Oncological outcomes of laparoscopic versus open rectal cancer resections: meta-analysis of randomized clinical trials

Laparoscopic approach for rectal cancer surgery: triumph of reason or necessity of evolution?

The role of laparoscopy in rectal cancer surgery has evolved considerably since the early 2000s. Initial randomized trials, such as COLOR II and COREAN, indicated that laparoscopic approaches offered similar pathological outcomes with better postoperative recovery than open surgery. In contrast, trials like ACOSOG Z6051 and ALaCaRT suggested noninferiority could not be established. Variability in trial outcomes, focusing on either disease-free survival or pathological measures, initially hindered consensus. Long-term analyses have shown no significant difference in disease-free survival between laparoscopic and open approaches. Meta-analyses have reinforced the benefits of laparoscopic surgery, with reduced mortality and similar oncologic effectiveness to open surgery. However, new techniques like transanal TME (TaTME) and robotic approaches have introduced alternatives, though each presents unique challenges, from recurrence rates in TaTME to costs in robotics. While laparoscopy remains the preferred method due to accessibility and outcomes, robotic surgery is expected to gain traction in high-volume centers.

Rectal Eversion as an Anus-sparing Technique in Laparoscopic Low Anterior Resection With Double Stapling Anastomosis: Long-term Functional Results

BACKGROUND

Rectal eversion (RE) is a natural orifice specimen extraction (NOSE) method that allows anus-sparing resection in very low rectal tumors. This study aims to share the long-term results of RE in laparoscopic rectal resection performed with double stapling anastomosis.

MATERIALS AND METHODS

A single-center retrospective cohort study was conducted for patients who underwent laparoscopic low anterior resection with RE. Age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, type of surgery, distance of the tumor to the dentate line, specimen extraction site, cancer stage, preoperative chemoradiotherapy, postoperative complications, and postoperative clinical follow-up findings were recorded. Incontinence was assessed using the Wexner score (WS). Low anterior resection syndrome (LARS) is determined by the LARS score. A 7-point Likert scale was used to evaluate the satisfaction of the patients.

RESULTS

A total of 17 patients underwent resection by RE for rectal tumors. Of the 11 patients included in the study, 4 were female and 7 were male. The mean age was 66.09±15.04 years. The mean follow-up was 64.18±16.83 months. The mean tumor diameter was 3.1 cm (range: 0.9 to 7.2 cm). The mean distance of the tumor from the dentate line was 2.7 cm (range: 1.2 to 5.6 cm). No anastomotic leak was observed in any patient. One patient had an anastomotic stenosis and was treated with balloon dilatation. The median LARS score was 16 (range 0 to 32) and 64% of the patients had no LARS. Two patients had minor LARS and 2 patients had major LARS. The median Wexner score was 3.5 (range 0 to 14). The median Likert scale was 7 (range 5 to 7). It was found that 55% of the patients were extremely satisfied, 18% were satisfied, and 27% were slightly satisfied with their surgery. There were no dissatisfied patients.

CONCLUSION

RE is a safe NOSE technique in laparoscopic double stapling anastomosis for rectal resection. There is a high level of long-term patient satisfaction with anus-sparing procedures via RE, even in the presence of various symptoms.

Comparative efficacy analysis of laparoscopic-assisted transanal total mesorectal excision vs laparoscopic transanal mesorectal excision for low-lying rectal cancer

BACKGROUND

With the continuous development of laparoscopic techniques in recent years, laparoscopic total mesorectal excision (LapTME) and laparoscopic-assisted transanal total mesorectal excision (TaTME) have gradually become important surgical techniques for treating low-lying rectal cancer (LRC). However, there is still controversy over the efficacy and safety of these two surgical modalities in LRC treatment.

AIM

To compare the efficacy of LapTME vs TaTME in patients with LRC.

METHODS

Ninety-four patients with LRC who visited and were treated at the Affiliated Hengyang Hospital of Hunan Normal University & Hengyang Central Hospital between December 2022 and March 2024 were selected and divided into the LapTME (n = 44) and TaTME (n = 50) groups. Clinical operation indexes, postoperative recovery indicators, and postoperative complications were recorded. The anal resting pressure (ARP), anal maximum systolic pressure (MSP), and maximum tolerated volume (MTV) of the anal canal were also measured. The intestinal function of patients was evaluated by the Memorial Sloan Kettering Cancer Center (MSKCC) bowel function questionnaire. Serum norepinephrine (NE), adrenaline (AD), and cortisol (Cor) levels were measured. The Quality of Life Questionnaire Core 30 (QLQ-C30) was used for quality of life assessment.

RESULTS

Compared with the LapTME group, the surgery time in the TaTME group was longer; intraoperative blood loss was low; time of anal exhaust, first postoperative ambulation, intestinal recovery, and hospital stay were shorter; and the distal incisal margin and specimen lengths were longer. The TaTME group also showed higher ARP, MSP, and MTV values and higher MSKCC and QLQ-C30 scores than the LapTME group 3 months postoperatively. Cor, AD, and NE levels were lower in the TaTME group than those in the LapTME group during recovery.

CONCLUSION

We demonstrated that TaTME better improved anal function, reduced postoperative stress, and accelerated postoperative recovery and, hence, was safer for patients with LRC.

Comparison of Early Clinical and Long-Term Oncological Outcomes of Laparoscopic Versus Converted Rectal Cancer Resection: A Retrospective Cohort Study

Aim The effects of conversion to open surgery during laparoscopic resection in rectal cancer on perioperative clinical and long-term oncological outcomes are still controversial. This study aimed to evaluate and compare the impact of conversion to laparoscopic resection for rectal cancer on perioperative and long-term oncological outcomes. Material and methods Between January 2019 and December 2023, 84 consecutive patients who underwent curative surgery for rectal cancer at a single academic center were evaluated retrospectively. Patients were classified and compared as the laparoscopic (LAP-G) and converted (CONV-G) groups. Perioperative, pathological, and long-term oncological outcomes were compared. Results Of the 84 consecutive patients included, 18 were converted to open surgery, leading to a 21.4% conversion rate. Intraoperative blood loss was higher in CONV-G (180 ml vs. 80 ml, p<0.001), but early clinical outcomes were similar in both groups. The median follow-up period was 23.5 (range 3-65) and 30.5 (range 6-61) months in the LAP-G and CONV-G, respectively, and recurrence occurred in 11 (16.7%) and 3 (16.6%) patients, respectively. Three-year overall survival was 96.9% and 89.4% (p=0.609) and 3-year disease-free survival was 92.4% and 83.3% (p=0.881) in LAP-G and CONV-G, respectively, and the results were similar. Conclusion Conversion from laparoscopic rectal resection to open surgery does not have a significant negative impact on morbidity and long-term oncological outcomes.

Unraveling variations and enhancing prediction of successful sphincter-preserving resection for low rectal cancer: a post hoc analysis of the multicentre LASRE randomized clinical trial

BACKGROUND

Accurate prediction of successful sphincter-preserving resection (SSPR) for low rectal cancer enables peer institutions to scrutinize their own performance and potentially avoid unnecessary permanent colostomy. The aim of this study is to evaluate the variation in SSPR and present the first artificial intelligence (AI) models to predict SSPR in low rectal cancer patients.

STUDY DESIGN

This was a retrospective post hoc analysis of a multicenter, non-inferiority randomized clinical trial (LASRE, NCT01899547) conducted in 22 tertiary hospitals across China. A total of 604 patients who underwent neoadjuvant chemoradiotherapy (CRT) followed by radical resection of low rectal cancer were included as the study cohort, which was then split into a training set (67%) and a testing set (33%). The primary end point of this post hoc analysis was SSPR, which was defined as meeting all the following criteria: (1) sphincter-preserving resection; (2) complete or nearly complete TME, (3) a clear CRM (distance between margin and tumour of 1 mm or more), and (4) a clear DRM (distance between margin and tumour of 1 mm or more). Seven AI algorithms, namely, support vector machine (SVM), logistic regression (LR), extreme gradient boosting (XGB), light gradient boosting (LGB), decision tree classifier (DTC), random forest (RF) classifier, and multilayer perceptron (MLP), were employed to construct predictive models for SSPR. Evaluation of accuracy in the independent testing set included measures of discrimination, calibration, and clinical applicability.

RESULTS

The SSPR rate for the entire cohort was 71.9% (434/604 patients). Significant variation in the rate of SSPR, ranging from 37.7 to 94.4%, was observed among the hospitals. The optimal set of selected features included tumour distance from the anal verge before and after CRT, the occurrence of clinical T downstaging, post-CRT weight and clinical N stage measured by magnetic resonance imaging. The seven different AI algorithms were developed and applied to the independent testing set. The LR, LGB, MLP and XGB models showed excellent discrimination with area under the receiver operating characteristic (AUROC) values of 0.825, 0.819, 0.819 and 0.805, respectively. The DTC, RF and SVM models had acceptable discrimination with AUROC values of 0.797, 0.766 and 0.744, respectively. LR and LGB showed the best discrimination, and all seven AI models had superior overall net benefits within the range of 0.3-0.8 threshold probabilities. Finally, we developed an online calculator based on the LGB model to facilitate clinical use.

CONCLUSIONS

The rate of SSPR exhibits substantial variation, and the application of AI models has demonstrated the ability to predict SSPR for low rectal cancers with commendable accuracy.

STAPLED FASCIAL CLOSURE VS. CONTINUOUS HAND-SEWN SUTURE: EXPERIMENTAL STUDY OF THE ABDOMINAL WALL ON PORCINE MODEL AND HUMAN CADAVER

BACKGROUND

One of the primary complications associated with large incisions in abdominal surgery is the increased risk of fascial closure rupture and incisional hernia development. The choice of the fascial closure method and closing with minimal tension and trauma is crucial for optimal results, emphasizing the importance of uniform pressure along the suture line to withstand intra-abdominal pressure.

AIMS

To evaluate the resistance to pressure and tension of stapled and sutured hand-sewn fascial closure in the abdominal wall.

METHODS

Nine abdominal wall flaps from human cadavers and 12 pigs were used for the experimentation. An abdominal defect was induced after the resection of the abdominal wall and the creation of a flap in the cadaveric model and after performing a midline incision in the porcine models. The models were randomized into three groups. Group 1 was treated with a one-layer hand-sewn small bite suture, Group 2 was treated with a two-layer hand-sewn small bite suture, and Group 3 was treated with a two-layer stapled closure. Tension measurements were assessed in cadaveric models, and intra-abdominal pressure was measured in porcine models.

RESULTS

In the human cadaveric model, the median threshold for fascial rupture was 300N (300-350) in Group 1, 400N (350-500) in Group 2, and 350N (300-380) in Group 3. Statistical comparisons revealed non-significant differences between Group 1 and Group 2 (p=0.072, p>0.05), Group 1 and Group 3 (p=0.346, p>0.05), and Group 2 and Group 3 (p=0.184, p>0.05). For porcine subjects, Group 1 showed a median pressure of 80 mmHg (85-105), Group 2 had a median of 92.5 mmHg (65-95), and Group 3 had a median of 102.5 mmHg (80-135). Statistical comparisons indicated non-significant differences between Group 1 and Group 2 (p=0.243, p>0.05), Group 1 and Group 3 (p=0.468, p>0.05), and Group 2 and Group 3 (p=0.083, p>0.05).

CONCLUSIONS

Stapled and conventional suturing resist similar pressure and tension thresholds.

Robotic-Assisted versus Laparoscopic Surgery for Rectal Cancer: An Analysis of Clinical and Financial Outcomes from a Tertiary Referral Center

Background: The popularity of robotic-assisted surgery for rectal cancer is increasing, but its superiority over the laparoscopic approach regarding safety, efficacy, and costs has not been well established. Methods: A retrospective single-center study was conducted comparing consecutively performed robotic-assisted and laparoscopic surgeries for rectal cancer between 1 January 2016 and 31 September 2021. In total, 125 adult patients with sporadic rectal adenocarcinoma (distal extent ≤ 15 cm from the anal verge) underwent surgery where 66 were operated on robotically and 59 laparoscopically. Results: Severe postoperative complications occurred less frequently with robotic-assisted compared with laparoscopic surgery, as indicated by Clavien-Dindo classification grades 3b-5 (13.6% vs. 30.5%, p = 0.029). Multiple logistic regression analyses after backward selection revealed that robotic-assisted surgery was associated with a lower rate of total (Clavien-Dindo grades 1-5) (OR = 0.355; 95% CI 0.156-0.808; p = 0.014) and severe postoperative complications (Clavien-Dindo grades 3b-5) (OR = 0.243; 95% CI 0.088-0.643; p = 0.005). Total inpatient costs (median EUR 17.663 [IQR EUR 10.151] vs. median EUR 14.089 [IQR EUR 12.629]; p = 0.018) and surgery costs (median EUR 10.156 [IQR EUR 3.551] vs. median EUR 7.468 [IQR EUR 4.074]; p < 0.0001) were higher for robotic-assisted surgery, resulting in reduced total inpatient profits (median EUR -3.196 [IQR EUR 9.101] vs. median EUR 232 [IQR EUR 6.304]; p = 0.004). Conclusions: In our study, robotic-assisted surgery for rectal cancer resulted in less severe and fewer total postoperative complications. Still, it was associated with higher surgery and inpatient costs. With increasing experience, the operative time may be reduced, and the postoperative recovery may be further accelerated, leading to reduced surgery and total inpatient costs.

Impact of laparoscopic versus open surgery on humoral immunity in patients with colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery (LS) is hypothesized to result in milder proinflammatory reactions due to less severe operative trauma, which may contribute to the observed clinical benefits after LS. However, previous systematic reviews and meta-analyses on the impact of LS on immunocompetence are outdated, limited and heterogeneous. Therefore, the humoral response after laparoscopic and open colorectal cancer (CRC) resections was evaluated in a comprehensive systematic review and meta-analysis.

METHODS

Included were randomized controlled trials (RCTs) measuring parameters of humoral immunity after LS compared to open surgery (OS) in adult patients with CRC of any stage. MEDLINE, Embase, Web of Science (SCI-EXPANDED), Cochrane Library, Google Scholar, ClinicalTrials.gov and ICTRP (World Health Organization) were systematically searched. Risk of bias (RoB) was assessed using the Cochrane RoB2 tool. Weighted inverse variance meta-analysis of mean differences was performed for C-reactive protein (CRP), interleukin (IL)-6, IL-8, tumour necrosis factor (TNF)α and vascular endothelial growth factor (VEGF) using the random-effects method. Methods were prospectively registered in PROSPERO (CRD42021264324).

RESULTS

Twenty RCTs with 1131 participants were included. Narrative synthesis and meta-analysis up to 8 days after surgery was performed. Quantitative synthesis found concentrations to be significantly lower after LS at 0-2 h after surgery (IL-8), at 3-9 h (CRP, IL-6, IL-8, TNFα) and at postoperative day 1 (CRP, IL-6, IL-8, VEGF). At 3-9 h, IL-6 was notably lower in the LS group by 86.71 pg/ml (mean difference [MD] - 86.71 pg/ml [- 125.05, - 48.37], p < 0.00001). Combined narratively, 13 studies reported significantly lower concentrations of considered parameters in LS patients, whereas only one study reported lower inflammatory markers (for CRP and IL-6) after OS.

CONCLUSION

The increase in postoperative concentrations of several proinflammatory parameters was significantly less pronounced after LS than after OS in this meta-analysis. Overall, the summarized evidence reinforces the view of a lower induction of inflammation due to LS.

Transanal Total Mesorectal Excision With Delayed Coloanal Anastomosis (TaTME-DCAA) Versus Laparoscopic Total Mesorectal Excision (LTME) and Robotic Total Mesorectal Excision (RTME) for Low Rectal Cancer: A Propensity Score-Matched Analysis of Short-term Outcomes, Bowel Function, and Cost

INTRODUCTION

Total mesorectal excision (TME) with delayed coloanal anastomosis (DCAA) is surgical option for low rectal cancer, replacing conventional immediate coloanal anastomosis (ICAA) with bowel diversion. This study aimed to assess the outcomes of transanal TME (TaTME) with DCAA versus laparoscopic TME (LTME) with ICAA versus robotic TME (RTME) with ICAA.

METHODS

This was a retrospective propensity score-matched analysis of patients who underwent elective TaTME-DCAA between November 2021 and June 2022. Patients were propensity-score matched in a ratio of 1:3 to patients who underwent LTME-ICAA and RTME-ICAA from January 2019 to December 2020. Outcome measures were histopathologic results, postoperative morbidity, function, and inpatient costs.

RESULTS

Twelve patients in the TaTME-DCAA group were compared with 36 patients in the LTME-ICAA and RTME-ICAA groups each after propensity score matching. Histopathologic results and postoperative morbidity rates were statistically similar. Overall stoma-related complication rates in the ICAA groups were 11%. Median total length of hospital stays for TME plus stoma reversal surgery was similar across all techniques (10 vs. 10 vs. 9 days; P =0.532). Despite a significantly shorter duration of follow-up, bowel function after TaTME-DCAA was comparable to that of LTME-ICAA and RTME-ICAA. Overall median inpatient costs of TaTME-DCAA were comparable to LTME-ICAA and significantly cheaper than RTME-ICAA ($31,087 vs. $29,927 vs. $36,750; P =0.002).

CONCLUSIONS

TaTME with DCAA is a feasible and safe technique compared with other minimally invasive methods of TME, while avoiding bowel diversion and stoma-related complications, as well as comparing favorably in terms of overall hospitalization costs.

Rectal cancer surgery: does low volume imply worse outcome-a single surgeon experience

BACKGROUND

The centralisation of rectal cancer management to high-volume oncology centres has translated to improved oncological and survival outcomes. We hypothesise that individual surgeon caseload, specialisation, and experience may be as significant in determining oncologic and postoperative outcomes in rectal cancer surgery.

METHODS

A prospectively maintained colorectal surgery database was reviewed for patients undergoing rectal cancer surgery between January 2004 and June 2020. Data studied included demographics, Dukes' and TNM staging, neoadjuvant treatment, preoperative risk assessment scores, postoperative complications, 30-day readmission rates, length of stay (LOS), and long-term survival. Primary outcome measures were 30-day mortality and long-term survival compared to national and international standards and best practice guidelines.

RESULTS

In total, 87 patients were included (mean age: 66 years [range: 36-88]). The mean length of stay (LOS) was 16.5 days (SD 6.0). The median ICU LOS was 3 days (range 2-17). Overall, 30-day readmission rate was 16.4%. Twenty-four patients (26.4%) experienced ≥ 1 postoperative complication. The 30-day operative mortality rate was 3.45%. Overall 5-year survival rate was 66.6%. A significant correlation was observed between P-POSSUM scores and postoperative complications (p = 0.041), and all four variants of POSSUM, CR-POSSUM, and P-POSSUM scores and 30-day mortality.

CONCLUSION

Despite improved outcomes seen with centralisation of rectal cancer services at an institutional level, surgeon caseload, experience, and specialisation is of similar importance in obtaining optimal outcomes within institutions.

Impact of imaging magnification on colorectal surgery: a matched analysis of a single tertiary center

BACKGROUND

Laparoscopy has been increasingly applied in colorectal surgery, and imaging systems have been improving concurrently. The present study aims to compare outcomes following colorectal surgery with the 4K and traditional high-definition (HD) video systems.

METHODS

All consecutive patients undergoing laparoscopic colorectal surgery between April 2016 and June 2020 were retrospectively retrieved from a prospective institutional database. The study population was matched according to the imaging system (4K versus HD groups) through a propensity score matching (PSM) based on perioperative characteristics of 15 patients. A stratified analysis according to surgical procedures (right, left colectomy, and low anterior resection) was also performed. Primary endpoints were intraoperative blood loss and perioperative transfusions. Also, intra- and postoperative morbidity, operative time, lymph node harvest, and length of hospital stay (LOS) were investigated as secondary outcomes.

RESULTS

After PSM, 225 patients were included in both 4K and HD groups. The intraoperative blood loss was significantly lower in the 4K group (p = 0.008), although no different volumes of blood transfusion were required. Postoperative complications presented in similar proportions, while significantly higher rates of abdominal collection (p = 0.045), reoperation (p = 0.005), and postoperative urinary disorders occurred in the HD group. After stratification, the right colectomy subgroup shared similar associations with the study population. LOS did not change between groups, although readmissions were significantly lower in the 4K group (p < 0.001).

CONCLUSIONS

The 4K imaging system represents a technological advance providing better surgical outcomes, such as the minimization of intraoperative blood loss and postoperative morbidity.

Minimally invasive distal pancreatectomy for adenocarcinoma of the pancreas

INTRODUCTION

Minimally invasive (MI) surgery has been widely adopted to treat left-sided pancreatic cancer. However, outcomes are not clearly defined.

MATERIALS

Retrospective cohort study utilizing NCDB and NSQIP data.

RESULTS

Patients undergoing distal pancreatectomy for pancreatic adenocarcinoma from 2004 to 2016 were included (n = 7347). Utilizing NSQIP (n = 2406), patients were divided into two groups: intention-to-treat (ITT) MI (including MI converted to open, n = 929) and open (n = 1477). Patients undergoing open pancreatectomy were more likely to have longer length of stay (6 vs. 5 days, p=<0.001). On multivariate analysis, open procedures were not associated with mortality (OR 1.24; CI 0.51-3.30, p = 0.64), serious complications (OR 1.03; CI 0.90-1.37, p = 0.79), and any complications (OR 1.07; CI 0.86-1.32, p = 0.56). NCDB patients (n = 4941) were also divided into two groups, ITT MI (n = 1,769, 36%) and open group (n = 3,172, 64%). The median survival was lower in open procedure patients, 23 vs. 27.1 months (p < 0.001). This finding was maintained on multivariable analysis (HR 1.16; CI 1.03-1.32, p = 0.017).

CONCLUSION

Based on these data, MI distal pancreatectomy could be considered a standard of care for pancreatic cancer when technically feasible. Although morbidity and mortality were similar, the laparoscopic approach had a shorter length of stay and could hasten recovery.

Short- and long-term results of open vs laparoscopic multisegmental resection and anastomosis for synchronous colorectal cancer located in separate segments

BACKGROUND

It remains unclear whether laparoscopic multisegmental resection and anastomosis (LMRA) is safe and advantageous over traditional open multisegmental resection and anastomosis (OMRA) for treating synchronous colorectal cancer (SCRC) located in separate segments.

AIM

To compare the short-term efficacy and long-term prognosis of OMRA as well as LMRA for SCRC located in separate segments.

METHODS

Patients with SCRC who underwent surgery between January 2010 and December 2021 at the Cancer Hospital, Chinese Academy of Medical Sciences and the Peking University First Hospital were retrospectively recruited. In accordance with the inclusion and exclusion criteria, 109 patients who received right hemicolectomy together with anterior resection of the rectum or right hemicolectomy and sigmoid colectomy were finally included in the study. Patients were divided into the LMRA and OMRA groups (n = 68 and 41, respectively) according to the surgical method used. The groups were compared regarding the surgical procedure's short-term efficacy and its effect on long-term patient survival.

RESULTS

LMRA patients showed markedly less intraoperative blood loss than OMRA patients (100 vs 200 mL, P = 0.006). Compared to OMRA patients, LMRA patients exhibited markedly shorter postoperative first exhaust time (2 vs 3 d, P = 0.001), postoperative first fluid intake time (3 vs 4 d, P = 0.012), and postoperative hospital stay (9 vs 12 d, P = 0.002). The incidence of total postoperative complications (Clavien-Dindo grade: ≥ II) was 2.9% and 17.1% (P = 0.025) in the LMRA and OMRA groups, respectively, while the incidence of anastomotic leakage was 2.9% and 7.3% (P = 0.558) in the LMRA and OMRA groups, respectively. Furthermore, the LMRA group had a higher mean number of lymph nodes dissected than the OMRA group (45.2 vs 37.3, P = 0.020). The 5-year overall survival (OS) and disease-free survival (DFS) rates in OMRA patients were 82.9% and 78.3%, respectively, while these rates in LMRA patients were 78.2% and 72.8%, respectively. Multivariate prognostic analysis revealed that N stage [OS: HR hazard ratio (HR) = 10.161, P = 0.026; DFS: HR = 13.017, P = 0.013], but not the surgical method (LMRA/OMRA) (OS: HR = 0.834, P = 0.749; DFS: HR = 0.812, P = 0.712), was the independent influencing factor in the OS and DFS of patients with SCRC.

CONCLUSION

LMRA is safe and feasible for patients with SCRC located in separate segments. Compared to OMRA, the LMRA approach has more advantages related to short-term efficacy.

The impact on health-related quality of a stoma or poor functional outcomes after rectal cancer surgery in Dutch patients: A prospective cohort study

BACKGROUND

As the survival of patients with rectal cancer has improved in recent decades, more and more patients have to live with the consequences of rectal cancer surgery. An influential factor in long-term Health-related Quality of Life (HRQoL) is the presence of a stoma. This study aimed to better understand the long-term consequences of a stoma and poor functional outcomes.

METHODS

Patients who underwent curative surgery for a primary tumor located in the rectosigmoid and rectum between 2013 and 2020 were identified from the nationwide Prospective Dutch Colorectal Cancer (PLCRC) cohort study. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, and the LARS-score at 12 months, 24 months and 36 months after surgery.

RESULTS

A total of 1,170 patients were included of whom 751 (64.2%) had no stoma, 122 (10.4%) had a stoma at primary surgery, 45 (3.8%) had a stoma at secondary surgery and 252 (21.5%) patients that underwent abdominoperineal resection (APR). Of all patients without a stoma, 41.4% reported major low-anterior resection syndrome (LARS). Patients without a stoma reported significantly better HRQoL. Moreover, patients without a stoma significantly reported an overall better HRQoL.

CONCLUSION

The presence of a stoma and poor functional outcomes were both associated with reduced HRQoL. Patients with poor functional outcomes, defined as major LARS, reported a similar level of HRQoL compared to patients with a stoma. In addition, the HRQoL after rectal cancer surgery does not change significantly after the first year after surgery.

A novel training program: laparoscopic versus robotic-assisted low anterior resection for rectal cancer can be trained simultaneously

Background

Current expectations are that surgeons should be technically proficient in minimally invasive low anterior resection (LAR)-both laparoscopic and robotic-assisted surgery. However, methods to effectively train surgeons for both approaches are under-explored. We aimed to compare two different training programs for minimally invasive LAR, focusing on the learning curve and perioperative outcomes of two trainee surgeons.

Methods

We reviewed 272 consecutive patients undergoing laparoscopic or robotic LAR by surgeons A and B, who were novices in conducting minimally invasive colorectal surgery. Surgeon A was trained by first operating on 80 cases by laparoscopy and then 56 cases by robotic-assisted surgery. Surgeon B was trained by simultaneously performing 80 cases by laparoscopy and 56 by robotic-assisted surgery. The cumulative sum (CUSUM) method was used to evaluate the learning curves of operative time and surgical failure.

Results

For laparoscopic surgery, the CUSUM plots showed a longer learning process for surgeon A than surgeon B (47 vs. 32 cases) for operative time, but a similar trend in surgical failure (23 vs. 19 cases). For robotic surgery, the plots of the two surgeons showed similar trends for both operative times (23 vs. 25 cases) and surgical failure (17 vs. 19 cases). Therefore, the learning curves of surgeons A and B were respectively divided into two phases at the 47th and 32nd cases for laparoscopic surgery and at the 23rd and 25th cases for robotic surgery. The clinicopathological outcomes of the two surgeons were similar in each phase of the learning curve for each surgery.

Conclusions

For surgeons with rich experience in open colorectal resections, simultaneous training for laparoscopic and robotic-assisted LAR of rectal cancer is safe, effective, and associated with accelerated learning curves.

A systematic review and meta-analysis of minimally invasive total mesorectal excision versus transanal total mesorectal excision for mid and low rectal cancer

Background

Minimally invasive total mesorectal excision (MiTME) and transanal total mesorectal excision (TaTME) are popular trends in mid and low rectal cancer. However, there is currently no systematic comparison between MiTME and TaTME of mid and low-rectal cancer. Therefore, we systematically study the perioperative and pathological outcomes of MiTME and TaTME in mid and low rectal cancer.

Methods

We have searched the Embase, Cochrane Library, PubMed, Medline, and Web of Science for articles on MiTME (robotic or laparoscopic total mesorectal excision) and TaTME (transanal total mesorectal excision). We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42022374141).

Results

There are 11010 patients including 39 articles. Compared with TaTME, patients who underwent MiTME had no statistical difference in operation time (SMD -0.14; CI -0.31 to 0.33; I²⁼84.7%, P=0.116), estimated blood loss (SMD 0.05; CI -0.05 to 0.14; I²⁼48%, P=0.338), postoperative hospital stay (RR 0.08; CI -0.07 to 0.22; I²⁼0%, P=0.308), over complications (RR 0.98; CI 0.88 to 1.08; I²⁼25.4%, P=0.644), intraoperative complications (RR 0.94; CI 0.69 to 1.29; I²⁼31.1%, P=0.712), postoperative complications (RR 0.98; CI 0.87 to 1.11; I²⁼16.1%, P=0.789), anastomotic stenosis (RR 0.85; CI 0.73 to 0.98; I²⁼7.4%, P=0.564), wound infection (RR 1.08; CI 0.65 to 1.81; I²⁼1.9%, P=0.755), circumferential resection margin (RR 1.10; CI 0.91 to 1.34; I²⁼0%, P=0.322), distal resection margin (RR 1.49; CI 0.73 to 3.05; I²⁼0%, P=0.272), major low anterior resection syndrome (RR 0.93; CI 0.79 to 1.10; I²⁼0%, P=0.386), lymph node yield (SMD 0.06; CI -0.04 to 0.17; I²⁼39.6%, P=0.249), 2-year DFS rate (RR 0.99; CI 0.88 to 1.11; I²⁼0%, P = 0.816), 2-year OS rate (RR 1.00; CI 0.90 to 1.11; I²⁼0%, P = 0.969), distant metastasis rate (RR 0.47; CI 0.17 to 1.29; I²⁼0%, P = 0.143), and local recurrence rate (RR 1.49; CI 0.75 to 2.97; I²⁼0%, P = 0.250). However, patients who underwent MiTME had fewer anastomotic leak rates (SMD -0.38; CI -0.59 to -0.17; I²⁼19.0%, P<0.0001).

Conclusion

This study comprehensively and systematically evaluated the safety and efficacy of MiTME and TaTME in the treatment of mid to low-rectal cancer through meta-analysis. There is no difference between the two except for patients with MiTME who have a lower anastomotic leakage rate, which provides some evidence-based reference for clinical practice. Of course, in the future, more scientific and rigorous conclusions need to be drawn from multi-center RCT research.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42022374141.

Three-dimensional visualization of the total mesorectal excision plane for dissection in rectal cancer surgery and its ability to predict surgical difficulty

Total mesorectal excision (TME) for rectal cancer is often technically challenging. We aimed to develop a method for three-dimensional (3D) visualization of the TME dissection plane and to evaluate its ability to predict surgical difficulty. Sixty-six patients with lower rectal cancer who underwent robot-assisted surgery were retrospectively analyzed. A 3D TME dissection plane image for each case was reconstructed using Ziostation2. Subsequently, a novel index that reflects accessibility to the deep pelvis during TME, namely, the TME difficulty index, was defined and measured. Representative bony pelvimetry parameters and clinicopathological factors were also analyzed. The operative time for TME was used as an indicator of surgical difficulty. Univariate regression analysis revealed that sex, body mass index, mesorectal fat area, and TME difficulty index were associated with the operative time for TME, whereas bony pelvimetry parameters were not. Multivariate regression analysis found that TME difficulty index (β = - 0.398, P = 0.0025) and mesorectal fat area (β = 0.223, P = 0.045) had significant predictability for the operative time for TME. Compared with conventional bony pelvimetry parameters, the TME difficulty index and mesorectal fat area might be more useful in predicting the difficulty of rectal cancer surgery.

The Impact of Postoperative Complications on Short- and Long-Term Health-Related Quality of Life After Total Mesorectal Excision for Rectal Cancer

BACKGROUND

Survival for rectal cancer patients has improved over the past decades. In parallel, long-term health-related quality of life (HRQoL) is gaining interest. This study focuses on the effect of complications following rectal cancer surgery on HRQoL and survival.

METHODS

The TME-trial (1996-1999) randomized patients with operable rectal cancer between surgery with preoperative short-course radiotherapy and surgery. Questionnaires including the Rotterdam Symptom Checklist were sent at 6 time points within the first 24 months and after 14 years the EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires. Differences in HRQoL and survival between patients with and without complications were analyzed.

RESULTS

A total of 1207 patients were included, of which 482 (39.9%) patients experienced complications, surgical complications occurred in 177 (14.6%) patients, non-surgical complications in 197 (16.3%) and 108 patients (8.9%) had a combination of both types of complications. Three months after surgery, patients with a combination of surgical- and non-surgical complications, especially patients with anastomotic leakage, had the worst HRQoL. Twelve months postoperative HRQoL returned to a similar level as before surgery, regardless of complications. In patients who survived 14 years, no significant differences in HRQoL were seen between patients with and without complications. However, patients with complications did have lower overall survival.

CONCLUSION

This study shows that survival and short-term HRQoL are negatively affected by complications. Twelve months after surgery HRQoL had returned to the preoperative level regardless, of complications. Also, in patients that survived 14 years, there was no effect of complications on HRQoL detected.

Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomised controlled trial

BACKGROUND

Robotic surgery for rectal cancer is gaining popularity, but evidence on long-term oncological outcomes is scarce. We aimed to compare surgical quality and long-term oncological outcomes of robotic and conventional laparoscopic surgery in patients with middle and low rectal cancer. Here we report the short-term outcomes of this trial.

METHODS

This multicentre, randomised, controlled, superiority trial was done at 11 hospitals in eight provinces of China. Eligible patients were aged 18-80 years with middle (>5 to 10 cm from the anal verge) or low (≤5 cm from the anal verge) rectal adenocarcinoma, cT1-T3 N0-N1 or ycT1-T3 Nx, and no evidence of distant metastasis. Central randomisation was done by use of an online system and was stratified according to participating centre, sex, BMI, tumour location, and preoperative chemoradiotherapy. Patients were randomly assigned at a 1:1 ratio to receive robotic or conventional laparoscopic surgery. All surgical procedures complied with the principles of total mesorectal excision or partial mesorectal excision (for tumours located higher in the rectum). Lymph nodes at the origin of the inferior mesenteric artery were dissected. In the robotic group, the excision procedures and dissection of lymph nodes were done by use of robotic techniques. Neither investigators nor patients were masked to the treatment allocation but the assessment of pathological outcomes was masked to the treatment allocation. The primary endpoint was 3-year locoregional recurrence rate, but the data for this endpoint are not yet mature. Secondary short-term endpoints are reported in this article, including two key secondary endpoints: circumferential resection margin positivity and 30-day postoperative complications (Clavien-Dindo classification grade II or higher). The outcomes were analysed according in a modified intention-to-treat population (according to the original assigned groups and excluding patients who did not undergo surgery or no longer met inclusion criteria after randomisation). This trial was registered with ClinicalTrials.gov, number NCT02817126. Study recruitment has completed, and the follow-up is ongoing.

FINDINGS

Between July 17, 2016, and Dec 21, 2020, 1742 patients were assessed for eligibility. 502 patients were excluded, and 1240 patients were enrolled and randomly assigned to receive either robotic surgery (620 patients) or laparoscopic surgery (620 patients). 69 patients were excluded (34 in the robotic surgery group and 35 in the laparoscopic surgery group). 1171 patients were included in the modified intention-to-treat analysis (586 in the robotic group and 585 in the laparoscopic group). Six patients in the robotic surgery group received laparoscopic surgery and seven patients in the laparoscopic surgery group received robotic surgery. 22 (4·0%) of 547 patients in the robotic group had a positive circumferential resection margin as did 39 (7·2%) of 543 patients in the laparoscopic group (difference -3·2 percentage points [95% CI -6·0 to -0·4]; p=0·023). 95 (16·2%) of patients in the robotic group had at least one postoperative complication (Clavien-Dindo grade II or higher) within 30 days after surgery, as did 135 (23·1%) of 585 patients in the laparoscopic group (difference -6·9 percentage points [-11·4 to -2·3]; p=0·003). More patients in the robotic group had a macroscopic complete resection than in the laparoscopic group (559 [95·4%] of 586 patients vs 537 [91·8%] of 585 patients, difference 3·6 percentage points [0·8 to 6·5]). Patients in the robotic group had better postoperative gastrointestinal recovery, shorter postoperative hospital stay (median 7·0 days [IQR 7·0 to 11·0] vs 8·0 days [7·0 to 12·0], difference -1·0 [95% CI -1·0 to 0·0]; p=0·0001), fewer abdominoperineal resections (99 [16·9%] of 586 patients vs 133 [22·7%] of 585 patients, difference -5·8 percentage points [-10·4 to -1·3]), fewer conversions to open surgery (10 [1·7%] of 586 patients vs 23 [3·9%] of 585 patients, difference -2·2 percentage points [-4·3 to -0·4]; p=0·021), less estimated blood loss (median 40·0 mL [IQR 30·0 to 100·0] vs 50·0 mL [40·0 to 100·0], difference -10·0 [-20·0 to -10·0]; p<0·0001), and fewer intraoperative complications (32 [5·5%] of 586 patients vs 51 [8·7%] of 585 patients; difference -3·3 percentage points [-6·3 to -0·3]; p=0·030) than patients in the laparoscopic group.

INTERPRETATION

Secondary short-term outcomes suggest that for middle and low rectal cancer, robotic surgery resulted in better oncological quality of resection than conventional laparoscopic surgery, with less surgical trauma, and better postoperative recovery.

FUNDING

Shenkang Hospital Development Center, Shanghai Municipal Health Commission (Shanghai, China), and Zhongshan Hospital Fudan University (Shanghai, China).

Verbreitung von Fast-Track-Konzepten in Deutschland

Hintergrund

Fast-Track-Konzepte haben die perioperative Betreuung von Patienten in den letzten 30 Jahren grundlegend verändert. Evidenz für diese Konzepte ist ausreichend vorhanden.

Ziel der Arbeit

Ziel dieses Artikels war es, die Verbreitung von Fast-Track-Konzepten in Deutschland anhand von Routinedaten zu evaluieren.

Material und Methoden

Es wurde eine retrospektive Analyse aller kolorektalen Resektionen der Helios-Kliniken der Jahre 2016 bis 2021 durchgeführt. Diese wurden bezüglich Krankenhausverweildauer, Intensivbelegung, Beatmungsanteil, Mortalität, Komplikationsrate und Zugangsweg analysiert.

Ergebnisse und Diskussion

Eine intensivmedizinische Belegung nach kolorektalen Resektionen ist in Deutschland weiterhin die Regel. Insbesondere bei onkologischen kolorektalen Resektionen werden nach wie vor zwei Drittel der Patienten perioperativ intensivmedizinisch betreut. Die stationäre Liegedauer bei kolorektalen Resektionen ist im internationalen Vergleich weiter überdurchschnittlich lang und auch über die letzten Jahre nur langsam rückläufig (z. B. Kolonkarzinom 2016: 18,6 ± 11,9 Tage/2021: 13,8 ± 9,3). Der Anteil offen-chirurgischer kolorektaler Eingriffe ist rückläufig, macht aber auch 30 Jahre nach Einführung der Laparoskopie einen relevanten Anteil aus (z. B. Kolonkarzinom 2016: 71,10 %/2021: 56,44 %). Die Versorgung von Patienten mit kolorektalen Resektionen scheint demnach weiterhin nicht nach Fast-Track-Prinzipen umgesetzt zu sein.

Minimally Invasive Pancreatoduodenectomy: Contemporary Practice, Evidence, and Knowledge Gaps

Minimally invasive pancreatoduodenectomy has gained popularity throughout the last decade. For laparoscopic pancreatoduodenectomy, some high-level evidence exists, but with conflicting results. There are currently no published randomized controlled trials comparing robotic and open pancreatoduodenectomy. Comparative long-term data for patients with pancreatic ductal adenocarcinoma is lacking to date. Based on the existing evidence, current observed benefits of minimally invasive pancreatoduodenectomy over open pancreatoduodenectomy seem scarce, but retrospective data indicate the safety of these procedures in selected patients. As familiarity with the robotic platform increases, studies have shown an expansion in indications, also including patients with vascular involvement and even indicating favorable results in patients with obesity and high-risk morphometric features. Several ongoing randomized controlled trials aim to investigate potential differences in short- and long-term outcomes between minimally invasive and open pancreatoduodenectomy. Their results are much awaited.

Impact of frailty on oncological outcomes in patients undergoing surgery for colorectal cancer - A systematic review and meta-analysis

INTRODUCTION

Frailty describes patients who are at an extreme risk of vulnerability to stressors that may lead to adverse clinical outcomes. The impact of frailty on clinical, oncological and survival outcomes in colorectal cancer (CRC) remains unclear.

AIM

To determine the anticipated oncological and survival outcomes for patients who are frail when diagnosed and undergo treatment with curative intent for CRC.

METHODS

A systematic review and meta-analysis was performed as per PRISMA guidelines. Descriptive statistics were used to determine associations between frailty and survival outcomes. The impact of frailty on disease-free and overall survival were expressed as hazard Ratios (HRs) and 95% confidence intervals (CIs) were estimated using the time-to-effect generic inverse variance and Mantel-Haenszel method.

RESULTS

Nine studies including 15,555 patients were included, of whom 8.1% were frail (1206/14,831). The mean age was 77.1 years (range: 42-94 years), 61.1% were female (9510/15,555) and mean follow-up was 48.0 months. Overall, frailty was associated with an increased risk of mortality (HR: 2.95, 95% CI: 1.64-5.29, P < 0.001) and worse disease-free survival (HR: 1.80, 95% CI: 1.34-2.41, P < 0.001). Frailty was also associated with an increased risk of mortality at 1-year (HR: 3.70, 95% CI: 1.00-13.66, P = 0.050) and 5-years (HR: 2.79, 95% CI: 1.65-4.71, P < 0.001) follow-up respectively.

CONCLUSION

Frailty is associated with poorer oncological and survival outcomes in patients diagnosed and treated with curative intent for CRC. CRC multidisciplinary team meetings should incorporate these findings into the management paradigm for these patients and patient counselling should be tailored to include these findings.

Comparison of Non-Oncological Postoperative Outcomes Following Robotic and Laparoscopic Colorectal Resection for Colorectal Malignancy: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis is to compare the postoperative outcomes of robotic and laparoscopic colorectal resection for colorectal malignancy. We performed a systematic review using a comprehensive search strategy on several electronic databases (PubMed, PubMed Central, Medline, and Google Scholar) in April 2022. Postoperative outcomes of robotic versus laparoscopic surgery for colorectal cancer were compared using 12 end points. Observational studies, randomized controlled trials, and nonrandomized clinical trials comparing robotic and laparoscopic resection for colorectal cancer were included. The statistical analysis was performed using the risk ratio (RR) for categorical variables and the standardized mean differences (SMD) for continuous variables. Sixteen studies involving 2,318 patients were included. The difference in length of hospital stay was significantly shorter with robotic access (SMD = -0.10, 95% CI = -0.19, -0.01, P = 0.04, I2 = 0%). Regarding intra-abdominal abscesses, the analysis showed an advantage in favor of the robotic group, but the result was not statically significant (RR = 0.54, 95% CI = 0.28, 1.05, P = 0.07, I2 = 0%). Mechanical obstruction was found to be higher in robotic group, favoring laparoscopic access, but was not significant (RR = 1.91, 95% CI = 0.95, 3.83, P = 0.07, I2 = 0%). There was no difference in time to pass flatus and consume a soft diet. The rates of anastomotic leakage, ileus, wound infection, readmission, mortality, and incisional hernias were similar with both approaches. Robotic surgery for colorectal cancer is associated with a shorter hospital stay, with no differences in mortality and postoperative morbidity.

Stoma versus anastomosis after sphincter-sparing rectal cancer resection; the impact on health-related quality of life

BACKGROUND

Surgical resection is the mainstay of curative treatment for rectal cancer. Post-operative complications, low anterior resection syndrome (LARS), and the presence of a stoma may influence the quality of life after surgery. This study aimed to gain more insights into the long-term trade-off between stoma and anastomosis.

METHODS

All patients who underwent sphincter-sparing surgical resection for rectal cancer in the Leiden University Medical Center and the Reinier de Graaf Gasthuis between January 2012 and January 2016 were included. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, EQ-5D-5L, and the LARS score. A comparison was made between patients with a stoma and without a stoma after follow-up.

RESULTS

Some 210 patients were included of which 149 returned the questionnaires (70.9%), after a mean follow-up of 3.69 years. Overall quality of life was not significantly different in patients with and without stoma after follow-up using the EORTC-QLQ-C30 (p = 0.15) or EQ-5D-5L (p = 0.28). However, after multivariate analysis, a significant difference was found for the presence of a stoma on global health status (p = 0.01) and physical functioning (p < 0.01). Additionally, there was no difference detected in the quality of life between patients with major LARS or a stoma.

CONCLUSION

This study shows that after correction for possible confounders, a stoma is associated with lower global health status and physical functioning. However, no differences were found in health-related quality of life between patients with major LARS and patients with a stoma. This suggests that the choice between stoma and anastomosis is mainly preferential and that shared decision-making is required.