [PMID: 36267970 PMCID: PMC9577482 DOI: 10.3389/fonc.2022.1002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework. Conclusion The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.
Collapse
Affiliation(s)
- S. P. Somashekhar
- Department of Surgical Oncology, Manipal Hospital, Bengaluru, Karnataka, India
- *Correspondence: S. P. Somashekhar,
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jagannath Dixit
- Department of GI Surgery, HCG Hospital, Bengaluru, Karnataka, India
| | - Jagdish Kothari
- Department of Surgical Oncology HCG Hospital, Ahmedabad, Gujarat, India
| | - Sandeep Nayak
- Department of Surgical Oncology, Fortis Hospital, Bengaluru, Karnataka, India
| | - O. V. Sudheer
- Department of GI Surgery and Surgical Oncology, Amrita Institute of Medical Science, Kochi, Kerala, India
| | - Surender Dabas
- Department of Surgical Oncology, BL Kapur-Max Superspeciality Hospital, Delhi, India
| | - Jagadishwar Goud
- Department of Surgical Oncology, AOI Hospital, Hyderabad, Telangana, India
| | | | - Pavan Sugoor
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - C. Ramachandra
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Shilpa Mehendale
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Akhil Dahiya
- Department of Clinical and Medical Affairs, Intuitive Surgical, California, CA, United States
| |
Collapse
|
5
|
Robotic-Assisted vs. Standard Laparoscopic Surgery for Rectal Cancer Resection: A Systematic Review and Meta-Analysis of 19,731 Patients. Cancers (Basel) 2021; 14:cancers14010180. [PMID: 35008344 PMCID: PMC8750860 DOI: 10.3390/cancers14010180] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Surgery remains a mainstay of combined modality treatment at patients with rectal cancer; however, there is a growing interest in using laparoscopic techniques (LG); including robotic-assisted techniques (RG). Therefore, we have prepared a meta-analysis of the literature regarding the safety and efficacy of robotic versus laparoscopic approaches in patients undergoing curative surgery for rectal cancer. The results indicate a number of advantages of RG in terms of both safety and efficacy. Operative time in the RG group was shorter and associated with a statistically significantly lower conversion of the procedure to open surgery. RG technique provided a shorter duration of hospital stay and lowered urinary risk retention. No differences were found between these techniques regarding TNM stage; N stage or lymph nodes harvested. Survival to hospital discharge or 30-day overall survival rate was 99.6% in RG vs. 98.8% for LG. Abstract Robotic-assisted surgery is expected to have advantages over standard laparoscopic approach in patients undergoing curative surgery for rectal cancer. PubMed, Cochrane Library, Web of Science, Scopus and Google Scholar were searched from database inception to 10 November 2021, for both RCTs and observational studies comparing robotic-assisted versus standard laparoscopic surgery for rectal cancer resection. Where possible, data were pooled using random effects meta-analysis. Forty-Two were considered eligible for the meta-analysis. Survival to hospital discharge or 30-day overall survival rate was 99.6% for RG and 98.8% for LG (OR = 2.10; 95% CI: 1.00 to 4.43; p = 0.05). Time to first flatus in the RG group was 2.5 ± 1.4 days and was statistically significantly shorter than in LG group (2.9 ± 2.0 days; MD = −0.34; 95%CI: −0.65 to 0.03; p = 0.03). In the case of time to a liquid diet, solid diet and bowel movement, the analysis showed no statistically significant differences (p > 0.05). Length of hospital stay in the RG vs. LG group varied and amounted to 8.0 ± 5.3 vs. 9.5 ± 10.0 days (MD = −2.01; 95%CI: −2.90 to −1.11; p < 0.001). Overall, 30-days complications in the RG and LG groups were 27.2% and 19.0% (OR = 1.11; 95%CI: 0.80 to 1.55; p = 0.53), respectively. In summary, robotic-assisted techniques provide several advantages over laparoscopic techniques in reducing operative time, significantly lowering conversion of the procedure to open surgery, shortening the duration of hospital stay, lowering the risk of urinary retention, improving survival to hospital discharge or 30-day overall survival rate.
Collapse
|
6
|
Valadão M, Cesar D, Véo CAR, Araújo RO, do Espirito Santo GF, Oliveira de Souza R, Aguiar S, Ribeiro R, de Castro Ribeiro HS, de Souza Fernandes PH, Oliveira AF. Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer. J Surg Oncol 2021; 125:194-216. [PMID: 34585390 DOI: 10.1002/jso.26676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice. OBJECTIVES The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence. METHODS Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts. RESULTS The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients. CONCLUSION These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.
Collapse
Affiliation(s)
- Marcus Valadão
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Daniel Cesar
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | - Rodrigo Otávio Araújo
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | | | - Samuel Aguiar
- Department of Surgical Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Reitan Ribeiro
- Department of Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
| | | | | | | |
Collapse
|
7
|
Outcomes of robotic-assisted vs conventional laparoscopic surgery among patients undergoing resection for rectal cancer: an observational single hospital study of 300 cases. J Robot Surg 2021; 16:179-187. [PMID: 33743145 DOI: 10.1007/s11701-021-01227-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
Robotic-assisted laparoscopic surgery attempts to facilitate rectal surgery in the narrow space of the pelvis. The aim of this study is to compare the outcomes of robotic versus laparoscopic surgery for rectal cancer. Monocentric retrospective study including 300 patients who underwent robotic (n = 178) or laparoscopic (n = 122) resection between Jan 2009 and Dec 2017 for high, mid and low rectal cancer. The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, except for sex and ASA status. There were no statistical differences between groups in the conversion rate to open surgery. Surgical morbidity and oncological quality did not differ in either group, except for the anastomosis leakage rate and the affected distal resection margin. There were no differences in overall survival rate between the laparoscopic and robotic group. Robotic surgery could provide some advantages over conventional laparoscopic surgery, such as three-dimensional views, articulated instruments, lower fatigue, lower conversion rate to open surgery, shorter hospital stays and lower urinary and sexual dysfunctions. On the other hand, robotic surgery usually implies longer operation times and higher costs. As shown in the ROLARR trial, no statistical differences in conversion rate were found between the groups in our study. When performed by experienced surgeons, robotic surgery for rectal cancer could be a safe and feasible option with no significant differences in terms of oncological outcomes in comparison to laparoscopic surgery.
Collapse
|
8
|
Abstract
Abstract
Introduction Minimally invasive surgery has revolutionized surgical management in the treatment of colorectal neoplasms, reducing morbidity and mortality, hospitalization, inactivity time and minimizing cost, as well as providing adequate oncological results when compared to the conventional approach. Robotic surgery, with Da Vinci Platform, emerges as a step ahead for its potentials. The objective of this article is to report the single institutional experience with the use of Da Vinci Platform in robotic colorectal surgeries performed at a reference center in oncological surgery in Brazil.
Materials and methods A retrospective cohort study was conducted based on the prospective database of patients from the institution submitted to robotic surgery for treatment of colorectal cancer from July 2012 to September 2017. Clinical and surgical variables were analyzed as predictors of morbidity and mortality.
Results A total of 117 patients underwent robotic surgery. The complications related to surgery occurred in 33 patients (28%), the most frequent being anastomotic fistula and surgical wound infection, which corresponded to 11% and 3%, respectively. Conversion rate was 1.7%. Median length of stay was 5 days. The only variable associated with increase of complications and death risk was BMI >30, with p-value of 0.038 and 0.027, respectively.
Conclusion Robotic surgery is safe and feasible for approaching colorectal cancer surgeries, presenting satisfactory results regarding length of hospital stay and rate of operative complications, as well as presenting a low rate of conversion. Obesity has been shown to be a risk factor for surgical complication in robotic colorectal surgery.
Collapse
|
9
|
Guo Y, Guo Y, Luo Y, Song X, Zhao H, Li L. Comparison of pathologic outcomes of robotic and open resections for rectal cancer: A systematic review and meta-analysis. PLoS One 2021; 16:e0245154. [PMID: 33439912 PMCID: PMC7806147 DOI: 10.1371/journal.pone.0245154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/23/2020] [Indexed: 02/07/2023] Open
Abstract
Objective The application of robotic surgery for rectal cancer is increasing steadily. The purpose of this meta-analysis is to compare pathologic outcomes among patients with rectal cancer who underwent open rectal surgery (ORS) versus robotic rectal surgery (RRS). Methods We systematically searched the literature of EMBASE, PubMed, the Cochrane Library of randomized controlled trials (RCTs) and nonrandomized controlled trials (nRCTs) comparing ORS with RRS. Results Fourteen nRCTs, including 2711 patients met the predetermined inclusion criteria and were included in the meta-analysis. Circumferential resection margin (CRM) positivity (OR: 0.58, 95% CI, 0.29 to 1.16, P = 0.13), number of harvested lymph nodes (WMD: −0.31, 95% CI, −2.16 to 1.53, P = 0.74), complete total mesorectal excision (TME) rates (OR: 0.93, 95% CI, 0.48 to 1.78, P = 0.83) and the length of distal resection margins (DRM) (WMD: −0.01, 95% CI, −0.26 to 0.25, P = 0.96) did not differ significantly between the RRS and ORS groups. Conclusion Based on the current evidence, robotic resection for rectal cancer provided equivalent pathological outcomes to ORS in terms of CRM positivity, number of harvested lymph nodes and complete TME rates and DRM.
Collapse
Affiliation(s)
- Yinyin Guo
- Lanzhou University Second Hospital, Lanzhou, China
| | - Yichen Guo
- Department of Emergency, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yanxin Luo
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xia Song
- Lanzhou University Second Hospital, Lanzhou, China
| | - Hui Zhao
- Lanzhou University Second Hospital, Lanzhou, China
- * E-mail: (LL); (HZ)
| | - Laiyuan Li
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
- * E-mail: (LL); (HZ)
| |
Collapse
|
10
|
Su WC, Huang CW, Ma CJ, Chen PJ, Tsai HL, Chang TK, Chen YC, Li CC, Yeh YS, Wang JY. Feasibility of robot-assisted surgery in elderly patients with rectal cancer. J Minim Access Surg 2021; 17:165-174. [PMID: 33723180 PMCID: PMC8083738 DOI: 10.4103/jmas.jmas_154_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background: Although surgical resection is the main treatment for rectal cancer, the optimal surgical protocol for elderly patients with rectal cancer remains controversial. This study evaluated the feasibility of robot-assisted surgery in elderly patients with rectal cancer. Patients and Methods: This retrospective study enrolled 156 patients aged 28–93 years diagnosed with Stage I–III rectal cancer, who underwent robot-assisted surgery between May 2013 and December 2018 at a single institution. Results: In total, 156 patients with rectal cancer, including 126 non-elderly (aged < 70 years) and 30 elderly (aged ≥70 years) patients, who underwent robot-assisted surgery were recruited. Between the patient groups, the post-operative length of hospital stay did not differ statistically significantly (P = 0.084). The incidence of overall post-operative complications was statistically significantly lower in the elderly group (P = 0.002). The disease-free and overall survival did not differ statistically significantly between the two groups (P = 0.719 and 0.390, respectively). Conclusions: Robot-assisted surgery for rectal cancer was well tolerated by elderly patients, with similar results to the non-elderly patients. Oncological outcomes and survival did not depend on patient age, suggesting that robot-assisted surgery is a feasible surgical modality for treating operable rectal cancer and leads to age-independent post-operative outcomes in elderly patients.
Collapse
Affiliation(s)
- Wei-Chih Su
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Department of Surgery, Division of Colorectal Surgery; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Jen Ma
- Department of Surgery, Division of Colorectal Surgery; Department of Surgery, Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Jung Chen
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Department of Surgery, Division of Colorectal Surgery, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Department of Surgery, Division of Colorectal Surgery; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Kun Chang
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Cheng Chen
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Chun Li
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yung-Sung Yeh
- Department of Surgery, Division of Colorectal Surgery; Department of Surgery, Division of Trauma and Surgical Critical Care, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Department of Surgery, Division of Colorectal Surgery; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital; Graduate Institute of Clinical Medicine, College of Medicine; Graduate Institute of Medicine, College of Medicine; Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
11
|
Achilli P, Radtke TS, Lovely JK, Behm KT, Mathis KL, Kelley SR, Merchea A, Colibaseanu DT, Larson DW. Preoperative predictive risk to cancer quality in robotic rectal cancer surgery. Eur J Surg Oncol 2020; 47:317-322. [PMID: 32928609 DOI: 10.1016/j.ejso.2020.08.019] [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: 03/13/2020] [Revised: 06/30/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery. METHODS This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated. RESULTS A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35-36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33-17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72-33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present. CONCLUSION Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes.
Collapse
Affiliation(s)
- Pietro Achilli
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
| | | | - Jenna K Lovely
- Reporting and Analytics, Mayo Clinic, Rochester, MN, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
12
|
Hsieh C, Cologne KG. Laparoscopic Approach to Rectal Cancer-The New Standard? Front Oncol 2020; 10:1239. [PMID: 32850374 PMCID: PMC7412716 DOI: 10.3389/fonc.2020.01239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/16/2020] [Indexed: 12/20/2022] Open
Abstract
Minimally invasive surgery has revolutionized the way surgeons perform colorectal surgery, and new technologies continually upend the way surgeons view and operate within the deep pelvis. Among other benefits, it is associated with decreased lengths of stay, wound and surgical site infections, pain scores, and has an overall lower complication rate vs. open surgery (1). Recently, however, the role of minimally invasive surgery has been called into question in the effective and safe treatment of rectal cancer. This manuscript will outline the history of minimally invasive rectal cancer surgery, examine evidence detailing its safety (compared with alternatives), and discuss important aspects of use, most notably the considerable learning curve required to achieve proficiency, the extent of its current use, and potential pitfalls. The current evidence suggests minimally invasive surgery is a very safe way to treat rectal cancer when performed by experienced and specialty trained surgeons.
Collapse
Affiliation(s)
- Christine Hsieh
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Kyle G Cologne
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
13
|
Outcomes of Minimally Invasive Versus Open Proctectomy for Rectal Cancer: A Propensity-Matched Analysis of Bi-National Colorectal Cancer Audit Data. Dis Colon Rectum 2020; 63:778-787. [PMID: 32109916 DOI: 10.1097/dcr.0000000000001654] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Minimally invasive surgery is commonly used in the treatment of rectal cancer, despite the lack of evidence to support oncological equivalence or improved recovery compared with open surgery. OBJECTIVE This study aims to analyze prospectively collected data from a large Australasian colorectal cancer database. DESIGN This is a retrospective cohort study using propensity score matching. SETTING This study was conducted using data supplied by the Bi-National Colorectal Cancer Audit. PATIENTS A total of 3451 patients who underwent open (n = 1980), laparoscopic (n = 1269), robotic (n = 117), and transanal total mesorectal excision (n = 85) for rectal cancer were included in this study. MAIN OUTCOME MEASURE The primary outcome was positive margin rates (circumferential resection margin and/or distal resection margin) in patients treated with curative intent. RESULTS Propensity score matching yielded 1132 patients in each of the open and minimally invasive surgery groups. Margin positivity rates and lymph node yields did not differ between groups. The open group had a significantly lower total complication rate (27.6% vs 35.8%, p < 0.0001), including a lower rate of postoperative small-bowel obstruction (1.2% vs 2.5%, p = 0.03). The minimally invasive surgery group had significantly lower wound infection rate (2.9% vs 5.0%, p = 0.02) and a shorter length of hospital stay (8 vs 9 days, p < 0.0001). There was no difference in 30-day mortality. LIMITATIONS Results are limited by the quality of registry data entries. CONCLUSION In this patient population, minimally invasive proctectomy demonstrated similar margin rates in comparison with open proctectomy, with a reduced length of stay but a higher overall complication rate. See Video Abstract at http://links.lww.com/DCR/B190. RESULTADOS DE LA PROCTECTOMÍA MÍNIMA INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: UN ANÁLISIS DE PROPENSIÓN DE LOS DATOS BINACIONALES DE AUDITORÍA DEL CÁNCER COLORRECTAL: La cirugía mínima invasiva, frecuentemente se utiliza en el tratamiento del cáncer rectal, a pesar de la falta de evidencia que respalde la equivalencia oncológica o la mejor recuperación, en comparación con la cirugía abierta.El estudio tiene como objetivo analizar datos prospectivamente obtenidos, de una gran base de datos de cáncer colorrectal de Australia.Estudio de cohorte retrospectivo utilizando el emparejamiento de puntaje de propensión.Este estudio se realizó utilizando datos proporcionados por la Auditoría Binacional del Cáncer Colorrectal.Se incluyeron en este estudio un total de 3451 pacientes que se trataron de manera abierta (n = 1980), laparoscópica (n = 1269), robótica (n = 117) y taTME (n = 85) para cáncer rectal.Los resultados primarios fueron de tasas de margen positivas (margen de resección circunferencial y/o margen de resección distal) en pacientes con intención curativa.La coincidencia de puntaje de propensión arrojó 1132 pacientes en cada uno de los grupos de cirugía abierta y mínima invasiva. Las tasas de positividad del margen y los rendimientos de los ganglios linfáticos no difirieron entre los dos grupos. El grupo abierto tuvo una tasa de complicaciones totales significativamente menor (27.6% vs 35.8%, p <0.0001), incluida una tasa menor de obstrucción postoperatoria del intestino delgado (1.2% vs 2.5%, p = 0.03). El grupo de cirugía mínimamente invasiva tuvo una tasa de infección de la herida significativamente menor (2.9% frente a 5.0%, p = 0,02) y una estancia hospitalaria más corta (8 frente a 9 días, p <0.0001). No hubo diferencias en la mortalidad a los 30 días.Los resultados están limitados por la calidad de la entrada de datos de registro.En esta población de pacientes, la proctectomía mínima invasiva demostró tasas de margen similares en comparación con la proctectomía abierta, con una estadía reducida pero una tasa más alta de complicaciones en general. Consulte Video Resumen en http://links.lww.com/DCR/B190. (Traducción-Dr. Fidel Ruiz Healy).
Collapse
|
14
|
Ng KT, Tsia AKV, Chong VYL. Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis. World J Surg 2019; 43:1146-1161. [PMID: 30610272 DOI: 10.1007/s00268-018-04896-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Minimally invasive surgery has been considered as an alternative to open surgery by surgeons for colorectal cancer. However, the efficacy and safety profiles of robotic and conventional laparoscopic surgery for colorectal cancer remain unclear in the literature. The primary aim of this review was to determine whether robotic-assisted laparoscopic surgery (RAS) has better clinical outcomes for colorectal cancer patients than conventional laparoscopic surgery (CLS). METHODS All randomized clinical trials (RCTs) and observational studies were systematically searched in the databases of CENTRAL, EMBASE and PubMed from their inception until January 2018. Case reports, case series and non-systematic reviews were excluded. RESULTS Seventy-three studies (6 RCTs and 67 observational studies) were eligible (n = 169,236) for inclusion in the data synthesis. In comparison with the CLS arm, RAS cohort was associated with a significant reduction in the incidence of conversion to open surgery (ρ < 0.001, I2 = 65%; REM: OR 0.40; 95% CI 0.30,0.53), all-cause mortality (ρ < 0.001, I2 = 7%; FEM: OR 0.48; 95% CI 0.36,0.64) and wound infection (ρ < 0.001, I2 = 0%; FEM: OR 1.24; 95% CI 1.11,1.39). Patients who received RAS had a significantly shorter duration of hospitalization (ρ < 0.001, I2 = 94%; REM: MD - 0.77; 95% CI 1.12, - 0.41; day), time to oral diet (ρ < 0.001, I2 = 60%; REM: MD - 0.43; 95% CI - 0.64, - 0.21; day) and lesser intraoperative blood loss (ρ = 0.01, I2 = 88%; REM: MD - 18.05; 95% CI - 32.24, - 3.85; ml). However, RAS cohort was noted to require a significant longer duration of operative time (ρ < 0.001, I2 = 93%; REM: MD 38.19; 95% CI 28.78,47.60; min). CONCLUSIONS This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time. However, the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.
Collapse
Affiliation(s)
- Ka Ting Ng
- Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Malaysia.
| | - Azlan Kok Vui Tsia
- Department of Surgery, International Medical University, Bukit Jalil, 50603, Kuala Lumpur, Malaysia
| | - Vanessa Yu Ling Chong
- Department of Surgery, International Medical University, Bukit Jalil, 50603, Kuala Lumpur, Malaysia
| |
Collapse
|
15
|
Huang YM, Huang YJ, Wei PL. Colorectal Cancer Surgery Using the Da Vinci Xi and Si Systems: Comparison of Perioperative Outcomes. Surg Innov 2018; 26:192-200. [DOI: 10.1177/1553350618816788] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose. Robotic surgery for colorectal cancer is an emerging technique. Potential benefits as compared with the conventional laparoscopic surgery have been demonstrated. However, experience with the previous da Vinci Si robotic system revealed several unsolved problems. The novel features of the new da Vinci Xi increase operational flexibility and maneuverability and are expected to facilitate the performance of multiquadrant surgery. Methods. Between December 2011 and May 2015, 120 patients with colon or rectal cancer were operated on using the Si robotic system (the Si group). Between May 2015 and October 2017, 60 more patients with colon or rectal cancer were operated on using the Xi robotic system (the Xi group). The clinicopathological characteristics and perioperative outcomes of these 2 groups of patients were compared. Results. The 2 groups of patients were comparable with regard to baseline clinical characteristics, types of resection performed, and the proportion of patients undergoing neoadjuvant chemoradiation therapy. The statuses of resection margin, the numbers of lymph nodes harvested, and the rates of postoperative complications were also similar between the 2 groups. Nevertheless, a lower rate of diverting ileostomy, a shorter operation time, less estimated blood loss, and a faster postoperative recovery was observed in the Xi group. Conclusions. Colorectal cancer surgery using the Xi robotic system was associated with improved perioperative outcomes. These benefits may be attributed to its improved, more user-friendly design.
Collapse
Affiliation(s)
- Yu-Min Huang
- Taipei Medical University, Taiwan
- Taipei Medical University Hospital, Taiwan
| | - Yan Jiun Huang
- Taipei Medical University, Taiwan
- Taipei Medical University Hospital, Taiwan
| | - Po-Li Wei
- Taipei Medical University, Taiwan
- Taipei Medical University Hospital, Taiwan
| |
Collapse
|
16
|
Jones K, Qassem MG, Sains P, Baig MK, Sajid MS. Robotic total meso-rectal excision for rectal cancer: A systematic review following the publication of the ROLARR trial. World J Gastrointest Oncol 2018; 10:449-464. [PMID: 30487956 PMCID: PMC6247103 DOI: 10.4251/wjgo.v10.i11.449] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/25/2018] [Accepted: 06/29/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare outcomes in patients undergoing rectal resection by robotic total meso-rectal excision (RTME) vs laparoscopic total meso-rectal excision (LTME).
METHODS Standard medical electronic databases such as PubMed, MEDLINE, EMBASE and Scopus were searched to find relevant articles. The data retrieved from all types of included published comparative trials in patients undergoing RTME vs LTME was analysed using the principles of meta-analysis. The operative, post-operative and oncological outcomes were evaluated to assess the effectiveness of both techniques of TME. The summated outcome of continuous variables was expressed as standardized mean difference (SMD) and dichotomous data was presented in odds ratio (OR).
RESULTS One RCT (ROLARR trial) and 27 other comparative studies reporting the non-oncological and oncological outcomes following RTME vs LTME were included in this review. In the random effects model analysis using the statistical software Review Manager 5.3, the RTME was associated with longer operation time (SMD, 0.46; 95%CI: 0.25, 0.67; z = 4.33; P = 0.0001), early passage of first flatus (P = 0.002), lower risk of conversion (P = 0.00001) and shorter hospitalization (P = 0.01). The statistical equivalence was seen between RTME and LTME for non-oncological variables like blood loss, morbidity, mortality and re-operation risk. The oncological variables such as recurrence (P = 0.96), number of harvested nodes (P = 0.49) and positive circumferential resection margin risk (P = 0.53) were also comparable in both groups. The length of distal resection margins was similar in both groups.
CONCLUSION RTME is feasible and oncologically safe but failed to demonstrate any superiority over LTME for many surgical outcomes except early passage of flatus, lower risk of conversion and shorter hospitalization.
Collapse
Affiliation(s)
- Katie Jones
- Department of General and Laparoscopic Colorectal Surgery, Brighton and Sussex University Hospitals NHS Trust, the Royal Sussex County Hospital, Brighton, West Sussex BN2 5BE, United Kingdom
| | - Mohamed G Qassem
- Department of General and Laparoscopic Colorectal Surgery, Brighton and Sussex University Hospitals NHS Trust, the Royal Sussex County Hospital, Brighton, West Sussex BN2 5BE, United Kingdom
- Lecturer of General Surgery, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
| | - Parv Sains
- Department of General and Laparoscopic Colorectal Surgery, Brighton and Sussex University Hospitals NHS Trust, the Royal Sussex County Hospital, Brighton, West Sussex BN2 5BE, United Kingdom
| | - Mirza K Baig
- Department of General and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, West Sussex BN11 2DH, United Kingdom
| | - Muhammad S Sajid
- Department of General and Laparoscopic Colorectal Surgery, Brighton and Sussex University Hospitals NHS Trust, the Royal Sussex County Hospital, Brighton, West Sussex BN2 5BE, United Kingdom
| |
Collapse
|
17
|
Aselmann H, Kersebaum JN, Bernsmeier A, Beckmann JH, Möller T, Egberts JH, Schafmayer C, Röcken C, Becker T. Robotic-assisted total mesorectal excision (TME) for rectal cancer results in a significantly higher quality of TME specimen compared to the laparoscopic approach-report of a single-center experience. Int J Colorectal Dis 2018; 33:1575-1581. [PMID: 29971488 DOI: 10.1007/s00384-018-3111-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2018] [Indexed: 02/07/2023]
Abstract
AIM Robotic surgery allows for a better visualization and more precise dissection especially in the narrow male pelvis and mid and lower third of the rectum. However, superiority to laparoscopic TME has yet to be proven. We therefore analyzed short-term outcomes of laparoscopic and robotic low anterior rectal resection for rectal cancer. PATIENTS AND METHODS From 2011 to 2016, 44 robotic (RTME) and 41 laparoscopic (LTME) low anterior rectal resection with total mesorectal excision were performed at a single institution. Specimen quality was assessed and reported by an independent pathologist following international guidelines. RESULTS The groups did not differ significantly regarding gender, age, ASA stage, BMI, and distance of the lower tumor margin from the anal verge. More patients in the RTME group underwent preoperative chemoradiation (43.2 vs. 19.5%, p = 0.019). The quality of the TME specimen was significantly better in the RTME group (complete/nearly complete/incomplete for RTME 97/0/3% and for LTME 78/17/5%, p = 0.03). The conversion rate tended to be lower in the RTME group (7 vs. 17%, p = 0.143). There was no difference in CRM positivity between the groups. CONCLUSION Robotic surgery is safe and can improve the quality of TME for rectal cancer compared to laparoscopy. Any effect on long-term survival remains to be established.
Collapse
Affiliation(s)
- Heiko Aselmann
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Jan-Niclas Kersebaum
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Alexander Bernsmeier
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Jan Henrik Beckmann
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Thorben Möller
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Jan Hendrik Egberts
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Clemens Schafmayer
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Christoph Röcken
- Institut für Pathologie, Christian Albrechts Universität zu Kiel und Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Thomas Becker
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| |
Collapse
|
18
|
Khan JS, Banerjee AK, Kim SH, Rockall TA, Jayne DG. Robotic rectal surgery has advantages over laparoscopic surgery in selected patients and centres. Colorectal Dis 2018; 20:845-853. [PMID: 30101574 DOI: 10.1111/codi.14367] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/30/2018] [Indexed: 02/08/2023]
Affiliation(s)
- J S Khan
- Department of Colorectal Surgery, Queen Alexandra Hospital Portsmouth, Portsmouth, UK
| | - A K Banerjee
- Department of Colorectal Surgery, Queen Alexandra Hospital Portsmouth, Portsmouth, UK
| | - S-H Kim
- Colorectal Division, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - T A Rockall
- Minimal Access Therapy Training Unit (MATTU), Royal Surrey County Hospital NHS Trust, Guildford, UK
| | - D G Jayne
- The John Goligher Colorectal Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
19
|
Martin AN, Berry PS, Friel CM, Hedrick TL. Impact of minimally invasive surgery on short-term outcomes after rectal resection for neoplasm within the setting of an enhanced recovery program. Surg Endosc 2017; 32:2517-2524. [PMID: 29101566 DOI: 10.1007/s00464-017-5956-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 10/21/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) for rectal cancer has increased in recent years. Enhanced recovery (ER) protocols are associated with improved outcomes, such as decreased length of stay (LOS). We examined the impact of MIS and ER protocols on outcomes after rectal resection for neoplasm. METHODS A retrospective analysis was performed for patients undergoing elective open (OS) or MIS rectal resection for neoplasm from 2010 to 2015 at a single institution. MIS was defined as any laparoscopic or robotic procedure. An ER protocol was implemented in 8/2013. Regression models were used to estimate outcomes including LOS, 30-day morbidity, readmission, and hospital costs. RESULTS Among 325 patients, 252 (77.5%) underwent OS; 73 (22.5%) underwent MIS rectal resection. Prior to ER implementation, only 6.1% underwent MIS, compared to 23.1 and 54.4% in the 2 years following ER implementation (p < 0.001). Prior to ER implementation, median LOS was 7 days (n = 181) with 23.8% 30-day morbidity. Following ER implementation, median LOS was 4 days (n = 144); patients receiving OS had median LOS of 5.5 days (n = 82) and 30-day morbidity of 19.5%. ER patients receiving MIS had median LOS of 3 days (n = 62) and 30-day morbidity of 14.5%. Univariate regression demonstrated that MIS patients on ER protocol were more likely to have a shortened LOS (< 6 days) compared to OS patients on non-ER protocol (both p < 0.001). CONCLUSIONS The combination of MIS and ER protocol is significantly associated with reduced LOS for patients undergoing rectal resection for neoplasm. Further research is needed to determine which patients are best suited to MIS from an oncologic standpoint.
Collapse
Affiliation(s)
- Allison N Martin
- Department of Surgery, Section of Colon and Rectal Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA
| | - Puja Shah Berry
- Department of Surgery, Section of Colon and Rectal Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA
| | - Charles M Friel
- Department of Surgery, Section of Colon and Rectal Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA
| | - Traci L Hedrick
- Department of Surgery, Section of Colon and Rectal Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA.
| |
Collapse
|
20
|
Huang YM, Huang YJ, Wei PL. Outcomes of robotic versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiation therapy and the effect of learning curve. Medicine (Baltimore) 2017; 96:e8171. [PMID: 28984767 PMCID: PMC5738003 DOI: 10.1097/md.0000000000008171] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Randomized controlled trials have demonstrated that laparoscopic surgery for rectal cancer is safe and can accelerate recovery without compromising oncological outcomes. However, such a surgery is technically demanding, limiting its application in nonspecialized centers. The operational features of a robotic system may facilitate overcoming this limitation. Studies have reported the potential advantages of robotic surgery. However, only a few of them have featured the application of this surgery in patients with advanced rectal cancer undergoing neoadjuvant chemoradiation therapy (nCRT).From January 2012 to April 2015, after undergoing nCRT, 40 patients with mid or low rectal cancer were operated using the robotic approach at our institution. Another 38 patients who were operated using the conventional laparoscopic approach were matched to patients in the robotic group by sex, age, the body mass index, and procedure. All operations were performed by a single surgical team. The clinicopathological characteristics and short-term outcomes of these patients were compared. To assess the effect of the learning curve on the outcomes, patients in the robotic group were further subdivided into 2 groups according to the sequential order of their procedures, with an equal number of patients in each group. Their outcome measures were compared.The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, rectal resection type, and pathological examination result. After undergoing nCRT, more patients in the robotic group exhibited clinically advanced diseases. The complication rate was similar between the 2 groups. The operation time and the time to the resumption of a soft diet were significantly prolonged in the robotic group. Further analysis revealed that the difference was mainly observed in the first robotic group. No significant difference was observed between the second robotic and laparoscopic groups.Although the robotic approach may offer potential advantages for rectal surgery, comparable short-term outcomes may be achieved when laparoscopic surgery is performed by experienced surgeons. However, our results suggested a shorter learning curve for robotic surgery for rectal cancer, even in patients who exhibited more advanced disease after undergoing nCRT.
Collapse
Affiliation(s)
- Yu-Min Huang
- Department of Surgery, College of Medicine
- Division of Gastrointestinal Surgery, Department of Surgery
- Cancer Research Center
| | - Yan Jiun Huang
- Department of Surgery, College of Medicine
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital
| | - Po-Li Wei
- Department of Surgery, College of Medicine
- Cancer Research Center
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital
- Division of Colorectal Surgery, Department of Surgery, Wan Fang Hospital
- Translational Laboratory, Department of Medical Research, Taipei Medical University Hospital
- Graduate Institute of Cancer Biology and Drug Discovery, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
21
|
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.
Collapse
|
22
|
Odermatt M, Ahmed J, Panteleimonitis S, Khan J, Parvaiz A. Prior experience in laparoscopic rectal surgery can minimise the learning curve for robotic rectal resections: a cumulative sum analysis. Surg Endosc 2017; 31:4067-4076. [PMID: 28271267 DOI: 10.1007/s00464-017-5453-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/03/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The learning curve for robotic colorectal surgery is ill-defined. This study aimed to investigate the learning curve of experienced laparoscopic rectal surgeons when starting with robotic total mesorectal excision (TME) using cumulative sum (CUSUM) charts. METHODS This retrospective case series analysed patients who underwent curative and elective laparoscopic or robotic TMEs for rectal cancer performed by two surgeons. The first consecutive robotic TME cases of each surgeon were 1:1 propensity score matched to their laparoscopic TME cases using age, body mass index, American Society of Anesthesiologists grade, T stage (AJCC) and tumour location height. The matched laparoscopic cases defined individual standards for the quality indicators: operating time, R stage, lymph node harvest, length of hospital stay and major complications (Clavien-Dindo grade 3-5). Deviation of more than a quarter of a standard deviation from the mean for the continuous indicators, or exceeding the observed risk for the binary indicators was defined as off-target with an upward inflection in the CUSUM curve. RESULTS From 2006 to 2015, 384 (294 laparoscopic; 90 robotic) TMEs met the inclusion criteria. Surgeon A performed 206 (70.1%) of the laparoscopic and 43 (47.8%) of the robotic cases. Surgeon B performed 88 (29.9%) of the laparoscopic and 47 (52.2%) of the robotic cases. After matching, no covariate exhibited an absolute standardised mean difference >0.25. For surgeon A, the CUSUM curves showed no apparent learning process compared to his laparoscopic standards. For surgeon B, a learning process for operation time, lymph node harvest and major complications was demonstrated by an initial upward inflection of the CUSUM curves; after 15 cases, all quality indicators were generally on target. CONCLUSIONS For experienced laparoscopic colorectal surgeons, the formal learning process for robotic TME may be short to reach a similar performance level as obtained in conventional laparoscopy.
Collapse
Affiliation(s)
- Manfred Odermatt
- Minimally Invasive Colorectal Unit, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth, PO6 3LY, UK.
| | - Jamil Ahmed
- Poole Hospital NHS Foundation Trust, Poole, UK
| | | | - Jim Khan
- Minimally Invasive Colorectal Unit, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth, PO6 3LY, UK
| | - Amjad Parvaiz
- FRCS (Gen) FRCS, European Academy of Robotic Colorectal Surgery, Poole Hospital NHS Foundation Trust, Poole, UK.,Laparoscopic and Robotic Colorectal Surgery Champalimaud Foundation, Lisbon, Portugal
| |
Collapse
|
23
|
Qu ZW, Meng QB, Xiao XB, Chen HT, Zhao CX. Clinical application of laparoscopic cylindrical abdominoperineal resection and extraperitoneal sigmoidostomy for low rectal cancer. Shijie Huaren Xiaohua Zazhi 2016; 24:3309-3313. [DOI: 10.11569/wcjd.v24.i21.3309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the clinical efficacy of laparoscopic cylindrical abdominoperineal resection and extraperitoneal sigmoidostomy for low rectal cancer.
METHODS: We retrospectively analyzed the clinicopathological data for 25 low rectal cancer patients who underwent laparoscopic cylindrical abdominoperineal resection and extraperitoneal sigmoidostomy at the First Hospital of Wuhan from January 2013 to February 2015.
RESULTS: Laparoscopic surgery was successful in all the 25 cases. Operative time was 162.5 min ± 35.6 min, and intraoperative blood loss was 55.5 mL ± 26.8 mL. Fat liquefaction and infection at the perineal incision occurred in two cases. After a median follow-up of 25 mo (range, 3-36 mo), no recurrence occurred.
CONCLUSION: Laparoscopic cylindrical abdominoperineal resection plus extraperitoneal sigmoidostomy is feasible for low rectal cancer and is associated with few complications, low recurrence rate, and satisfactory short-term curative effect.
Collapse
|