Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial

Development of a laparoscopic sigmoidectomy simulator: Sigmaster

The sigmoid colon simulator was designed to accurately reproduce the anatomical layer structure and the arrangement of characteristic organs in each layer, and to have conductivity so that energy devices can be used. Dry polyester fibers were used to reproduce the layered structures, which included characteristic blood vessels, nerve sheaths, and intestinal tracts. The adhesive strength of the layers was controlled to allow realistic peeling techniques. The features of the Sigmaster are illustrated through a comparison of simulated sigmoidectomy using Sigmaster and actual surgery. We developed a laparoscopic sigmoidectomy simulator called Sigmaster. Sigmaster is a training device that closely reproduces the membrane structures of the human body and allows surgeons to experience the entire laparoscopic sigmoidectomy process.

Impact of surgical proximal and distal margins on the recurrence of resectable colon cancer: a single-center observational cohort study

PURPOSE

Few studies have investigated the impact of the surgical proximal and distal margins on colon cancer recurrence. We conducted this study to investigate the effect of resection margins on the prognosis of resectable colon cancer.

METHODS

We analyzed data on 1458 patients who underwent colorectal resection in our institute between January, 2004 and March, 2020, including 579 patients with resectable colon cancer. The association between the resection margin and recurrence for each oncological status was assessed and the value of the resection length that influenced recurrence was analyzed.

RESULTS

Patients who had pT4 colon cancer with margins of more than 7 cm had a trend of fewer recurrences and longer relapse-free survival (RFS) than those with colon cancer of other stages (P = 0.033; hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.20-0.89). Multivariate analysis identified a margin of < 7 cm as an independent risk factor for RFS in patients with pT4 colon cancer (P = 0.023; HR, 2.65; 95% CI 1.013-6.17). No correlation was found between resection margins and recurrence, depending on the extent of lymph node metastasis and tumor location.

CONCLUSION

A resection margin of at least 7 cm should be maintained for patients with pT4 colon cancer.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy for overweight colon cancer patients: a case-control study

INTRODUCTION

Either extracorporeal anastomosis (EA) or intracorporeal anastomosis (IA) could be selected for digestive reconstruction in laparoscopic right hemicolectomy (LRH). However, whether LRH with IA is feasible and beneficial for overweight right-side colon cancer (RCC) is unclear. This study aims to investigate the feasibility and advantage of IA in LRH for overweight RCC.

METHODS

Forty-eight consecutive overweight RCC patients undergoing LRH with IA were matched with 48 consecutive cases undergoing LRH with EA. Both clinical and surgical data were collected and analyzed.

RESULTS

The incidence of postoperative complications was 20.8% (10/48) in the EA group and 14.6% (7/48) in the IA group respectively, with no statistical difference. Compared to the EA group, patients in the IA group revealed faster gas (40.2 + 7.8 h vs. 45.6 + 7.9 h, P = 0.001) and stool discharge (4.0 + 1.2 d vs. 4.5 + 1.1 d, P = 0.040), shorter assisted incision (5.3 + 1.3 cm vs. 7.5 + 1.2 cm, P = 0.000), and less analgesic used (3.3 + 1.3 d vs. 4.0 + 1.3 d, P = 0.012). There were no significant differences in operation time, blood loss, or postoperative hospital stays. In the IA group, the first one third of cases presented longer operation time (228.4 + 29.3 min) compared to the middle (191.0 + 35.0 min, P = 0.003) and the last one third of patients (182.2 + 20.7 min, P = 0.000).

CONCLUSION

LRH with IA is feasible and safe for overweight RCC, with faster bowel function recovery and less pain. Accumulation of certain cases of LRH with IA will facilitate surgical procedures and reduce operation time.

MIRO study: Do the results of a randomized controlled trial apply in a real population?

BACKGROUND

The aim of our study was to evaluate the external validity of the MIRO randomized controlled trial findings in a similar nationwide setting "real life" population, especially the benefit of a hybrid approach in esophageal resection for pulmonary complication. The external validity of randomized controlled trial findings to the general population with the same condition remains problematic because of the inherent selection bias and rigid inclusion criteria.

METHODS

This study was a cohort study from a National Health Database (Programme de Medicalisation des Systemes d'Informations) between 2010 and 2022. All adult patients operated on using Ivor Lewis resection for esophageal cancer were included. We first validated the detection algorithm of postoperative complications in the health database. Then, we assessed the primary outcome, which was the comparison of postoperative severe pulmonary complications, leak rate, and 30-day mortality between the 2 surgical approaches (hybrid versus open) over a decade.

RESULTS

Between 2010 and 2012, 162 of 205 patients in the MIRO trial were anonymously identified in the health care database. No difference between randomized controlled trials and healthcare database measurements was found within severe respiratory complications (24% vs 22%, respectively) nor within leak rate (10% vs 9%, respectively). After application of selection criteria according to the MIRO trial, 3,852 patients were included between 2013 and 2022. The hybrid approach was a protective factor against respiratory complications after adjustment for confounding variables (odds ratio = 0.83; 95% confidence interval = 0.71-0.98, P = .025). No significant difference in the 30-day mortality rate or 30-day leakage rate between the types of approach was reported.

CONCLUSION

This national cohort study demonstrates the external validity of the MIRO randomized controlled trial findings in a real-life population within France.

Surgical and Oncological Outcome of Laparoscopic Resection of Colorectal Cancers: A Single-Center Experience

BACKGROUND

Laparoscopy is one of the major advances in surgery in the last 30 years and has many benefits. Although laparoscopy was initially used for resection of benign colon lesions, it is now widely used for colorectal cancer resections after strong evidence has confirmed its safety and efficacy. We aim to report both the surgical and oncological outcomes of our first series of laparoscopic colorectal cancer resections.

METHODS

In 2013, a laparoscopic colorectal resection service was established in northern Iraq at Zheen Hospital, Erbil. Data from all consecutive colorectal cancers were collected. Patients with locally advanced diseases and those who required emergency operations for bowel obstruction or perforation were excluded. We analyzed demographic, operative, postoperative, and histopathological data for all patients who were included in the study.

RESULTS

A total of 124 patients with colorectal cancers presented to our unit between January 2013 and January 2023. Only 112 patients fulfilled the inclusion criteria and underwent laparoscopic resections. The median age of the patients was 54.5 years. The majority of patients were men (n=62; 55.4%). In 39 patients (35%), the cancer was located in the sigmoid; in 33 patients (29.5%) the cancer was in the rectum. Laparoscopic anterior resection was the most common procedure (n=50; 45%), followed by right hemicolectomy in 17 cases (15.1%). The conversion rate to open surgery was 8% (nine cases). The most common causes of conversion to open surgery were dilated bowel loops and tumour adherence to other structures. The mean operative time was 190 minutes and the mean hospital stay was three days. No complications were reported in 94 patients (84%). Among the complications, wound infection was seen in seven patients (7.8%). There were six anastomotic leaks (6.7%). The mean number of lymph nodes harvested was 13. In 70 patients (62.5%), the lymph node count was ≥12 with a median of 13. The mean distal resection margin was 6 cm and 2.5 cm for colon and rectal resections, respectively.

CONCLUSION

This study reveals that laparoscopic resection for colorectal cancers is surgically practicable and safe with the benefits of a short hospital stay, adequate resection margins, and adequate lymph node yield.

A Case of Direct-Acting Oral Anticoagulant-Induced Intramural Colon Hematoma Successfully Treated by Laparoscopic Surgery

Intramural intestinal hematoma is a rare disease, one of the triggering factors of which is the use of anticoagulants. In previous reports, most patients were on treatment with warfarin. Herein, we report a case of direct-acting oral anticoagulant (DOAC)-induced intramural hematoma of the ascending colon in a patient refractory to conservative treatment and required laparoscopic right hemicolectomy. An 80-year-old male patient with a history of atrial fibrillation and cerebral infarction, on treatment with apixaban, was brought to our hospital with the chief complaints of abdominal pain, vomiting, and melena. Imaging revealed the cause of symptoms to be intestinal obstruction caused by a mass lesion on the wall of the ascending colon. We initially opted for conservative treatment with discontinuation of apixaban and insertion of an ileus tube. Intestinal dilatation findings showed improvement; however, subsequent imaging examinations did not reveal the shrinkage of a lesion in the ascending colon. If the mass was not removed, recurrence of bowel obstruction symptoms was expected, so we decided to perform surgical intervention. A laparoscopic right hemicolectomy was performed, and an intramural hematoma of the ascending colon was diagnosed based on the excised specimen. He needed a blood transfusion for anemia but was discharged on postoperative day 14 with no other complications. DOACs are now widely used in patients with atrial fibrillation, and the risk of bleeding as a side effect is extremely low compared to conventional anticoagulants, including warfarin. However, when abdominal pain occurs, as in the present case, an intramural hematoma should be considered in the differential diagnosis. There is no established treatment plan for intestinal intramural hematoma. Although conservative treatment is effective in some cases, it is difficult to evaluate the risk of bleeding associated with DOACs using coagulation tests. Even if conservative treatment is selected, it is essential to determine surgical resection, if necessary, based on the clinical course and imaging and blood test findings.

Evaluation of bacterial contamination and medium-term oncological outcomes of intracorporeal anastomosis for colon cancer: A propensity score matching analysis

BACKGROUND

Although intracorporeal anastomosis (IA) for colon cancer requires longer operative time than extracorporeal anastomosis (EA), its short-term postoperative results, such as early recovery of bowel movement, have been reported to be equal or better. As IA requires opening the intestinal tract in the abdominal cavity under pneumoperitoneum, there are concerns about intraperitoneal bacterial infection and recurrence of peritoneal dissemination due to the spread of bacteria and tumor cells. However, intraperitoneal bacterial contamination and medium-term oncological outcomes have not been clarified.

AIM

To clarify the effects of bacterial and tumor cell contamination of the intra-abdominal cavity in IA.

METHODS

Of 127 patients who underwent laparoscopic colon resection for colon cancer from April 2015 to December 2020, 75 underwent EA (EA group), and 52 underwent IA (IA group). After propensity score matching, the primary endpoint was 3-year disease-free survival rates, and secondary endpoints were 3-year overall survival rates, type of recurrence, surgical site infection (SSI) incidence, number of days on antibiotics, and postoperative biological responses.

RESULTS

Three-year disease-free survival rates did not significantly differ between the IA and EA groups (87.2% and 82.7%, respectively, P = 0.4473). The 3-year overall survival rates also did not significantly differ between the IA and EA groups (94.7% and 94.7%, respectively; P = 0.9891). There was no difference in the type of recurrence between the two groups. In addition, there were no significant differences in SSI incidence or the number of days on antibiotics; however, postoperative biological responses, such as the white blood cell count (10200 vs 8650/mm3, P = 0.0068), C-reactive protein (6.8 vs 4.5 mg/dL, P = 0.0011), and body temperature (37.7 vs 37.5 °C, P = 0.0079), were significantly higher in the IA group.

CONCLUSION

IA is an anastomotic technique that should be widely performed because its risk of intraperitoneal bacterial contamination and medium-term oncological outcomes are comparable to those of EA.

Laparoscopic versus laparotomic surgical treatment in apparent stage I ovarian cancer: a multi-center retrospective cohort study

BACKGROUND

Laparoscopic treatment shows non-inferior survival outcomes and better surgical outcomes in apparent stage I ovarian cancer (OC) in some studies but has not been well defined.

METHODS

We conducted a retrospective study of patients with apparent stage I OC treated in two hospitals between 2012 and 2022. The surgical and oncologic outcomes were evaluated between patients receiving laparoscopic and laparotomic surgery.

RESULTS

We identified 37 patients with apparent stage I OC, including 15 (40.5%) serous carcinomas, 9 (24.3%) mucinous cancers, 3 (8.1%) endometroid cancers, 2 clear cell carcinomas, and 8 (21.6%) non-epithelial cancers. Sixteen patients received laparoscopic surgery and the other 21 patients underwent laparotomic surgery. The median age (44.5 vs. 49.0 years), mean mass size (10.5 vs. 11.3 cm), and median follow-up time (43.5 vs. 75.0 months) showed no statistically significant differences between patients in laparoscopic and laparotomic groups (all P > 0.05). All the patients underwent comprehensive surgical staging surgery, and the mean surgical time (213.5 vs. 203.3 min, P = 0.507), number of lymph nodes sampling (18.6 vs. 17.5, P = 0.359), proportion of upstaging (12.5% vs. 19.0%, P = 0.680), and postoperative complications (no Accordion Severity Grading System grade ≥ 3) were comparable between two surgical groups. Moreover, patients in the laparoscopic group had significantly less intraoperative blood loss (231.3 vs. 352.4 mL, P = 0.018), shorter interval between surgery and postoperative adjuvant chemotherapy (7.4 vs. 9.5 days, P = 0.004), shorter length of hospital stay (9.9 vs. 13.8 days, P < 0.001) than those treated with laparotomic surgery. During a median follow-up of 54.0 months, 9 (24.3%) relapsed and 1 (2.7%) died, with a 5-year recurrence-free survival (RFS) and disease-specific survival (DSS) rate of 70.6% and 100%, respectively. However, the 5-year RFS (93.3% vs. 58.8%, P = 0.084) and DSS (100% vs. 100%, P = 0.637) rates did not significantly differ between the two groups.

CONCLUSION

Laparoscopic surgical treatment had less intraoperative blood loss, earlier postoperative adjuvant chemotherapy administration, shorter hospitalization time, and non-inferior survival outcomes in apparent stage I OC when compared with laparotomic surgery.

LAPAROSCOPIC RIGHT AND LEFT COLECTOMY: WHICH PROVIDES BETTER POSTOPERATIVE RESULTS FOR ONCOLOGY PATIENTS?

BACKGROUND

The laparoscopic approach considerably reduced the morbidity of colorectal surgery when compared to the open approach. Among its benefits, we can highlight less intraoperative bleeding, early oral intake, lower rates of surgical site infection, incisional hernia, and postoperative pain, and earlier hospital discharge.

AIMS

To compare the perioperative morbidity of right versus left colectomy for cancer and the quality of laparoscopic oncologic resection.

METHODS

Retrospective analysis of patients submitted to laparoscopic right and left colctomy between 2006 and 2016. Postoperative complications were classified using the Clavien-Dindo scale, 30 days after surgery.

RESULTS

A total of 293 patients were analyzed, 97 right colectomies (33.1%) and 196 left colectomies (66.9%). The averageage was 62.8 years. The groups were comparable in terms of age, comorbidities, body mass index, and the American Society of Anesthesiology (ASA) classification. Preoperative transfusion was higher in the right colectomy group (5.1% versus 0.4%, p=0.004, p<0.05). Overall, 233 patients (79.5%) had no complications. Complications found were grade I and II in 62 patients (21.1%) and grade III to V in 37 (12.6%). Twenty-three patients (7.8%) underwent reoperation. The comparison between left and right colectomy was not statistically different for operative time, conversion, reoperation, severe postoperative complications, and length of stay. The anastomotic leak rate was comparable in both groups(5.6% versus 2.1%, p=0.232, p>0.05). The oncological results were similar in both surgeries. In multiple logistic regression, ASA statistically influenced the worst results (≥ III; p=0.029, p<0.05).

CONCLUSIONS

The surgical and oncological results of laparoscopic right and left colectomies are similar, making this the preferred approach for both procedures.

A Review of Cognitive Support Systems in the Operating Room

BACKGROUND

In recent years, numerous innovative yet challenging surgeries, such as minimally invasive procedures, have introduced an overwhelming amount of new technologies, increasing the cognitive load for surgeons and potentially diluting their attention. Cognitive support technologies (CSTs) have been in development to reduce surgeons' cognitive load and minimize errors. Despite its huge demands, it still lacks a systematic review.

METHODS

Literature was searched up until May 21st, 2021. Pubmed, Web of Science, and IEEExplore. Studies that aimed at reducing the cognitive load of surgeons were included. Additionally, studies that contained an experimental trial with real patients and real surgeons were prioritized, although phantom and animal studies were also included. Major outcomes that were assessed included surgical error, anatomical localization accuracy, total procedural time, and patient outcome.

RESULTS

A total of 37 studies were included. Overall, the implementation of CSTs had better surgical performance than the traditional methods. Most studies reported decreased error rate and increased efficiency. In terms of accuracy, most CSTs had over 90% accuracy in identifying anatomical markers with an error margin below 5 mm. Most studies reported a decrease in surgical time, although some were statistically insignificant.

DISCUSSION

CSTs have been shown to reduce the mental workload of surgeons. However, the limited ergonomic design of current CSTs has hindered their widespread use in the clinical setting. Overall, more clinical data on actual patients is needed to provide concrete evidence before the ubiquitous implementation of CSTs.

Incisional Hernia After Laparoscopic Right Colectomy for Colorectal Cancer: A Prospective Study with Retrospective Control on Intracorporeal Versus Extracorporeal Anastomosis

Background: Incisional hernias often occur after laparoscopic colorectal surgery, but the precise risk factors are not fully understood. This study's primary aim was to compare the incidence of incisional hernias following laparoscopic right colectomy with intracorporeal anastomotic reconstruction (ICA) versus extracorporeal anastomotic reconstruction (ECA). Materials and Methods: A cohort study compared two groups of patients who underwent elective laparoscopic right colectomy for colon cancer following a standardized perioperative enhanced recovery program (ERP): a prospective group underwent ICA from January 2018 to February 2020 and a retrospective group underwent ECA from January 2013 to December 2016. The presence of incisional hernias was assessed by reviewing patients' follow-up computed tomography scans or evaluating the patients by telephone interview or outpatient office visit and diagnostic imaging. Secondary objectives included the hospital length of stay, postoperative complications, 30-day readmission rate, reoperation, and mortality. Results: The study included 89 patients who had laparoscopic right colectomy for malignant colon neoplasms. Among these, 48 underwent ECA (ECA group), and 41 had ICA (ICA group). At a median follow-up of 36 months, incisional hernia was observed in 1 patient (2.4%) in the ICA group, in contrast to 11 (22.9%) confirmed cases in the ECA group (P = .010). The length of hospital stay was similar between the two groups (5 days versus 4 days; P = .064). The two groups showed similarities in terms of postoperative complications (P = .093), hospital readmission (P = .999), and the rate of reoperation within 30 days (P = .461). Conclusions: The ICA technique was associated with a reduced risk of incisional hernias compared with the ECA technique, with similar outcomes in short-term postoperative complications and overall patient recovery.

Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy

BACKGROUND

Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer, but we have experienced resistance to the introduction of the FreeHand® robotic camera holder to augment laparoscopic colorectal surgery.

AIM

To compare the initial results between conventional and FreeHand® robot-assisted laparoscopic colectomy in Trinidad and Tobago.

METHODS

This was a prospective study of outcomes from all laparoscopic colectomies performed for colorectal carcinoma from November 29, 2021 to May 30, 2022. The following data were recorded: Operating time, conversions, estimated blood loss, hospitalization, morbidity, surgical resection margins and number of nodes harvested. All data were entered into an excel database and the data were analyzed using SPSS ver 20.0.

RESULTS

There were 23 patients undergoing colectomies for malignant disease: 8 (35%) FreeHand®-assisted and 15 (65%) conventional laparoscopic colectomies. There were no conversions. Operating time was significantly lower in patients undergoing robot-assisted laparoscopic colectomy (95.13 ± 9.22 vs 105.67 ± 11.48 min; P = 0.045). Otherwise, there was no difference in estimated blood loss, nodal harvest, hospitalization, morbidity or mortality.

CONCLUSION

The FreeHand® robot for colectomies is safe, provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Short-term outcomes after laparoscopic colorectal cancer surgery in patients over 90 years old: a Japanese multicenter study

BACKGROUND

The effect of laparoscopic surgery on short-term outcomes in colorectal cancer patients over 90 years old has remained unclear.

METHODS

We reviewed 87 colorectal cancer patients aged over 90 years who underwent surgery between 2016 and 2022. Patients were divided into an open surgery group (n = 22) and a laparoscopic surgery group (n = 65). The aim of this study was to investigate the effect of laparoscopic surgery on postoperative outcome in elderly colorectal cancer patients, as compared to open surgery.

RESULTS

Seventy-eight patients (89.7%) had comorbidities. Frequency of advanced T stage was lower with laparoscopic surgery (p = 0.021). Operation time was longer (open surgery 146 min vs. laparoscopic surgery 203 min; p = 0.002) and blood loss was less (105 mL vs. 20 mL, respectively; p < 0.001) with laparoscopic surgery. Length of hospitalization was longer with open surgery (22 days vs. 18 days, respectively; p = 0.007). Frequency of infectious complications was lower with laparoscopic surgery (18.5%) than with open surgery (45.5%; p = 0.021). Multivariate analysis revealed open surgery (p = 0.026; odds ratio, 3.535; 95% confidence interval, 1.159-10.781) as an independent predictor of postoperative infectious complications.

CONCLUSIONS

Laparoscopic colorectal resection for patients over 90 years old is a useful procedure that reduces postoperative infectious complications.

Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England

BACKGROUND

Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity.

METHODS

Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis.

RESULTS

A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS.

CONCLUSIONS

MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.

Long-term outcomes of single-incision plus one-port laparoscopic surgery versus conventional laparoscopic surgery for rectosigmoid cancer: a randomized controlled trial

BACKGROUND

Though our previous study has demonstrated that the single-incision plus one-port laparoscopic surgery (SILS + 1) is safe and feasible for sigmoid colon and upper rectal cancer and has better short-term outcomes compared with conventional laparoscopic surgery (CLS), the long-term outcomes of SILS + 1 remains uncertain and are needed to evaluated by an RCT.

METHODS

Patients with clinical stage T1-4aN0-2M0 rectosigmoid cancer were enrolled. The participants were randomly assigned to either SILS + 1 (n = 99) or CLS (n = 99). The 3-year DFS, 5-year OS, and recurrence patterns were analyzed.

RESULTS

Between April 2014 and July 2016, 198 patients were randomly assigned to either the SILS + 1 group (n = 99) or CLS group (n = 99). The median follow-up in the SILS + 1 group was 64.0 months and in CLS group was 65.0 months. The 3-year DFS was 87.8% (95% CI, 81.6-94.8%) in SILS + 1 group and 86.9% (95% CI, 81.3-94.5%) in CLS group (hazard ratio: 1.09 (95% CI, 0.48-2.47; P = 0.84)). The 5-year OS was 86.7% (95% CI,79.6-93.8%) in the SILS + 1 group and 80.5% (95% CI,72.5-88.5%) in the CLS group (hazard ratio: 1.53 (95% CI, 0.74-3.18; P = 0.25)). There were no significant differences in the recurrence patterns between the two groups.

CONCLUSIONS

We found no significant difference in 3-year DFS and 5-year OS of patients with sigmoid colon and upper rectal cancer treated with SILS + 1 vs. CLS. SILS + 1 is noninferior to CLS when performed by expert surgeons.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02117557 (registered on 21/04/2014).

Resection margins, lymph node harvest and 3 year survival in open and laparoscopic colorectal cancer surgery; a prospective cohort study

INTRODUCTION

Laparoscopic colorectal cancer surgery has been gaining popularity in the last decade. However, there are concerns about adequate lymph node dissection and safe resection margins in laparoscopic colorectal cancer surgery. This study was aimed at comparing the lymph node (LN) clearance and surgical resection margins and 3-year survival for open and laparoscopic colorectal cancer surgery.

METHOD

A pre-tested interviewer administered questionnaire was used to assess the adoption of the laparoscopic approach by Sri Lankan surgeons. Data was collected prospectively from patients who underwent open or laparoscopic colorectal cancer surgery at the University Surgical Unit of the National Hospital of Sri Lanka from April 2016 to May 2019. The histopathology records were analysed to determine the longitudinal and circumferential resection margins(CRM) and the number of lymph nodes harvested. The resection margins were classified as positive or negative. The total number of LN examined was evaluated. Presence of local recurrence and liver metastasis was determined by contrast enhanced CT scan during 3-years of follow up. Chi square, T test and z test for proportions were used to compare CRM, LN harvest and survival rates between the groups.

RESULTS

Of the surgeons interviewed only 11 (18.4%) performed laparoscopic colorectal cancer surgery. A total of 137 patients (83 males and 54 females) were studied. Eighty-one procedures were laparoscopic and 56 procedures were open. All patients had clear longitudinal resection margins. Seventy-eight patients in the laparoscopic group (96%) and 51 patients (91%) in the open group had clear CRM (p > 0.05). A total of 2188 LNs (mean 15.9) were resected in all procedures. Six-hundred-eighty-nine lymph nodes were removed during open procedures (mean 12.3, SD 0.4) and 1499 (mean 18.5, SD 0.6) were removed during laparoscopy (p < 0.05). At 3 years follow-up the disease-free survival in the laparoscopic and open colon cancer patients was 27/41 (65.8%) and 16/29 (55.1%) respectively (p = 0.35). Disease free survival in the laparoscopic and open rectal cancer patients was 23/38 (60.5%) and 13/25 (52.0%) respectively (p = 0.40). Four patients were lost during follow-up.

DISCUSSION AND CONCLUSION

CRM was comparable in the two groups. Laparoscopic group had a significantly higher LN harvest. Three-year survival rates were similar in the two groups. Acceptable results can be obtained with laparoscopic colorectal cancer surgery.

Low-impact laparoscopy in colorectal resection-A multicentric randomised trial comparing low-pressure pneumoperitoneum plus microsurgery versus low-pressure pneumoperitoneum alone: The PAROS II trial

INTRODUCTION

Low-pressure pneumoperitoneum (LLP) in laparoscopy colorectal surgery (CS) has resulted in reduced hospital stay and lower analgesic consumption. Microsurgery (MS) in CS is a technique that has a significant impact with respect to postoperative pain. The combination of MS plus LLP, known as low-impact laparoscopy (LIL), has never been applied in CS. Therefore, this trial will assess the efficacy of LLP plus MS versus LLP alone in terms of decreasing postoperative pain 24 h after surgery, without taking opioids.

METHOD

PAROS II will be a prospective, multicentre, outcome assessor-blinded, randomised controlled phase III clinical trial that compares LLP plus MS versus LLP alone in patients undergoing laparoscopic surgery for colonic or upper rectal cancer or benign pathology. The primary outcome will be the number of patients with postoperative pain 24 h after the surgery, as defined by a visual analogue scale rating ≤3 and without taking opioids. Overall, PAROS II aims to recruit 148 patients for 50% of patients to reach the primary outcome in the LLP plus MS arm, with 80% power and an 5% alpha risk.

CONCLUSION

The PAROS II trial will be the first phase III trial to investigate the impact of LIL, including LLP plus MS, in laparoscopic CS. The results may improve the postoperative recovery experience and decrease opioid consumption after laparoscopic CS.

Laparoscopic radical surgery for locally advanced T4 transverse colon cancer and prognostic factors analysis: Evidence from multi-center databases

The safety and efficacies of laparoscopic radical procedures are still controversial for locally advanced pathological T4 (pT4) TCC (transverse colon cancer). Therefore, the aim of this study is to evaluate the oncologic and perioperative outcomes and to recognize the prognostic factors in radical resection for pT4 TCC derived from multi-center databases. 314 patients with TCC who underwent radical resection between January 2004 and May 2017, including 139 laparoscopic resections and 175 open resections, were extracted from multicenter databases. Oncological as well as perioperative outcomes were investigated. The baseline characteristics of the 2 groups did not differ significantly. Nevertheless, the laparoscopic technique was found to be linked with a significantly longer duration of surgery (208.96 vs 172.89 minutes, P = .044) and a significantly shorter postoperative hospital stay (12.23 vs 14.48 days, P = .014) when compared to the conventional open approach. In terms of oncological outcomes, lymph node resection (16.10 vs 13.66, P = .886), 5-year overall survival (84.7% vs 82.7%, P = .393), and disease-free survival (82.7% vs 83.9%, P = .803) were similar between the 2 approaches. Based on multivariate analysis, it was determined that differentiation and N classification were both independent prognostic factors for overall survival. However, it was found that only N classification was an independent prognostic factor for disease-free survival. These findings underscore the significance of differentiation and N classification as key determinants of patient outcomes in this context. Overall, the laparoscopic approach may offer advantages in terms of shorter hospital stays, while maintaining comparable oncological outcomes. Laparoscopic radical procedure can gain a couple of short-term benefits without reducing long-term oncological survival for patients with pT4 TCC.

Robotic natural orifice specimen extraction surgery (NOSES) for anterior resection

Minimally invasive colorectal surgery is currently well-accepted, with open techniques being reserved for very difficult cases. Laparoscopic colectomy has been proven to have lower mortality, complication, and ostomy rates; a shorter median length of stay; and lower overall costs when compared to its open counterpart. This trend is seen in both benign and malignant indications. Natural orifice specimen extraction surgery (NOSES) in colorectal surgery was first described in the early 1990s. Three recent meta-analyses comparing transabdominal extraction against NOSES concluded that NOSES was superior in terms of overall postoperative complications, recovery of gastrointestinal function, postoperative pain, aesthetics, and hospital stay. However, NOSES was associated with a longer operative time. Herein, we present our technique of robotic NOSES anterior resection using the da Vinci Xi platform in diverticular disease and sigmoid colon cancers.

Near-infrared fluorescence tattooing: a new approach for endoscopic marking of tumors in minimally invasive colorectal surgery using a persistent near-infrared marker

INTRODUCTION

Intraoperative accurate localization of tumors in the lower gastrointestinal tract is essential to ensure oncologic radicality. In minimally invasive colon surgery, tactile identification of tumors is challenging due to diminished or absent haptics. In clinical practice, preoperative endoscopic application of a blue dye (ink) to the tumor site has become the standard for marking and identification of tumors in the colon. However, this method has the major limitation that accidental intraperitoneal spillage of the dye can significantly complicate the identification of anatomical structures and surgical planes. In this work, we describe a new approach of NIR fluorescent tattooing using a near-infrared (NIR) fluorescent marker instead of a blue dye (ink) for endoscopic tattooing.

METHODS

AFS81x is a newly developed NIR fluorescent marker. In an experimental study with four domestic pigs, the newly developed NIR fluorescent marker (AFS81x) was used for endoscopic tattooing of the colon. 7-12 endoscopic submucosal injections of AFS81x were placed per animal in the colon. On day 0, day 1, and day 10 after endoscopic tattooing with AFS81x, the visualization of the fluorescent markings in the colon was evaluated during laparoscopic surgery by two surgeons and photographically documented.

RESULTS

The detection rate of the NIR fluorescent tattoos at day 0, day 1, and day 10 after endoscopic tattooing was 100%. Recognizability of anatomical structures during laparoscopy was not affected in any of the markings, as the markings were not visible in the white light channel of the laparoscope, but only in the NIR channel or in the overlay of the white light and the NIR channel of the laparoscope. The brightness, the sharpness, and size of the endoscopic tattoos did not change significantly on day 1 and day 10, but remained almost identical compared to day 0.

CONCLUSION

The new approach of endoscopic NIR fluorescence tattooing using the newly developed NIR fluorescence marker AFS81x enables stable marking of colonic sites over a long period of at least 10 days without compromising the recognizability of anatomical structures and surgical planes in any way.

Laparoscopic Right Hemicolectomy for Inflammatory Bowel Disease: Is Intracorporeal Anastomosis Feasible? A Retrospective Cohort Comparison Study

Background: Inflammatory bowel disease (IBD) affects all ages and backgrounds, and many individuals require surgical intervention during their disease course. The adoption of laparoscopic techniques in this patient population has been slow, including intracorporeal anastomosis (ICA). The aim of our study was to determine if ICA was feasible and safe in patients with IBD undergoing laparoscopic right hemicolectomy (LRHC). Methods: This is a retrospective, single institution cohort study of elective and emergent cases of LRHC at a single academic center. Patients included underwent LRHC or ileocolic resection for IBD. Exclusion criteria: conversion to laparotomy, resection without anastomosis, or unconfirmed diagnosis of IBD. Main outcomes studied were anastomotic leak rate, surgical site infection (SSI), postoperative length of stay, 30-day readmission/reoperation, and operative time. Secondary outcomes were incisional hernia rates and rates of disease recurrence. Results: A total of 70 patients were included, 12 underwent ICA and 58 extracorporeal anastomosis. Anastomotic leak rate (intracorporeal 8.3% [n = 1], extracorporeal 8.6% [n = 5], P = .97), and SSI rates (intracorporeal 0%, extracorporeal 6.9% [n = 4], P = .36) were similar. Mean postoperative length of stay, rates of 30-day readmission/reoperation and diagnosis of hernia at 1 year were not significantly different. Rates of IBD recurrence and location of recurrence at 1 year were similar. However, operative time was significantly longer in those undergoing ICA (intracorporeal 187 minutes versus extracorporeal 139 minutes, P = < .05). Conclusions: ICA is a safe option in patients with IBD undergoing LRHC.

A 3 mm Port Reduces Postoperative Pain After Laparoscopic Colon Cancer Surgery: A Case-control Matched Study

BACKGROUND

Recently, smaller-size trocars and instruments have been developed for laparoscopic colon cancer surgery; however, their effectiveness and safety have not been elucidated. This study aimed to investigate whether 3 mm trocars and instruments have benefits compared with conventional trocars and instruments.

PATIENTS AND METHODS

Patients with colon cancer who underwent laparoscopic anterior resection or right hemicolectomy were included. Patients who underwent combined resections of other organs and those with conversion to open surgery were excluded. In the 3 mm group, three 5 mm trocars were replaced by 3 mm trocars. The numeric rating scale (NRS) immediately postoperatively at 24, 48, and 72 hours, respectively, after surgery and the use of additional analgesics and perioperative outcomes were analyzed. Case-control matched analysis was used to reduce bias according to the type of surgery.

RESULTS

A total of 207 patients (conventional: n = 158, 3 mm: n = 49) were included. Before matching, NRS 48 hours postoperatively ( P = 0.049), proportion of patients using additional intravenous (IV) analgesics ( P = 0.007), postoperative hospital stay ( P < 0.001), and blood loss ( P < 0.001) were lower in the 3 mm group. In multivariable analysis, trocar type significantly impacted the proportion of patients using additional IV analgesics (odds ratio: 0.330; 95% CI: 0.153-0.712; P = 0.005). After case-control matching, NRS immediately postoperatively ( P = 0.015) and 24 hours postsurgery ( P = 0.043), patients using additional IV analgesics ( P = 0.019), postoperative hospital stay ( P = 0.010), intraoperative blood loss ( P < 0.001), and postoperative complication rate ( P = 0.028) were significantly lower in the 3 mm group compared with the 5 mm group.

CONCLUSIONS

The use of 3 mm trocars and instruments in laparoscopic colon cancer surgery can effectively reduce postoperative pain while maintaining perioperative safety.

Intracorporeal Versus Extracorporeal Colo-colic Anastomosis in Minimally-invasive Left Colectomy: a Systematic Review and Meta-analysis

PURPOSE

The primary aim was to investigate the operative outcomes of intracorporeal (IA) and extracorporeal (EA) anastomosis in left-sided minimally-invasive colectomy.

METHODS

A comprehensive literature search was conducted for studies comparing operative outcomes and follow-up data of IA versus EA in minimally-invasive left colectomy. Studies that investigated recto-sigmoid resections using transanal circular staplers were excluded. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios (ORs) and mean differences with 95 per cent confidence intervals were calculated.

RESULTS

Eight studies with a total of 750 patients were included (IA n = 335 versus EA n = 415). IA was associated with significantly lower overall morbidity (OR 0.40, 95% CI 0.26-0.61, p < 0.0001) and less frequent surgical site infection (SSI) (OR 0.27, 95% CI 0.12-0.61, p = 0.002) as primary outcomes compared to EA. Of the secondary outcomes, length of incision (SMD -2.51, 95% CI -4.21 to -0.81, p = 0.004), time to first oral diet intake (SMD -0.49, 95% CI -0.76 to -0.22, p = 0. 0004) and time to first bowel movement (SMD -0.40, 95% CI -0.71 to -0.09, p = 0.01) were significantly in favor of IA, while operative time was significantly shorter in the EA group (SMD 0.36, 95% CI 0.14-0.59, p = 0.001).

CONCLUSIONS

IA proves to be a safe and feasible option as it demonstrates benefits in terms of lower overall morbidity, fewer rates of SSI, smaller incision length, and faster postoperative gastrointestinal recovery despite a longer operative time compared to EA.

Assessment of Risk Factors for Iatrogenic Genitourinary Injuries During a Proctectomy

BACKGROUND

It is critical to avoid iatrogenic injuries affecting genitourinary organs in order to prevent postoperative urinary or sexual dysfunction, which lead to lengthier recovery and possibly reoperation.

METHODS

Using the 2016-2019 American College of Surgeons National Quality Improvement Program (ACS NSQIP) Targeted Proctectomy Database, we collated 2577 patients with non-metastatic rectal cancer who underwent a laparoscopic or open proctectomy. Univariate analysis was used to identify differences in perioperative factors and genitourinary injuries (GUIs) between operative approaches, and multivariate logistic regression was used to identify independent risk factors for sustaining an intraoperative GUI.

RESULTS

The rates of preoperative comorbidities were significantly higher among patients who received an open operation. The proportion of GUIs was also significantly higher in this patient population. Multivariate logistic regression demonstrated that patients who underwent a laparoscopic proctectomy were associated with a 51.4% lower risk of sustaining a GUI. Furthermore, >10% body weight loss in the past 6 months and ASA class 3 status were independently associated with a higher risk of GUI regardless of operation type.

CONCLUSION

Patients who undergo a laparoscopic proctectomy are associated with a lower risk of GUI. On the other hand, patients with >10% body weight loss and ASA class 3: Severe Systemic Disease were associated with a higher risk of GUI.

Short-term and long-term outcomes of single-incision plus one-port laparoscopic surgery for colorectal cancer: a propensity-matched cohort study with conventional laparoscopic surgery

BACKGROUND

Single-incision plus one-port laparoscopic surgery (SILS + 1) has been demonstrated to be minimally invasive while possessing better cosmesis and less pain compared with conventional laparoscopic surgery (CLS). However, SILS + 1 as an alternative to CLS for colorectal cancer is still controversial.

METHODS

A total of 1071 patients who underwent curative laparoscopic surgery for colon cancer between 2015 and 2018 were included. Of these patients, 258 SILS + 1 cases and 516 CLS cases were analyzed using propensity score matching. The baseline characteristics, surgical outcomes, pathologic findings and recovery course, morbidity and mortality within postoperative 30 days and 3-year disease-free and overall survival were compared.

RESULTS

Baseline characteristics were balanced between the groups. The mean operating time was significantly shorter in SILS + 1 group, with less estimated blood loss. Tumor size, tumor differentiation, number of harvested lymph nodes, resection margin and pathologic T, N, TNM stage was similar between the groups. There was no significant difference in overall perioperative complications. Uni- and multivariate analyses revealed that SILS + 1 was not a risk factor for complications. Postoperatively, SILS + 1 group showed faster recovery than CLS group in terms of ambulation, bowel function, oral intake and discharge. The 3-year disease-free survival rates of SILS + 1 and CLS groups were 90.1% and 87.3%(p = 0.59), respectively and the 3-year overall survival rates were 93.3% vs. 89.8%(p = 0.172).

DISCUSSION

Our study revealed that SILS + 1 is safe, feasible, oncologically efficient, and may be considered as a surgical option for selected patients with colorectal cancer.

Outcomes of Laparoscopic Surgery in Very Elderly Patients with Colorectal Cancer: A Survival Analysis and Comparative Study

(1) Background: Colorectal cancer (CRC) is a global health concern, particularly among the elderly population. This study aimed to assess the impact of laparoscopic surgery on CRC patients aged ≥80 years. (2) Methods: We conducted a retrospective analysis of prospectively collected data from consecutive CRC patients who underwent surgery at our institution between July 2018 and July 2023. The patients were categorized into three groups: those aged over 80 who underwent laparoscopic surgery (Group A), those aged over 80 who underwent open surgery (Group B), and those under 80 who underwent laparoscopic surgery (Group C). We examined various clinical and surgical parameters, including demographic data, medical history, surgical outcomes, and survival. (3) Results: Group A (N = 113) had shorter hospital stays than Group B (N = 23; p = 0.042), with no significant differences in complications or 30-day outcomes. Compared to Group C (N = 269), Group A had higher comorbidity indices (p < 0.001), more emergency admissions, anemia, low hemoglobin levels, colonic obstruction (p < 0.001), longer hospital stays (p < 0.001), and more medical complications (p = 0.003). Laparotomic conversion was associated with obstructive neoplasms (p < 0.001), and medical complications with ASA scores (p < 0.001). Both the medical and surgical complications predicted adverse 30-day outcomes (p = 0.007 and p < 0.001). Survival analysis revealed superior overall survival (OS) in Group A vs. Group B (p < 0.0001) and inferior OS vs. Group C (p < 0.0001). After a landmark analysis, the OS for patients aged 80 or older and those under 80 appeared to be similar (HR 2.55 [0.75-8.72], p = 0.136). (4) Conclusions: Laparoscopic surgery in very elderly CRC patients shows comparable oncological outcomes and surgical complications to younger populations. Survival benefits are influenced by age, comorbidities, and medical complications. Further prospective multicenter studies are needed in order to validate these findings.

Minimally Invasive Gastrointestinal Surgery: A Review

Minimally invasive surgery uses several procedures with fewer side effects (bleeding, infections, etc.), a shorter hospital stay, and less discomfort following minimally invasive surgery. Laparoscopy was one of the first forms of minimally invasive surgery. It involves doing surgery while using tiny cameras through one or more small incisions, surgical tools along with tubes. Robotic surgery is another kind of minimally invasive procedure. Along with supporting accurate, flexible, and regulated surgical procedures, it provides the physician with a three-dimensional, enlarged view of the operative site. Minimally invasive surgery continues to advance, making it an advantage for patients with a variety of illnesses. Nowadays, many surgeons prefer it to traditional surgery, which frequently necessitates a longer hospital stay and requires larger incisions. Since then, numerous surgical specialties have greatly increased their use of minimally invasive surgery. A minimally invasive procedure is preferred for the majority of patients who require gastrointestinal surgery. Minimally invasive gastrointestinal procedures are just as successful as open procedures and, in some situations, may result in more effective outcomes. While recovery from open surgeries frequently takes five to ten days in the hospital, minimally invasive surgeries are less painful for patients and hasten recovery. It is safe from the perspective of the patient and has a lower postoperative mortality rate. This procedure involves a learning curve among surgeons.

Robotic-assisted colectomy for right-sided colon cancer: Short-term surgical outcomes of a multi-institutional prospective cohort study in Japan

Background

In Japan, there are no substantial reports on robotic-assisted colectomy because few institutions performed the procedure, as it was not covered by national insurance until March 2022.

Aim

This study aimed to evaluate the safety and feasibility of robotic-assisted colectomy for patients with curatively resectable colon cancer in Japan.

Methods

This multi-institutional, prospective, single-arm, observational study enrolled patients diagnosed with curatively resectable clinical stage I-IIIC colon adenocarcinoma with D2 or D3 lymph node dissection and treated with robotic-assisted colectomy. The primary endpoint was the conversion rate to laparotomy. The non-inferiority of outcomes for robotic-assisted colectomy versus laparoscopic colectomy, which was determined from historical data, was verified.

Results

One hundred patients were registered between July 2019 and March 2022 and underwent robotic-assisted colectomy performed by seven expert surgeons at six institutions. Thirteen patients were excluded because their surgeons had insufficient experience performing robotic-assisted colectomy; therefore, 87 patients were eligible for the primary endpoint analysis. There was no conversion in these 87 patients, and robotic-assisted colectomy was non-inferior to laparoscopic colectomy in terms of conversion rate (90% confidence interval 0-3.38, p = 0.0006). No intraoperative adverse events occurred, and no mortality was observed in a total of 100 patients. The rate of patients with Clavien-Dindo complications grade III or higher was 4%.

Conclusion

This study showed the non-inferiority of the conversion rates between robotic-assisted colectomy and laparoscopic colectomy. Favorable perioperative outcomes also suggest the safety and feasibility of robotic-assisted colectomy.

Uptake of robot-assisted colon cancer surgery in the Netherlands

BACKGROUND

The robot-assisted approach is now often used for rectal cancer surgery, but its use in colon cancer surgery is less well defined. This study aims to compare the outcomes of robotic-assisted colon cancer surgery to conventional laparoscopy in the Netherlands.

METHODS

Data on all patients who underwent surgery for colon cancer from 2018 to 2020 were collected from the Dutch Colorectal Audit. All complications, readmissions, and deaths within 90 days after surgery were recorded along with conversion rate, margin and harvested nodes. Groups were stratified according to the robot-assisted and laparoscopic approach.

RESULTS

In total, 18,886 patients were included in the analyses. The operative approach was open in 15.2%, laparoscopic in 78.9% and robot-assisted in 5.9%. The proportion of robot-assisted surgery increased from 4.7% in 2018 to 6.9% in 2020. There were no notable differences in outcomes between the robot-assisted and laparoscopic approach for Elective cT1-3M0 right, left, and sigmoid colectomy. Only conversion rate was consistently lower in the robotic group. (4.6% versus 8.8%, 4.6% versus 11.6%, and 1.6 versus 5.9%, respectively).

CONCLUSIONS

This nationwide study on surgery for colon cancer shows there is a gradual but slow adoption of robotic surgery for colon cancer up to 6.9% in 2020. When comparing the outcomes of right, left, and sigmoid colectomy, clinical outcomes were similar between the robotic and laparoscopic approach. However, conversion rate is consistently lower in the robotic procedures.

Extent of Lymph Node Harvest: A Retrospective Cohort Comparison of Intracorporeal Versus Extracorporeal Anastomosis in Right Hemicolectomy

Background: Minimally invasive surgery has been demonstrated to have clear advantages in colon cancer management, with a decrease in the morbidity and mortality associated with surgery. With the introduction of intracorporeal anastomosis (ICA), the entire mesenteric dissection and division is performed under vision laparoscopically and may lead to superior lymph node harvest. The aim of our study is to evaluate lymph node harvest in patients undergoing totally laparoscopic right hemicolectomy with ICA compared to laparoscopic-assisted right hemicolectomy with extracorporeal anastomosis (ECA). Methods: This is a single institution retrospective cohort study. Eligible patients underwent laparoscopic right hemicolectomy at our institution between 2012 and 2022. Patients were identified using a hospital database, and surgeon office databases. Patients included underwent laparoscopic right hemicolectomy for neoplastic lesions (colon cancer/unresectable polyps), or benign etiologies. We excluded patients who underwent laparotomy (intra-operative conversion), resection without anastomosis, resection for IBD, or lack of documented lymph node number. Data were compared using two-sided t-test evaluation with a 95% confidence interval. Results: A total of 679 patients were included, 493 ECA (72.6%) and 186 ICA (27.4%). Patient demographics (age, biologic sex, American Society of Anesthesiologists and body mass index) were not significantly different. Lymph node harvest was significantly higher in those with ICA (24 ± 14 versus 21 ± 1, P < .05). In subgroup analysis, this difference was maintained in patients with malignant processes (27 ± 14 versus 23 ± 10, P < .05). Conclusions: In our experience, ICA has higher lymph node harvest in comparison to ECA. This may improve outcomes and options for adjuvant therapies in malignant indications.

Short-term outcomes associated with the use of a new powered circular stapler for rectal reconstructions: a retrospective study comparing it to manual circular staplers using inverse probability of treatment weight analysis

BACKGROUND

The most common postoperative complication in malignant rectal surgery is anastomotic leakage (AL). AL after anterior or low anterior resection in rectal tumors is a fatal postoperative complication. Recently, the first automated suture circular stapler, which is expected to reduce the incidence of AL, (J&J). MATERIALS AND METHODS: This study included a total of 248 rectal tumor patients who underwent double stapler technique (DST) anastomotic procedures in the department of gastroenterological surgery /pediatric surgery at Gifu University School of Medicine from January 2017 to December 2021. The experience of a single institution utilizing the The Echelon circular™ stapler (ECP stapler:Manual VS Automatic) in rectal surgery cases was evaluated retrospectively from maintained database.

RESULT

One hundred thirty-nine patients (58.4%) were performed by manual circular stapling, 99 patients (41.6%) by powerd circular stapling. Diverting stoma was performed in 45 cases (32.4%) by manual circular stapling, 42 patients (42.4%) by powerd circular stapling Postoperative complications were occurred clavien-dindo grade II or higher in 57 cases (23.9%) and grade III or higher in 20 cases (8.4%). Anastomotic leakage occurred in 14 patients (5.9%) within all grades. After IPTW, the variables of patient characteristics was SMD ≤ 0.2 (Table.3), and there was a significant difference in anastomotic leakage (Odds Ratio (OR), 0.57; 95% Confidence Interval(CI), 0.34-0.98; p = 0.041). In addition, there was no significant difference in postoperative complications in grade II or higher (OR, 0.88; 95%CI, 0.65-1.19; p = 0.417) and grade III or higher (OR, 0.46; 95%CI, 0.29-0.74; p = 0.001) were significantly remarkable lower in powered circular stapling group.

CONCLUSION

In this IPTW comparison of patients undergoing rectal reconstructions, the ECP trial cohort had lower risks of several surgical complications AL and statistically signifcant lower rates of ileus/bowel obstruction, infection, and bleeding as Clavien-Dindo ≥ grade II and III as compared with for whom manual circular staplers were used.

Closed-chest robotic repair of mitral prolapse. Surgical technique and early results

Background

Robotic mitral repair is generally performed with four intercostal trocars and a minithoracotomy. We describe our technique and results with a totally-thoracoscopic closed chest approach using a 12 mm valveless trocar as "working port", without a minithoracotomy. We compared our results with this technique with a control group of robotic mitral repairs performed earlier with a minithoracotomy.

Methods

Review of all patients with degenerative mitral valve disease who underwent robotic mitral valve repair surgery since December 2019 (n = 110). Patients with concomitant procedures (n = 8) were excluded. The remaining 102 patients were divided in two groups, depending on the approach used, minithoracotomy (n = 63) and totally thoracoscopic (n = 39).

Results

There were no significant differences between groups regarding preoperative characteristics. All procedures were completed robotically as planned, and repair rate was 100%. The minithoracotomy group showed a higher percentage of leaflet resections (17.9% vs. 38.7%; p = 0.03). All surgical times were significatively reduced in the totally thoracoscopic group: Cardiopulmonary bypass (97 vs. 115 min, p = 0.0008), ischemic time (67 vs. 80 min, p = 0.0013) and total surgical time (185 vs. 225 min; p < 0.00001). There were no differences in ICU length of stay (1 day, p = 0.07) but hospital length of stay was shorter in the totally thoracoscopic group (4 days; p = 0.0001). Postoperative complications were similar between groups. MR at discharge was mild or less in all cases.

Conclusions

Robotic mitral repair for degenerative disease can be safely performed as a closed-chest procedure, using a 12 mm trocar as "working port" and avoiding the need for a minithoracotomy. This approach does not seem to negatively affect the quality of the procedure by any measure, providing similar excellent clinical outcomes and repair rate. All surgical times were shorter in the closed-chest group.

Comparison of Robotic, Laparoscopic, and Open Resections of Nonmetastatic Colon Cancer

BACKGROUND

Laparoscopic resection for colon cancer has not been associated with improvements in oncological outcomes in comparison to open resection. Robotic resections are associated with increased lymph node yield and radicality of mesenteric resection in patients with right-sided tumors. It is unclear whether lymph node yield is higher in robotic resections in other parts of the colon and whether higher lymph node yield is associated with improved survival.

OBJECTIVE

To compare survival rates between robotic, laparoscopic, and open resections in a large cohort of patients with nonmetastatic colon cancer.

DESIGN

This is a retrospective observational study.

SETTING

A single comprehensive cancer center.

PATIENTS

Patients who underwent resection of nonmetastatic primary colon cancer between January 2006 and December 2018.

MAIN OUTCOME MEASURES

Univariable and multivariable models were used to identify predictors of disease-free and overall survival. Lymph node yield and perioperative outcomes were compared between operative approaches.

RESULTS

There were 2398 patients who met the inclusion criteria: 699 (29%) underwent open, 824 (34%) underwent laparoscopic, and 875 (36%) underwent robotic resection. The median follow-up was 3.8 years (45.4 months). Robotic surgery was associated with higher lymph node yield and radicality of mesenteric resection. On multivariable analysis, the surgical approach was not associated with a difference in disease-free or overall survival. Minimally invasive colectomy was associated with fewer complications and shorter length of stay in comparison to open surgery. In a direct comparison between the 2 minimally invasive approaches, robotic colectomy was associated with fewer complications, shorter length of stay, and lower conversion rate than laparoscopy.

LIMITATIONS

This was a single-center retrospective study.

CONCLUSIONS

Our data indicate that the 3 surgical approaches are similarly effective in treating primary resectable colon cancer and that differences in outcomes are observed primarily in the early postoperative period. See Video Abstract at http://links.lww.com/DCR/C115 .

COMPARACIN DE RESECCIONES ROBTICAS, LAPAROSCPICAS Y ABIERTAS DE CNCER DE COLON NO METASTSICO

ANTECEDENTES:La resección laparoscópica para el cáncer de colon no se ha asociado con mejoras en los resultados oncológicos en comparación con la resección abierta. Las resecciones robóticas se asocian con un mayor rendimiento de los ganglios linfáticos y la radicalidad de la resección mesentérica en pacientes con tumores del lado derecho. No está claro si la cosecha ganglionar es mayor en las resecciones robóticas en otras partes del colon y si un mayor rendimiento de los ganglios linfáticos se asocia con una mejor supervivencia.OBJETIVO:Comparar las tasas de supervivencia entre resecciones robóticas, laparoscópicas y abiertas en una gran cohorte de pacientes con cáncer de colon no metastásico.DISEÑO:Este es un estudio observacional retrospectivo.ESCENARIO:Este estudio se realizó en un único centro oncológico integral.PACIENTES:Pacientes que se sometieron a resección de cáncer de colon primario no metastásico entre enero de 2006 y diciembre de 2018.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizaron modelos univariables y multivariables para identificar predictores de supervivencia libre de enfermedad y global. La cosecha ganglionar y los resultados perioperatorios se compararon entre los abordajes quirúrgicos.RESULTADOS:Hubo 2398 pacientes que cumplieron con los criterios de inclusión: 699 (29%) se sometieron a cirugía abierta, 824 (34%) se sometieron a resección laparoscópica y 875 (36%) se sometieron a resección robótica. La mediana de seguimiento fue de 3,8 años (45,4 meses). La cirugía robótica se asoció con una mayor cosecha ganglionar y la radicalidad de la resección mesentérica. En el análisis multivariable, el abordaje quirúrgico no se asoció con una diferencia en la supervivencia general o libre de enfermedad. La colectomía mínimamente invasiva se asoció con menos complicaciones y una estancia más corta en comparación con la cirugía abierta. En una comparación directa entre los dos enfoques mínimamente invasivos, la colectomía robótica se asoció con menos complicaciones, una estancia más corta y una tasa de conversión más baja que la laparoscopia.LIMITACIONES:Este fue un estudio retrospectivo de un solo centro.CONCLUSIONES:Nuestros datos indican que los tres enfoques quirúrgicos son igualmente efectivos en el tratamiento del cáncer de colon resecable primario y que las diferencias en los resultados se observan principalmente en el período posoperatorio temprano. Consulte Video Resumen en http://links.lww.com/DCR/C115 . (Traducción-Dr. Felipe Bellolio ).

Stoma-site approach single-port laparoscopic versus conventional multi-port laparoscopic Miles's procedure for low rectal cancer: A prospective, randomized controlled trial

OBJECTIVE

The aim of this study was to compare perioperative outcomes of patients with low rectal cancer after stoma-site approach single-port laparoscopic Miles procedure or conventional multi-port laparoscopic Miles procedure, as well as to evaluate the safety and efficacy of stoma-site approach single-port laparoscopic surgery in low rectal cancer.

METHODS

Between September 2020 and September 2021, 51 low rectal cancer patients scheduled for Miles procedure at the Department of Gastrointestinal Surgery of Affiliated Hospital of North Sichuan Medical College were randomly assigned to the single-port laparoscopic surgery group (SPLS) and the multi-port laparoscopic surgery (MPLS) group. The perioperative outcomes were compared between the two groups.

RESULTS

In this study, 25 patients underwent SPLS and 26 underwent MPLS. All patients completed the study, and there were no perioperative deaths in either group. Observation indicators such as intraoperative bleeding (39 mL vs. 41 mL), number of lymph nodes (20.12 ± 3.29 vs. 21.84 ± 3.74), average hospital stay (7.15 ± 1.52 vs. 7.64 ± 1.66), and time to flatulence (2.5d vs. 2.5d) showed no significant differences between the SPLS and MPLS groups (p > 0.05). However, the operation duration (180 min vs. 118 min) and perioperative complications showed statistically significant differences between the two groups (p < 0.05). In addition, patients in the SPLS group had significantly higher satisfaction scores than those in the MPLS group (p < 0.05).

CONCLUSION

For patients with low rectal cancer requiring Miles surgery, stoma-site approach single-port laparoscopic surgery has comparable safety and efficacy to multi-port laparoscopic surgery.

Feasibility and safety of hybrid transvaginal natural orifice transluminal endoscopic surgery for colon cancer: Protocol for a multicenter, single-arm, phase II trial (vNOTESCA)

Introduction

It has been a decade since the first patient with colon cancer underwent colectomy by hybrid transvaginal natural orifice transluminal endoscopic surgery (hvNOTES). However, the efficacy and safety of this procedure is not well established.

Methods

This study is an open-label, multicenter, single-arm, phase 2 trial undertaken at six centers in China. Female patients aged over 18 years and below 80 years old with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, with pathologically proven, resectable, cT1-3N0-2M0 disease who have previously untreated colon cancer are eligible for inclusion. The primary endpoint is a composite of major intraoperative and postoperative complications (greater than grade III, the Common Terminology Criteria for Adverse Events [CTCAE], version 5.0). Secondary endpoints include conversion to laparoscopic or open surgery, postoperative concentration of C-Reactive Protein and procalcitonine, complete pathological assessment of complete mesocolic excision specimens, postoperative pain, amount of narcotic pain medication administered, time to first flatus after surgery, number of harvested lymph nodes, R0 resection rate, length of hospital stay, sexual function assessment, quality of recovery, satisfaction with surgical scars, quality of life, postoperative recurrence patterns, relapse-free survival, and overall survival.

Ethics and dissemination

The study was approved by the Research Ethics Committee, Renmin Hospital of Wuhan University, China, number: WDRY2022-K053. All patients will receive written information of the trial and provide informed consent before enrollment. The results of this trial will be disseminated in academic conferences and peer-reviewed medical journals.Trial registration number NCT04048421.

Implementation of totally robotic right hemicolectomy: lessons learned from a prospective cohort

Robotics facilitates the realization of intra-corporeal anastomosis during right hemicolectomy and allows extracting the operative specimen through a C-section, offering potential benefits in terms of post-operative recovery and incidence of incisional hernia. Therefore, we progressively implemented robotic right hemicolectomy (robRHC) in our centre, and would like to report our initial experience with the technique. Consecutive patients who underwent robRHC within a single centre were prospectively included. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected. Sixty patients underwent robRHC in our centre. Indications for robRHC were colon cancer in 58 patients (96.7%) and polyps not amenable to endoscopic resection in 2 patients (3.3%). Fifty-eight patients underwent robRHC with D2 lymphadenectomy and central vessel ligation (96.7%), and two patients (3.3%) had robRHC associated with another procedure. All patients had intra-corporeal anastomosis. The mean ± operative time was of 200.4 ± 114.9 min. Two conversions (3.3%) to open surgery were performed. The mean ± SD length of stay was of 5.4 ± 3.8 days. Seven patients (11.7%) experienced a post-operative complication with a Clavien-Dindo score ≥ 2. Two patients (3.5%) had an anastomotic leak. The mean ± SD number of harvested lymph nodes was of 22.4 ± 7.6. All patients had negative pathological margins (R0 resection). To conclude, robotic RHC is a safe procedure, which can be implemented with satisfying peri- and post-operative outcomes. The potential benefits of the technique remain to be demonstrated by randomized controlled trials.

Postoperative inflammatory response in colorectal cancer surgery: a meta-analysis

PURPOSE

Surgical removal of the cancerous tissue remains the cornerstone of curative treatment for colorectal cancer and results in an inflammatory response. An exaggerated inflammatory response has been implicated in the promotion of tumor proliferation and has shown associations with postoperative complications. Literature on the preferred surgical technique to minimize inflammatory response is inconclusive. Therefore, the aim of this study was to assess the inflammatory response and postoperative incidence of infectious complications following surgery for colorectal cancer.

METHODS

Embase, PubMed, and Cochrane databases were searched for RCTs that reported inflammatory parameters as a function of surgical modality only. Data related to CRP or IL-6 levels on postoperative days 1 and 3 and data related to postoperative infections were subject to a pairwise meta-analysis to compare open versus laparoscopic techniques.

RESULTS

The literature search and screening process yielded 4151 studies. Ten studies met criteria, including 568 patients. Only studies on laparoscopic and open surgery were found. Pooled analyses found lower Il-6 and CRP levels on postoperative day 1 and lower CRP levels on postoperative day 3 for laparoscopic surgery compared to open surgery. However, there was no difference in incidence of postoperative infectious complications.

CONCLUSION

The findings of this study indicate a superior inflammatory profile for laparoscopic surgery compared to an open approach for colorectal cancer surgery. For future research, it would be worthwhile to conduct a randomized controlled trial to compare the postoperative inflammatory response and related clinical outcomes between minimally invasive surgical approaches, including laparoscopic and robot-assisted surgery.

Clinical outcomes of elective robotic vs laparoscopic surgery for colon cancer utilizing a large national database

BACKGROUND

Prior studies have shown comparable outcomes between laparoscopic and robotic approaches across a range of surgeries; however, these have been limited in size. This study investigates differences in outcomes following robotic (RC) vs laparoscopic (LC) colectomy across several years utilizing a large national database.

METHODS

We analyzed data from ACS NSQIP for patients who underwent elective minimally invasive colectomies for colon cancer from 2012 to 2020. Inverse probability weighting with regression adjustment (IPWRA) incorporating demographics, operative factors, and comorbidities was used. Outcomes included mortality, complications, return to the operating room (OR), post-operative length of stay (LOS), operative time, readmission, and anastomotic leak. Secondary analysis was performed to further assess anastomotic leak rate following right and left colectomies.

RESULTS

We identified 83,841 patients who underwent elective minimally invasive colectomies: 14,122 (16.8%) RC and 69,719 (83.2%) LC. Patients who underwent RC were younger, more likely to be male, non-Hispanic White, with higher body mass index (BMI) and fewer comorbidities (for all, P < 0.05). After adjustment, there were no differences between RC and LC for 30-day mortality (0.8% vs 0.9% respectively, P = 0.457) or overall complications (16.9% vs 17.2%, P = 0.432). RC was associated with higher return to OR (5.1% vs 3.6%, P < 0.001), lower LOS (4.9 vs 5.1 days, P < 0.001), longer operative time (247 vs 184 min, P < 0.001), and higher rates of readmission (8.8% vs 7.2%, P < 0.001). Anastomotic leak rates were comparable for right-sided RC vs LC (2.1% vs 2.2%, P = 0.713), higher for left-sided LC (2.7%, P < 0.001), and highest for left-sided RC (3.4%, P < 0.001).

CONCLUSIONS

Robotic approach for elective colon cancer resection has similar outcomes to its laparoscopic counterpart. There were no differences in mortality or overall complications, however anastomotic leaks were highest after left RC. Further investigation is imperative to better understand the potential impact of technological advancement such as robotic surgery on patient outcomes.

Risk factors for small-bowel obstruction after colectomy for colorectal cancer: a retrospective study

PURPOSE

Postoperative adhesions are a concerning complication of abdominal surgery with major implications on quality of life. This study aimed to investigate the risk factors for postoperative small-bowel obstruction (SBO) after colectomy for colorectal cancer.

METHODS

We reviewed the clinicopathological variables of 1646 patients who underwent colectomy for colorectal cancer between 2009 and 2018.

RESULTS

SBO occurred following primary tumor resection for colorectal cancer in 67 (4.1%) of the 1646 patients. The median observation period was 7.5 (range: 3.0-12.0) years. Multivariate analysis revealed that rectal tumors, anastomotic leakages, previous abdominal surgeries, and longer operating times were all correlated with postoperative SBO, but there were no differences in the incidence of SBO between laparoscopic vs. open surgery. The use of adhesion prevention material had no effect on SBO. Our data showed that the onset of SBO tended to be relatively early, within a year after surgery (89.5%).

CONCLUSIONS

Tumor localization in the rectum is associated with several problems, including a wide resection area, prolonged operative duration, and high risk of anastomotic leakage, which may increase the risk of SBO. Laparoscopic surgery and adhesion prevention material did not demonstrate a clear preventive effect against SBO.

Adjuvant Chemotherapy Is Associated with Improved Survival for Stage III Colon Cancer When Initiated Beyond 8 Weeks

BACKGROUND

The National Comprehensive Cancer Network (NCCN) guidelines recommend adjuvant chemotherapy (AC) within 6-8 weeks of surgical resection for patients with stage III colon cancer. However, postoperative complications or prolonged surgical recovery may affect the receipt of AC. The aim of this study was to assess the utility of AC for patients with prolonged postoperative recovery.

METHODS

We queried the National Cancer Database (2010-2018) for patients with resected stage III colon cancer. Patients were categorized as having either normal or prolonged length of stay (PLOS: >7 days, 75th percentile). Multivariable Cox proportional hazard regression and logistic regressions were used to identify factors associated with overall survival and receipt of AC.

RESULTS

Of the 113,387 patients included, 30,196 (26.6%) experienced PLOS. Of the 88,115 (77.7%) patients who received AC, 22,707 (25.8%) initiated AC more than 8 weeks after surgery. Patients with PLOS were less likely to receive AC (71.5% vs. 80.0%, OR: 0.72, 95%CI=0.70-0.75) and displayed inferior survival (75 vs. 116 months, HR: 1.39, 95%CI=1.36-1.43). Receipt of AC was also associated with patient factors such as high socioeconomic status, private insurance, and White race (p<0.05 for all). AC within and after 8 weeks of surgery was associated with improved survival for patients with both normal LOS and PLOS (normal LOS: <8 weeks HR: 0.56, 95% CI: 0.54-0.59, >8 weeks HR: 0.68, 95% CI: 0.65-0.71; PLOS: <8 weeks HR: 0.51, 95% CI: 0.48-0.54, >8 weeks HR: 0.63, 95% CI 0.60-0.67). AC was associated with significantly improved survival if initiated up to 15 weeks postoperatively (normal LOS: HR: 0.72, 95%CI=0.61-0.85; PLOS: HR: 0.75, 95%CI=0.62-0.90), and very few patients (<3.0%) initiated AC beyond this time.

CONCLUSION

Receipt of AC for stage III colon cancer may be affected by surgical complications or otherwise prolonged recovery. Timely and even delayed AC (>8 weeks) are both associated with improved overall survival. These findings highlight the importance of delivering guideline-based systemic therapies, even after complicated surgical recovery.

Immune changes induced by periampullary adenocarcinoma are reversed after tumor resection and modulate the postoperative survival

BACKGROUND

Tumor growth encompasses multiple immunologic processes leading to impaired immunity. Regarding cancer surgery, the perioperative period is characterized by additional immunosuppression, which may contribute to poorer outcomes. In this exploratory study, we assessed plasma parameters characterizing the perioperative immunity with a particular focus on their prognostic value.

PATIENTS AND METHODS

31 patients undergoing pancreatoduodenectomy were enrolled (adenocarcinoma of the pancreatic head and its periampullary region: n = 24, benign pancreatic diseases n = 7). Abundance and function of circulating immune cells and the plasma protein expression were analyzed in blood samples taken pre- and postoperatively using flow cytometry, ELISA and Proximity Extension Assay.

RESULTS

Prior to surgery, an increased population of Tregs, a lower level of intermediate monocytes, a decreased proportion of activated T-cells, and a reduced response of T-cells to stimulation in vitro were associated with cancer. On the first postoperative day, both groups showed similar dynamics. The preoperative alterations did not persist six weeks postoperatively. Moreover, several preoperative parameters correlated with postoperative survival.

CONCLUSION

Our data suggests systemic immunologic changes in adenocarcinoma patients, which are reversible six weeks after tumor resection. Additionally, the preoperative immune status affects postoperative survival. In summary, our results implicate prognostic and therapeutic potential, justifying further trials on the perioperative tumor immunity to maximize the benefit of surgical tumor therapy.

Benefits of a laparoscopic approach for second colorectal resection after colectomy or proctectomy -a retrospective study

BACKGROUND

A laparoscopic approach generally provides several benefits in patients who undergo colon or rectal surgery without jeopardizing oncological outcomes. However, there is a paucity of studies on comparative outcomes of laparoscopic versus open approaches for second primary colorectal lesions after colectomy or proctectomy.

METHODS

From patients with colorectal disease who underwent surgery between 2008 and 2022 at our hospital, we collected 69 consecutive patients who had previous colorectal surgery for this retrospective study. Based on the second surgery approach (laparoscopic or open), patients were classified into the Lap (n = 37) or Op group (n = 32). Patients' baseline data and perioperative and postoperative outcomes were compared between the two groups.

RESULTS

Four patients (11%) of the Lap group needed conversion to laparotomy. The intraoperative blood loss was lower in the Lap group than the Op group (median: 45 ml vs. 205 ml, p = 0.001). The time to first bowel movement was shorter in the Lap group than the Op group (median: 2.8 days vs. 3.6 days, p = 0.007). The operative time, frequencies of postoperative morbidities, and overall survival did not differ between the two groups.

CONCLUSION

Laparoscopic surgery appeared feasible and beneficial for selected patients undergoing second colorectal resection after colectomy or proctectomy regarding blood loss and bowel function recovery without affecting other outcomes.

Short-term outcomes following intracorporeal vs. extracorporeal anastomosis after laparoscopic right and left-sided colectomy: a propensity score-matched study

BACKGROUND

To compare the short-term outcomes of patients undergoing intracorporeal anastomosis (IA) during laparoscopic colectomy to those undergoing extracorporeal anastomosis (EA).

METHODS AND MATERIALS

The study was a single-centre retrospective propensity score-matched analysis conducted. Consecutive patients who underwent elective laparoscopic colectomy without the double stapling technique between January 2018 and June 2021 were investigated. The main outcome was overall postoperative complications within 30 days after the procedure. The authors also performed a sub-analysis of the postoperative results of ileocolic anastomosis and colocolic anastomosis, respectively.

RESULTS

A total of 283 patients were initially extracted; after propensity score matching, there were 113 patients in each of the IA and EA groups. There were no differences in patient characteristics between the two groups. The IA group had a significantly longer operative time than the EA group (208 vs. 183 min, P =0.001). The rate of overall postoperative complications was significantly lower in the IA group ( n =18, 15.9%) than in the EA group ( n =34, 30.1%; P =0.02), especially in colocolic anastomosis after left-sided colectomy (IA: 23.8% vs. EA: 59.1%; P =0.03). Postoperative inflammatory marker levels were significantly higher in the IA group on postoperative day 1 but not on postoperative day 7. There was no difference in the postoperative lengths of hospital stay between the two groups, and no deaths occurred.

CONCLUSION

The data suggest that performing IA during laparoscopic colectomy can potentially reduce the risk of postoperative complications, especially in colocolic anastomosis after left-sided colectomy.

Randomized controlled trial comparing cosmetic results of midline incision versus off-midline incision for specimen extraction in laparoscopic colectomy

PURPOSE

A notable advantage of laparoscopic colorectal surgery is that only a small incision at the extraction site is necessary, which is considered to be cosmetically beneficial. Meanwhile, the optimal extraction site for the resected specimen in laparoscopic colectomy is controversial in terms of cosmetic benefit. This randomized controlled trial compares midline and off-midline extraction sites in laparoscopic colectomy in patients with colon cancer, with consideration of cosmetic benefits as the primary endpoint.

METHODS

Included were patients that underwent elective laparoscopic colectomy at WMUH between October 2014 and February 2017. Patients were randomly assigned to either midline incision group or off-midline incision group. Prospectively collected data included cosmetic results (patients and observer assessment scale) and complications including incidence of incisional hernia, SSI, and pain. This trial was registered with UMIN Clinical Trials (UMIN000028943).

RESULTS

Finally, 98 patients with colorectal cancer were analyzed. No significant differences were found between the two groups in patient and observer assessment scales of cosmetic results (midline 8 ± 1.1 vs off-midline 11 ± 5.9 p = 0.16, midline 13.5 ± 6.6 vs off-midline 15 ± 11 p = 0.58, respectively) or in postoperative pain. However, incisional hernia occurred in four cases in the midline group (8%), which was significantly higher than that in the off-midline group (no cases, 0%).

CONCLUSION

There was no significant difference in terms of cosmetic benefit, the primary endpoint, between the two groups. In this study, only the extraction site location was compared; future studies will examine differences depending on the incisional direction, including the incidence of incisional hernia.

Clinical outcomes and cost comparison of laparoscopic versus open surgery in elderly colorectal cancer patients over 80 years

PURPOSE

The growth of Singapore's geriatric population, coupled with the rise in colorectal cancer (CRC), has increased the number of colorectal surgeries performed on elderly patients. This study aimed to compare the clinical outcomes and costs of laparoscopic versus open elective colorectal resections in elderly CRC patients over 80 years.

METHODS

A retrospective cohort study using data from the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) identified patients over 80 years undergoing elective colectomy and proctectomy between 2018 and 2021. Patient demographics, length of stay (LOS), 30-day postoperative complications, and mortality rates were analysed. Cost data in Singapore dollars were obtained from the finance database. Univariate and multivariate regression models were used to determine cost drivers. The 5-year overall survival (OS) for the entire octogenarian CRC cohort with and without postoperative complications was estimated using the Kaplan-Meier curves.

RESULTS

Of the 192 octogenarian CRC patients undergoing elective colorectal surgery between 2018 and 2021, 114 underwent laparoscopic resection (59.4%), while 78 underwent open surgery (40.6%). The proportion of proctectomy cases was similar between laparoscopic and open groups (24.6% vs. 23.1%, P = 0.949). Baseline characteristics, including Charlson Comorbidity Index, albumin level, and tumour staging, were comparable between both groups. Median operative duration was 52.5 min longer in the laparoscopic group (232.5 vs. 180.0 min, P < 0.001). Both groups had no significant differences in postoperative complications and 30-day and 1-year mortality rates. Median LOS was 6 days in the laparoscopic group compared to 9 days in the open group (P < 0.001). The mean total cost was 11.7% lower in the laparoscopic group (S$25,583.44 vs. S$28,970.85, P = 0.012). Proctectomy (P = 0.024), postoperative pneumonia (P < 0.001) and urinary tract infection (P < 0.001), and prolonged LOS > 6 days (P < 0.001) were factors contributing to increased costs in the entire cohort. The 5-year OS of octogenarians with minor or major postoperative complications was significantly lower than those without complications (P < 0.001).

CONCLUSION

Laparoscopic resection is associated with significantly reduced overall hospitalization costs and decreased LOS compared to open resection among octogenarian CRC patients, with comparable postoperative outcomes and 30-day and 1-year mortality rates. The extended operative time and higher consumables costs from laparoscopic resection were mitigated by the decrease in other inpatient hospitalization costs, including ward accommodation, daily treatment fees, investigation costs, and rehabilitation expenditures. Comprehensive perioperative care and optimised surgical approach to mitigate the impact of postoperative complications can improve survival in elderly patients undergoing CRC resection.

Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review

Background

Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety.

Methods

A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery.

Conclusion

The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.

Current Controversies in the Management of Locally Advanced Colon Cancer

n/a.

"Caudal to cranial" versus "medial to lateral" approach in laparoscopic right hemicolectomy with complete mesocolic excision for the treatment of stage II and III colon cancer: perioperative outcomes and 5-year prognosis

The purpose of this study was to compare the "caudal to cranial" (CC) versus "medial to lateral" (ML) approach for laparoscopic right hemicolectomy. Pertinent data from all patients with stage II and III between January 2015 and August 2017 were entered into a retrospective database. A total of 175 patients underwent the ML (N = 109) or CC approach (N = 66). Patient characteristics were equivalent between groups. The CC group showed a shorter surgical time 170.00 (145.00, 210.00) vs. (206.50 (178.75, 226.25) min) than the ML group (p < 0.001). The time to oral intake was shorter in the CC group than in the ML group ((3.00 (1.00, 4.00) vs. 3.00 (2.00, 5.00) days; p = 0.007). For the total harvested lymph nodes, there was no statistical significance between the CC group 16.50 (14.00, 21.25) and the ML group 18.00 (15.00, 22.00) (p = 0.327), and no difference was found in the positive harvested lymph nodes (0 (0, 2.00) vs. 0 (0, 1.50); p = 0.753). Meanwhile, no differences were found in other perioperative or pathological outcomes, including blood loss and complications. For 5-year prognosis, overall survival rates were 75.76% in the CC group and 82.57% in the ML group (HR 0.654, 95% CI 0.336-1.273, p = 0.207); disease-free survival rates were 80.30% in the CC group and 85.32% in the ML group (HR 0.683, 95% CI 0.328-1.422, p = 0.305). Both approaches were safe and feasible and resulted in excellent survival. The CC approach was beneficial in terms of the surgical time and time to oral intake.

Disparities in access to robotic technology and perioperative outcomes among patients treated with radical prostatectomy

BACKGROUND

Most radical prostatectomies are completed with robotic assistance. While studies have previously evaluated perioperative outcomes of robot-assisted radical prostatectomy (RARP), this study investigates disparities in access and clinical outcomes of RARP.

STUDY DESIGN

The National Cancer Database (NCDB) was used to identify patients who received radical prostatectomy for cancer between 2010 and 2017 with outcomes through 2018. RARP was compared to open radical prostatectomy (ORP). Odds of receiving RARP were evaluated while adjusting for covariates. Overall survival was evaluated using a propensity-score matched cohort.

RESULTS

Overall, 354 752 patients were included with 297 676 (83.9%) receiving RARP. Patients who were non-Hispanic Black (82.8%) or Hispanic (81.3%) had lower rates of RARP than non-Hispanic White (84.0%) or Asian patients (87.7%, p < 0.001). Medicaid or uninsured patients were less likely to receive RARP (75.5%) compared to patients with Medicare or private insurance (84.4%, p < 0.001). Medicaid or uninsured status was associated with decreased odds of RARP in adjusted multivariable analysis (OR 0.61, 95% CI 0.49-0.76). RARP was associated with decreased perioperative mortality and improved overall survival compared to ORP.

CONCLUSION

Patients who were underinsured were less likely to receive RARP. Improved access to RARP may lead to decreased disparities in perioperative outcomes for prostate cancer.

Factors Influencing Performance in Laparoscopic Suturing and Knot Tying: A Cohort Study

BACKGROUND

 Laparoscopic suturing and knot tying are regarded as some of the most difficult laparoscopic skills to learn. Training is essential to reach proficiency, but available training opportunities are limited. Various techniques to improve training have been evaluated. It appears that individual-related factors affect initial performance and response to training. Thus, the current study aimed to assess factors influencing laparoscopic-suturing and knot-tying performances.

METHODS

 All patients were trained one-on-one (teacher-student) for 3 hours. Patients were tested before training (bowel anastomosis model) and directly after training (congenital diaphragmatic hernia or esophageal atresia model) to evaluate transferability. Primary endpoints were time, knot quality, precision, knot strength, and overall laparoscopic knotting performance. Moreover, factors such as (1) age, (2) gender, (3) handedness, (4) previous training or operative experience, (5) playing an instrument, (6) sportive activities, and (7) computer gaming which may influence the primary endpoints were assessed.

RESULTS

 In total, 172 medical students or novice surgical residents were included. Training significantly improved all outcome parameters assessed in the current study. More than 50% of the patients reached proficiency after 3 hours of training. Personal factors like operative experience, playing music instruments, sportive activities, and computer gaming affected some outcome parameters. Handedness and gender affected initial performance but differences partially subsided after training. Younger participants showed a much better response to training.

CONCLUSION

 In conclusion, several factors influence initial performance and response to the training of laparoscopic suturing and knot tying. Surgeons who want to improve their laparoscopic performance, should concentrate on playing a musical instrument and performing sports rather than playing videos gaming. It appears that training is a key and more practice opportunities should be incorporated into medical school and surgical curricula. Moreover, handedness may affect the outcome but only if the training concepts are not tailored to the dominant hand of the surgeon. Future training and surgical curricula should adapt to this and tailor their concepts accordingly.