Long-term outcomes of laparoscopic versus open D3 dissection for stage II/III colon cancer: Results of propensity score analyses

Oncological outcomes following minimally invasive surgery for pathological N2M0 colorectal cancer: A propensity score-matched analysis

INTRODUCTION

Whether minimally invasive surgery (MIS) is safe and effective for patients with N2M0 colorectal cancer (CRC) remains controversial. This study aimed to compare short- and long-term outcomes between MIS and open surgery (Open) groups for patients with pathological (p)N2M0 CRC, and evaluate the oncological outcomes of MIS for pN2M0 CRC.

MATERIALS AND METHODS

We retrospectively analyzed 125 consecutive patients with pN2M0 CRC who underwent curative surgery between 2010 and 2017, using propensity score-matching (PSM) analysis.

RESULTS

Median follow-up was 59.4 months. After PSM, we enrolled 68 patients (n = 34 in each group). The conversion rate was 9.6% for the entire patient cohort and 5.9% for the matched cohort. In colon cancer (CC), short-term outcomes were similar between groups. On the other hand, in rectal cancer (RC), estimated blood loss, rate of anastomosis leakage, and length of postsurgical stay were lower in the MIS group than the Open group. R0 resection was achieved in all patients with MIS. No surgical mortality was encountered in any group. No significant differences were found between groups in terms of 3-year local recurrence rate, overall survival, cancer-specific survival, or recurrence-free survival among the entire patient cohort or the matched cohort, regardless of the primary tumor site (CC or RC). Surgical approach (MIS vs Open) had no significant influence on survival outcomes.

CONCLUSIONS

MIS is a safe and effective option for patients with pN2M0 CRC, with acceptable short- and long-term outcomes comparable to the open approach. MIS can be considered for patients with pN2M0 CRC.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of Short-term Results after Laparoscopic Complete Mesocolic Excision and Standard Colectomy for Right-Sided Colon Cancer: Analysis of a Western Center Cohort

Purpose

Laparoscopic complete mesocolic excision (CME) right colectomy is a technically demanding procedure infrequently employed in Western centers. This retrospective cohort study aims to analyze the safety of laparoscopic CME colectomy compared to standard colectomy for right-sided colon cancer in a Western series.

Methods

Prospectively collected data from 60 patients who underwent laparoscopic CME right colectomy were compared to the ones of 55 patients who underwent laparoscopic standard right colectomy.

Results

No differences in clinical characteristics were observed between the CME and standard right colectomy groups. No differences were demonstrated in terms of blood loss (P = 0.060), intraoperative complications (P = 1), conversion rate (P = 0.102), and operative time (P = 0.473). No deaths were observed in either group, while complication rate was 40.0% in the CME and 49.1% in the standard group (P = 0.353). Severe complications occurred in 10.0% vs. 9.1% (P = 0.842), redo surgery in 5.0% vs. 7.3% (P = 0.708), and unplanned readmission in 5.0% vs. 5.5% (P = 1) after CME and standard colectomy, respectively. A significant difference in favor of CME was observed in the total length of specimen (P < 0.001), proximal (P = 0.018), and distal margins (P = 0.037). The number of lymph nodes harvested was significantly higher in the CME group (27 vs. 22, P = 0.037).

Conclusion

In Western series, where patients have less favorable clinical characteristics, laparoscopic CME allows to obtain better quality surgical specimens and comparable short-term outcomes compared to standard right colectomy.

Laparoscopic gastrectomy plus D2 lymphadenectomy is as effective as open surgery in terms of long-term survival: a single-institution study on gastric cancer

BACKGROUND

Laparoscopic surgery has been widely accepted to treat early-stage gastric cancer. However, it is still controversial to perform laparoscopic gastrectomy plus D2 lymphadenectomy for locally advanced gastric cancer. We performed the present study to compare the long-term outcomes of patients after laparoscopic or open gastrectomy plus D2 lymphadenectomy.

METHODS

The clinicopathological data of 182 gastric cancer patients receiving gastrectomy plus D2 lymphadenectomy between January 2011 and December 2015 at Shenzhen Traditional Chinese Medicine Hospital were retrospectively retrieved. The overall survival (OS) and disease-free survival (DFS) of these 182 patients were compared. Then, the prognostic significance of positive lymph node ratio (LNR) was assessed.

RESULTS

As a whole, OS (P = 0.789) and DFS (P = 0.672) of patients receiving laparoscopic gastrectomy plus D2 lymphadenectomy were not significantly different from those of patients receiving open surgery. For stage I patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.573) and DFS (P = 0.157). Similarly, for stage II patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.567) and DFS (P = 0.830). For stage III patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.773) and DFS (P = 0.404). Laparoscopic or open gastrectomy plus D2 lymphadenectomy was not proven by Cox regression analysis to be an independent prognostic factor for OS and DFS. High LNR was significantly associated with worse OS (P < 0.001) and DFS (P < 0.001). Surgical type did not significantly affect prognosis of patients with low LNR or survival of patients with high LNR.

CONCLUSIONS

For patients with gastric cancer, laparoscopic gastrectomy plus D2 lymphadenectomy was not inferior to open surgery in terms of long-term outcomes. LNR is a useful prognostic marker for GC patients.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTINGS

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

PATIENTS

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

INTERVENTIONS

Surgical resection of N2 colorectal cancer was performed.

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

Postoperative, but not preoperative, inflammation-based prognostic markers are prognostic factors in stage III colorectal cancer patients

Background

Recent evidence suggests that both preoperative and postoperative inflammation-based prognostic markers are useful for predicting the survival of colorectal cancer (CRC) patients. However, associations between longitudinal changes in inflammation-based prognostic markers and prognosis are controversial.

Methods

The subjects of this study were 568 patients with stage III CRC between 2008 and 2014. Preoperative and postoperative neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), C-reactive protein/albumin ratio (CAR) and lymphocyte-to-C-reactive protein ratio (LCR) were calculated to assess the inflammatory state of subjects. Subjects were stratified into three groups for each marker: preoperatively low inflammatory state (normal group), preoperatively high but postoperatively low inflammatory state (normalised group) and persistently high inflammatory state (elevated group). Multivariable analyses for overall survival (OS) and recurrence-free survival (RFS) were performed to adjust for well-established clinicopathologic factors.

Results

For all assessed markers, the normalised group had a significantly better prognosis than the elevated group and a similar prognosis as the normal group for both OS and RFS.

Conclusions

Postoperative, but not preoperative, inflammation-based prognostic markers more accurately predict OS and RFS in patients with stage III CRC.

Prognostic impact of primary tumor location in Stage III colorectal cancer-right-sided colon versus left-sided colon versus rectum: a nationwide multicenter retrospective study

BACKGROUND

Previous studies investigating the impact of tumor location on colorectal cancer prognosis only compared two groups by location, e.g., 'right-sided colon vs. left-sided colon,' 'colon vs. rectum,' and 'right-sided (right-sided colon) vs. left-sided (left-sided colon and rectum).' This nationwide multicenter retrospective study aimed to clarify the prognostic impact of tumor location in patients with stage III colorectal cancer by classifying tumors into three groups: right-sided colon, left-sided colon, and rectum.

METHODS

Subjects were 9194 patients with stage III colorectal cancer who underwent curative surgery from 1997 to 2012. Relapse-free survival (RFS) after primary surgery and overall survival (OS) after recurrence were examined.

RESULTS

Rectal cancer (n = 2922) was associated with worse RFS compared to right-sided colon cancer (n = 2362) (hazard ratio (HR) 0.65; 95% CI 0.59-0.72; p < 0.001) and left-sided colon cancer (n = 3910) (HR 0.72; 95% CI 0.66-0.78; p < 0.001) after adjusting for key clinical factors (i.e., sex, age, histological type, CEA, adjuvant therapy, T category, and N category). Among patients with recurrence (n = 2823), rectal cancer was associated with better OS compared to right-sided colon cancer (HR 1.23; 95% CI 1.08-1.40; p = 0.002) and worse OS compared to left-sided colon cancer (HR 0.88; 95% CI 0.79-0.99; p = 0.029). Twenty percent of right-sided colon cancer recurrences exhibited peritoneal dissemination, 42% of left-sided colon cancer recurrences were liver metastases, and 33% of rectal cancer recurrences were local recurrences.

CONCLUSIONS

The three tumor locations (right-sided colon, left-sided colon, rectum) had different prognostic implications for recurrence after curative resection and overall mortality, suggesting that tumor location serves as a prognostic biomarker in stage III colorectal cancer.

Long-Term Outcomes of Laparoscopic Versus Open Surgery for Colon Cancer in Noncancer-Specific Hospital: Propensity Score Analysis

Background: Noninferiority of the laparoscopic approach compared with open surgery for colon cancer treatment has remained controversial. In this study, we aimed to evaluate the long-term outcomes of laparoscopic surgery (LS) versus open surgery (OPS). Methods: A total of 418 patients with Stage I-III colon cancer, who received radical surgery at the Tokyo Medical University Hospital from 2000 to 2014 were included. Propensity score analysis with overall survival (OS) and relapse-free survival (RFS) as the primary endpoints was performed retrospectively to reduce the effects of confounding factors between groups, including age, sex, body mass index, tumor size, clinical T stage, and clinical N stage. Results: After case matching, the 5-year OS rate was 87.8% in the OPS group (n = 97) and 90.1% in the LS group (n = 97; P = .59), indicating no significant difference. The 5-year RFS rate was 79.0% in the OPS group (n = 97) and 84.1% in the LS group (n = 97; P = .29), indicating no significant difference. Five-year cumulative local recurrence (LR) rates were 7.6% and 0% in the OPS group and the LS group, respectively, indicating a significant difference (P = .007). Five-year cumulative distant metastasis rates were 9.2% and 12.7% in the OPS group and the LS group, respectively (P = .49). Conclusion: Laparoscopic surgery appears to be a reasonable option with similar long-term outcomes and to have low LR rate to open surgery in colon cancer patients.

Laparoscopic versus Open Colectomy for Elderly Patients with Colon Cancer: A Propensity Score Analysis with the Controlling Nutritional Status (CONUT) Score

The feasibility of laparoscopic surgery for elderly patients remains unclear, as these patients usually present with comorbidities. Recently, the controlling nutritional status (CONUT) score has drawn attention as an evaluation score of patients' general status as well as a predictor of survival. We retrospectively analyzed overall survival in 424 patients aged ≥75 years with colon cancer, who underwent curative surgery (laparoscopic (n = 167) or open surgery (n = 257)) between January 2004 and December 2013. To adjust for heterogeneity in both groups, a propensity score-matched analysis was performed, with the CONUT score as a confounding covariate. 5-year overall survival rates of patients with normal (0-1), mildly abnormal (2-4), or abnormal (≥5) CONUT score were 88.6%, 79.4%, and 41.4%, respectively (p < 0.001). T3 or less, N negative, late period (2009-2013), and normal CONUT score were associated with the tendency to undergo laparoscopic surgery (p < 0.001). The analysis of the propensity score-matched cohort (124 pairs) revealed that patients in the laparoscopic surgery group had a similar prognosis to those in the open surgery group, with a 5-year overall survival of 91.9% vs. 82.0%, respectively (p = 0.102). Laparoscopic surgery for colon cancer is an acceptable surgical approach in elderly patients.

Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer

Background

Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) avoids extra abdominal extraction incision during colorectal surgery. Some surgeons realized the benefits of NOSE on clinical efficacy. We compared the clinical efficacy of laparoscopic NOSE, laparoscopic non-NOSE and open surgery (OS) for short-term recovery and quality of life (QoL).

Methods

A single randomized controlled trial of NOSE for middle and upper rectal cancer between April 2014 and February 2018. Preoperative and postoperative clinical variables were analyzed and compared between the groups. Preoperative and 6 months postoperative QoL was assessed with the SF-36 QoL questionnaire.

Results

A total of 378 patients were enrolled, 334 patients randomly divided into NOSE group (n=104), non-NOSE group (n=119), OS group (n=111). The NOSE group was superior to the other two groups on the QoL after surgery. The NOSE group had the lowest postoperative VAS score between three groups. The postoperative time for bowel function recovery and the length of hospital stay was statistically significantly different among the three groups, with the NOSE group having the shortest time. The incidence of postoperative complications was lower in the NOSE group (12/104, 11.5%) than in the non-NOSE group (20/119, 16.8%), the difference was statistically significant. The Kaplan-Meier (K-M) survival curve showed no statistically significant difference in the disease-free survival (DFS) rate between the three groups.

Conclusions

Comparing NOSE to non-NOSE and OS, the NOSE had significantly better functional recovery and better QoL. The NOSE group had a significant lower surgical complication rate than the non-NOSE group.

Prognostic impact of preoperatively elevated and postoperatively normalized carcinoembryonic antigen levels following curative resection of stage I-III rectal cancer

BACKGROUND

Preoperative and early postoperative serum carcinoembryonic antigen (CEA) levels are known prognostic factors in rectal cancer. Recently, a large-scale study on colon cancer revealed that "preoperatively elevated and postoperatively normalized CEA levels" is not an indicator of poor prognosis. However, whether this hold true in rectal cancer patients is unknown. This study aimed to investigate the prognostic significance of preoperatively elevated and postoperatively normalized CEA levels in rectal cancer patients undergoing curative resection.

METHODS

Subjects were consecutive stage I-III rectal cancer patients who underwent curative resection without preoperative treatment at National Cancer Center Hospital between 2000 and 2015. Overall survival (OS) and the hazard function of recurrence or death were analyzed according to the CEA levels, as follows: normal preoperative CEA (normal group), preoperatively elevated but postoperatively normalized CEA (normalized group), and preoperatively and postoperatively elevated CEA (elevated group).

RESULTS

The normalized group (n =235) had worse OS (HR 1.49, 95% CI 1.08-2.04; P = .0142) compared to the normal group (n = 1208), and better OS compared to the elevated group (n = 47) (HR 0.53, 95% CI 0.31-0.91; P = .0208). The elevated group had the highest and earliest peak in hazard function, followed by the normalized group and the normal group, with median times to recurrence of 8.8, 15.5, and 18.5 months, respectively (P = .0223).

CONCLUSIONS

Prognosis after resection of rectal cancer was worse in patients with preoperatively elevated and postoperatively normalized CEA compared to those with normal preoperative CEA. Patients with elevated preoperative CEA might require intensive follow-up even if levels normalize after resection, especially in earlier periods, for early detection of recurrence.

Laparoscopic surgery facilitates administration of adjuvant chemotherapy in locally advanced colon cancer: propensity score analyses

Purpose

The aim of this study was to evaluate the impact of a laparoscopic approach on long-term oncological outcomes in curative intent surgery for pT4 colon cancer, in both overall and stratified subgroups with distinct clinical entities.

Patients and methods

Patients with a pT4N0-2M0 colon cancer from four centers between 2000 and 2014 were included. Laparoscopic and open approaches were compared according to the intention-to-treat principle. Propensity scores were used to adjust for baseline differences between the groups in three manners: i) as a linear predictor in a Cox regression model, ii) to create a 1:1 matched cohort, and iii) to stratify patients into four groups with an increasing chance of receiving laparoscopy.

Results

In total, 424 patients were included. After 1:1 matching, a laparoscopic approach correlated with higher rates of radical resection, lower morbidity, and a higher percentage of patients receiving adjuvant chemotherapy. This translated into better 5-year disease-free survival (52% vs 40%, HR 0.70; 95% CI 0.50–0.96) and 5-year overall survival (68% vs 57%, HR 0.66; 95% CI 0.43–0.99). These results were confirmed in the other two propensity score analyses. In the multivariable models, adjuvant chemotherapy remained independently associated with better survival, whereas surgical approach lost significance.

Conclusions

In locally advanced colon cancer, an intentional laparoscopic approach in experienced hands seems to decrease morbidity and to increase the proportion of patients receiving adjuvant chemotherapy. Receiving adjuvant chemotherapy was independently associated with improved survival.

Laparoscopic surgery in patients diagnosed with clinical N2 colon cancer

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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