The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Ann Surg. 2008;248:1-7. [PMID: 18580199 DOI: 10.1097/sla.0b013e31816a9d65]

Safety and efficacy of flexible articulated instrument (ArtiSential®) in laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic surgery for rectal cancer remains challenging because of limited joint motion during dissection in the deep and narrow pelvis. Handheld multiarticulated instruments have been developed to address these limitations. This study aimed to assess the safety and efficacy of a flexible articulated instrument, the ArtiSential® (Livsmed Co, Korea), at reducing the duration of laparoscopic rectal cancer surgery.

STUDY DESIGN

We retrospectively reviewed patients who underwent laparoscopic low or ultralow anterior resection for primary mid to low rectal cancer (tumor distance from anal verge, ≤ 10 cm) performed by a single surgeon in 2012-2022. Patients were divided into groups based on the use of ArtiSential® or straight device, and their clinical characteristics, surgical procedures, pathological findings, postoperative complications, and survival outcomes were analyzed.

RESULTS

The study included 93 patients (articulating group, 32; straight group, 61). Low anterior resection was predominant in both groups, while operative time was significantly shorter in the articulating group (148.08 ± 49.72 vs. 188.13 ± 57.86; p = 0.003). Total mesorectal excision quality and resection margin status did not differ between groups. Postoperative complications, including anastomotic leakage, length of hospital stay, 3-year recurrence-free survival rate (90.6% vs. 88.5%, p = 0.760), and overall survival rate (100% vs. 85.2%, p = 0.092), did not differ between groups.

CONCLUSION

Use of the flexible articulated instrument (ArtiSential®) can reduce operative time without impairing surgical quality or oncologic outcomes. These results suggest that laparoscopic rectal cancer surgery can be performed safely and effectively using a flexible articulated instrument.

CLINICAL TRIAL NUMBER

Not applicable.

Discolored peritoneal dialysis (PD) fluid after colonoscopy: Not so black and white

In peritoneal dialysis, the appearance of effluent with an abnormal appearance or color is usually a sign of a serious complication such as peritonitis. In other cases, it may be a specific event that lacks clinical importance. Even in these mild cases, the alarm and concern of patients and professionals can be high.

Impact of single-port laparoscopic approach on scar assessment by patients and observers: a multicenter retrospective study

PURPOSE

This study aimed to compare the wound cosmesis of a single-incision approach on scar assessment after laparoscopic surgery for colon cancer.

METHODS

This study included 32 patients undergoing single-port laparoscopic surgery (SPLS) and 61 patients undergoing multiport laparoscopic surgery (MPLS) for colon cancer at 3 tertiary referral hospitals between September 2011 and December 2019. We modified and applied the Korean version of the Patient and Observer Scar Assessment Scale (POSAS) to assess cosmetic outcomes. To assess the interobserver reliability using intraclass correlation coefficient values for the Observer Scar Assessment Scale (OSAS), the surgeons evaluated 5 images of postoperative scars.

RESULTS

No significant differences were observed in the time before the return of normal bowel function, time to sips of water and soft diet initiation, length of in-hospital stay, and postoperative complication rate. The SPLS group had a shorter total incision length than the MPLS group. The POSAS favored the SPLS approach, revealing significant differences in the Patient Scar Assessment Scale (PSAS), OSAS, and overall scores. The SPLS approach was an independent factor influencing the POSAS, PSAS, and OSAS scores. Eleven colorectal surgeons had a significantly substantial intraclass coefficient.

CONCLUSION

The cosmetic outcomes of SPLS as assessed by the patients and surgeons were superior to those of MPLS in colon cancer. Reducing the number of ports is an independent factor affecting scar assessment by patients and observers.

Short-Term Outcomes of Laparoscopic Rectal Cancer Surgery at a High-Volume Center in Peshawar, Pakistan

BACKGROUND

Rectal cancer is a serious worldwide health issue, and laparoscopic surgery is becoming a common therapeutic choice because of its advantages, which include less pain after surgery, quicker recovery, and oncological results that are comparable to those of open surgery. Even though laparoscopic rectal cancer surgery has proven successful in developed countries, it is still not well-studied in places with low resources, like Pakistan.

OBJECTIVE

 The primary objective of this study was to evaluate the clinical outcomes and surgical efficacy of laparoscopic rectal cancer surgery in 209 patients, focusing on operative details, histopathological findings, and postoperative complications. The secondary objective was to assess 90-day disease-free survival (DFS), mortality rates, and the need for reexploration or readmission.

MATERIALS AND METHODS

This retrospective observational study was performed at the Surgical Oncology department, Shaukat Khanum Memorial Cancer Hospital, Peshawar, a high-volume center for colorectal surgery. Assessment of short-term surgical results of laparoscopic rectal cancer operation ensued from April 1, 2021, to March 31, 2024. The sample comprised 209 patients with rectal cancer who were treated by laparoscopic rectal cancer surgery. A consecutive sampling technique was used to enroll eligible patients during the study duration.

RESULTS

The mean age of the patients was 43.07 ± 22.1 years. The male-to-female ratio was 1.4:1, with males comprising 131 patients (62.7%) and females, 78 patients (37.3%). The regional distribution included 54 (25.8%) from Afghanistan, 11 (5.2%) from the federally administered tribal area (FATA), 141 (67.5%) from Khyber Pakhtunkhwa (KPK), and three (1.4%) from Punjab. Preoperative assessment classified 191 (91.4%) patients as American Society of Anesthesiologists (ASA)-II, and 18 (8.6%) cases as ASA-III.

CONCLUSION

Laparoscopic rectal cancer surgery demonstrates favorable short-term outcomes, including minimal morbidity, low conversion rates, and promising oncological results in a high-volume center in Peshawar, Pakistan. These findings support the feasibility of laparoscopic surgery for rectal cancer in resource-constrained settings.

Robotic versus laparoscopic surgery for rectal cancer: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The usage of robotic surgery in rectal cancer was increasing, but there was an ongoing debate as to whether it provided any benefit. The aim of this study was to evaluate the safety, efficacy, and prognosis of elective rectal resection for rectal cancer by robotic surgery compared with conventional laparoscopic surgery.

METHOD

Electronic databases were searched from their inception to 1 February 2024, for randomized controlled trials (RCTs) involving a comparison between robotic surgery (RS) and laparoscopic surgery (LS) and performed a meta-analysis of all RCTs according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

RESULTS

11 RCTs including a total of 3107 cases were identified. Compared with LS, RS had a significantly lower conversion rate (odds ratio: 0.42; 95% confidence interval: 0.28 to 0.63; P < 0.0001), lower reoperation rate (odds ratio: 0.454; 95% confidence interval: 0.31 to 0.94; P = 0.03), more lymph nodes harvested (mean difference: 0.67; 95% confidence interval: 0.30 to 1.04; P = 0.0004), a smaller incidence of positive circumferential margin (CRM) (odds ratio: 0.59; 95% confidence interval: 0.41 to 0.85; P = 0.004). RS had less time to first autonomous urination (mean difference: -0.78; 95% confidence interval: -1.15 to -0.41; P < 0.0001), less time to first defecation (mean difference: -0.40; 95% confidence interval: -0.78 to -0.01; P = 0.04) and less time to first flatus (mean difference: -0.45; 95% confidence interval: -0.89 to -0.01; P = 0.04), more operating time (mean difference: 23.46; 95% confidence interval: 15.76 to 31.16; P < 0.00001). Overall postoperative complication, short-term postoperative complication, estimate blood loss, hospital stays, Intraoperative complication, postoperative mortality, preventive ostomy rates, readmission did not differ significantly between approaches. (P > 0.05).

CONCLUSION

Compared to laparoscopic surgery, robotic surgery demonstrated superior safety, efficacy, and prognosis. This meta-analysis supports that RS is a safe and effective option.

The Role of Reactive Oxygen Species in Colorectal Cancer Initiation and Progression: Perspectives on Theranostic Approaches

Altered levels of reactive oxygen species (ROS) are recognized as one of the key factors in mediating tumor cell survival in the tissue microenvironment, where they play a role in the initiation, progression and recurrence/relapse of colorectal cancer (CRC). Tumor cells can adapt to oxidative stress (OS) using genetic or metabolic reprogramming in the long or short term. In addition, tumor cells defend themselves through positive regulation of antioxidant molecules, enhancing ROS-driven proliferation. Balanced oxidative eustress levels can influence chemotherapy resistance, allowing tumor cells to survive treatment. Secondary effects of chemotherapy include increased ROS production and redox stress, which can kill cancer cells and eliminate drug resistance. Anticancer treatments based on manipulating ROS levels could represent the gold standard in CRC therapy. Therefore, exploring the modulation of the response to OS in deregulated signaling pathways may lead to the development of new personalized CRC treatments to overcome therapy resistance. In this review, we explore the role of ROS in the initiation and progression of CRC and their diagnostic implications as biomarkers of disease. Furthermore, we focused on the involvement of ROS in different CRC therapeutic options, such as surgery, radiotherapy, theranostic imaging, chemotherapy and immunotherapy and other precision medicine approaches.

Comparative effectiveness of laparoscopic versus open colectomy in colon cancer patients: a study protocol for emulating a target trial using cancer registry data

INTRODUCTION

The objective of this study is to compare the 5 year overall survival of patients with stage I-III colon cancer treated by laparoscopic colectomy versus open colectomy.

METHODS

Using Mecklenburg-Western Pomerania Cancer Registry data from 2008 to 2018, we will emulate a phase III, multicenter, open-label, two-parallel-arm hypothetical target trial in adult patients with stage I-III colon cancer who received laparoscopic or open colectomy as an elective treatment. An inverse-probability weighted Royston‒Parmar parametric survival model (RPpsm) will be used to estimate the hazard ratio of laparoscopic versus open surgery after confounding factors are balanced between the two treatment arms. Further to the hazard ratio, we will also compute differences in the absolute risk (at 1, 3, and 5 years) and restricted mean survival time (up to 1, 3, and 5 years). A weighted Kaplan‒Meier curve will be used to compare five-year overall survival in both treatment arms. Various comparator and sensitivity analyses will be performed to check the robustness of the results that will be estimated by the RPpsm main model. Treatment period- and stage-specific results will also be provided.

DISCUSSION

This study aims to causally model the effect of laparoscopic versus open colectomy on 5 year overall survival using a target trial emulation approach. As the cancer registry data do not cover BMI, comorbidity, and previous abdominal surgery for non-malignant indications, the potential for residual confounding arising from these factors is a limitation of this study. This will be approached in a quantitative bias analysis using the E-method. The results will substantiate existing evidence on the comparative effectiveness of laparoscopic versus open colectomy in patients with stage I-III colon cancer and may guide clinical decisions as to whether a laparoscopic approach is as safe as an open approach in terms of improving 5-year overall survival in these patient groups.

Trends and outcomes in colorectal cancer surgery: a multicenter cross-sectional study of minimally invasive versus open techniques in Germany

BACKGROUND

The objective of this study was to assess the trend from open to modern minimally invasive (laparoscopic and robot-assisted) surgical techniques for colorectal cancer (CRC) in Germany, with a particular focus on hospital mortality, postoperative complications, and length of hospital stay.

METHODS

A multicenter cross-sectional study was conducted using data from 36 German hospitals, encompassing 1,250,029 cases from January 2019 to December 2023. The study included all hospitalized patients aged ≥ 18 with CRC who underwent surgery. Surgical cases were categorized as open or minimally invasive. Outcomes assessed included in-hospital mortality, morbidity, and hospital length of stay. Statistical analyses involved multivariable logistic and linear regression models adjusted for main diagnosis, metastasis presence, age, sex, and comorbidities.

RESULTS

The study included 4525 CRC cases: 2767 underwent open surgery and 1758 underwent minimally invasive surgery (173 robotic). In-hospital mortality was significantly higher in open surgery (6.1% vs. 1.7%). Open surgery was also significantly associated with higher rates of acute post-hemorrhagic anemia (OR: 2.38; 95% CI: 1.87-3.02), respiratory failure (OR: 1.71; 95% CI: 1.34-2.18), and intraoperative and postprocedural complications (OR: 3.64; 95% CI: 2.83-4.70). Average hospital stay was longer for open surgery (19.5 days vs. 11.0 days).

CONCLUSION

Despite the advantages of minimally invasive surgery, including reduced mortality, morbidity, and shorter hospital stays, open surgery remains the predominant approach for CRC in Germany. These findings underscore the need for increased adoption of minimally invasive techniques and highlight the potential benefits of shifting toward minimally invasive methods to enhance the overall quality of CRC care.

Assessing Surgeons' Attitude to Teaching Intra-Corporeal Anastomosis

Introduction: There is a controversy in minimally invasive colorectal procedures regarding choosing optimal technique between intra-corporeal (ICA) and extra-corporeal anastomosis (ECA). Previous studies recognize the short-term benefits in right hemicolectomy with intra-corporeal approach; however, ICA can result in increased operative difficulty. The aim of this study is to understand attitudes towards teaching ICA in colorectal procedures and how this varies between subspeciality training. Methods: Active members of General Surgeons Australia were contacted through email to participate in a voluntary, unincentivized survey. Demographic details were collected and participants were asked to rate agreement for simulation-based training for increasing adoption of ICA through a Likert scale and when preferences for teaching ICA. Descriptive statistics were completed to describe frequencies and ordinal regression was completed to determine factors for Likert scale question. Results: There were 43 respondents and most participants recognized that ECA was easier to teach trainees and should be taught first. 53.5% of respondents recognized that simulation-based training would assist the adoption of ICA. Surgeons who routinely close bowel or enteric defects intra-corporeally are 354% more likely to show an interest in simulation-based training for adopting ICA, however, surgeons who are not involved in teaching trainees did not show an interest in simulation-based training. Conclusion: There is significant agreement that ECA forms the basis to learn ICA and simulation-based training would assist with the uptake of ICA. However, a multimodal approach, including expanding training avenues and providing financial incentives, would be necessary to enhance the adoption of ICA in colorectal surgery.

Robotic versus laparoscopic right colectomy for nonmetastatic pT4 colon cancer: A European multicentre propensity score-matched analysis

AIM

Minimally invasive surgery has been increasingly adopted for locally advanced colon cancer. However, evidence comparing robotic (RRC) versus laparoscopic right colectomy (LRC) for nonmetastatic pT4 cancers is lacking.

METHODS

This was a multicentre propensity score-matched (PSM) study of a cohort of consecutive patients with pT4 right colon cancer treated with RRC or LRC. The two surgical approaches were compared in terms of R0, number of lymph nodes harvested, intra- and postoperative complication rates, overall (OS), and disease-free survival (DFS).

RESULTS

Among a total of 200 patients, 39 RRC were compared with 78 PS-matched LRC patients. The R0 rate was similar between RRC and LRC (92.3% vs. 96.2%, respectively; p = 0.399), as was the odds of retrieving 12 or more lymph nodes (97.4% vs. 96.2%; p = 1). No significant difference was noted for the mean operating time (192.9 min vs. 198.3 min; p = 0.750). However, RRC was associated with fewer conversions to laparotomy (5.1% vs. 20.5%; p = 0.032), less blood loss (36.9 vs. 95.2 mL; p < 0.0001), fewer postoperative complications (17.9% vs. 41%; p = 0.013), a shorter time to flatus (2 vs. 2.8 days; p = 0.009), and a shorter hospital stay (6.4 vs. 9.5 days; p < 0.0001) compared with LRC. These results were confirmed even when converted procedures were excluded from the analysis. The 1-, 3- and 5-year OS (p = 0.757) and DFS (p = 0.321) did not significantly differ between RRC and LRC.

CONCLUSION

Adequate oncological outcomes are observed for RRC and LRC performed for pT4 right colon cancer. However, RRC is associated with lower conversion rates and improved short-term postoperative outcomes.

Evaluating Surgical Outcomes and Survival in Colon Cancer Patients Over 80 Years Old

BACKGROUND AND AIMS

In the context of an increasing older population, knowing the surgical outcomes of older patients is of paramount importance to define a comprehensive strategy for colon cancer treatment in these patients. This study aimed to analyze the surgical outcomes and survival of patients over 80 years old undergoing surgery for colon cancer.

MATERIALS AND METHODS

This is an observational retrospective longitudinal study of patients over 80 years old with colon cancer diagnosis who underwent surgery for this condition, between 2018 and 2021, in a Portuguese hospital. Demographic and clinical features were characterized. Kaplan-Meier method was used for survival analysis.

RESULTS

Out of 90 patients in the study, 41.1% were female. The majority (56.7%) had an Eastern Cooperative Oncology Group (ECOG) performance status of 1 or 0, with a median Charlson Comorbidity Index of 7.0. Tumors were primarily located in the right colon (52.2%) and sigmoid colon (25.6%), with most patients having stage II (35.6%) or stage III (25.5%) disease. Elective surgeries accounted for 73% of procedures, and 80.0% had curative intent, with laparoscopic surgery performed in 66.7% of cases. Only 8.3% of those undergoing curative-intent procedures received adjuvant chemotherapy. Emergent admissions were associated with more advanced cancer stages, higher rates of palliative intent procedures (45.8% versus 10.6%, p < 0.001), and more open surgeries (75.0% versus 9.1%, p < 0.001) when compared to elective procedures. Postoperative mortality was higher in the emergent group (20.8% versus 10.6%), though there was no association between the type of admission and postoperative complications. Median overall survival for all patients was 36.7 (95% CI 28.1 to 45.3) months, with significant differences between curative-intent and palliative surgeries (median of 39.8 (95% CI 32.6 to 47.0) versus 10.6 (95% CI 0.67 to 20.5) months, p = 0.015). The elective group of patients had significantly better overall survival compared to the emergent group (median of 36.7 (95% CI 30.7 to 42.7) versus 11.9 (95% CI 6.0 to 17.8) months, p = 0.01). Among the patients who underwent curative-intent procedures, there were no significant differences in overall or disease-free survival between elective and emergent groups.

CONCLUSIONS

Despite the increased complexity of managing older patients, particularly in emergent cases, these findings emphasize the importance of elective, curative-intent surgeries to optimize overall survival. Effective treatment strategies and perioperative management tailored to this age group are essential for improving surgical outcomes and extending survival in elderly colon cancer patients.

The effects of anaesthesia and analgesia on short- and long-term outcomes following colorectal cancer surgery: Protocol for an international, pragmatic, cohort study (ENCORE∗)

BACKGROUND

Colorectal cancer (CRC) is the second most frequent cause of global cancer mortality. Most patients with CRC require surgical tumour resection, with certain stages of CRC (Stage II/III) also requiring postoperative chemotherapy. The timing of postoperative chemotherapy is largely determined by postoperative recovery. Delayed return to intended oncologic therapy (RIOT) by >8 weeks results in worse oncologic outcomes. RIOT is thus an important surrogate marker of outcome for patients with stage II/III CRC. We will test the hypothesis that anaesthetic technique during CRC resection surgery may affect RIOT.

OBJECTIVE

To test the association between anaesthetic and analgesic technique during CRC surgery and RIOT. To document Short-term Secondary outcomes including individual postoperative complications and a composite of all postoperative complications, the Comprehensive Complications Index (CCI) and to measure the time to recurrence (TTR) of cancer at 3 years.

DESIGN

This is a prospective, international, multicentre, observational cohort study.

SETTING

Global healthcare setting, with >140 centres in >30 nations.

PATIENTS

Inclusion criteria: All patients age >18 years, ASA I-III, with CRC stage I-III scheduled for elective CRC surgery (open or minimally invasive).Exclusion criteria: Uncontrolled renal or liver disease, restrictive (limiting mobility) heart failure or ischemic heart disease (ASA IV-V). Speech, language, or cognitive difficulties precluding signing informed consent to participate and Stage IV CRC.

PRIMARY OUTCOME MEASURES

Short -term: The duration from day of surgery to RIOT among patients expected to receive postoperative chemotherapy. Long-term: incidence of recurrence and time to recurrence (TTR) at 3 years after primary curative surgery.

SECONDARY OUTCOMES

Postoperative complications within 30 days of surgery, length of hospital stay, Days at Home at 30 and 90 days (DAH-30, DAH-90) after surgery, and adverse events related to oncological treatment. We will also assess the burden of preoperative modifiable comorbid disease in patients. Exploratory endpoints will assess practice variation (including incidence of RIOT by demographic e.g. gender of patient, type of institution, country).

RESULTS

N/A.

CONCLUSIONS

N/A.

TRIAL REGISTRATION

The Effects of aNesthesia in COloREctal cancer outcome study: ENCORE, ClinicalTrials.gov Identifier: NCT04493905.

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.

Short-Term Outcomes of First 100 Laparoscopic Colorectal Surgeries at a Newly Developed Surgical Setup at Peshawar

BACKGROUND

The incidence of colorectal cancer (CRC) has risen steadily, necessitating innovative strategies for diagnosis and treatment. Minimally invasive surgery, exemplified by laparoscopic techniques, has emerged as a transformative approach in colorectal surgical practices. Laparoscopy offers advantages such as improved aesthetic outcomes, reduced post-operative pain, early patient mobilization, and shorter hospital stays.

OBJECTIVE

This study aims to present the short-term surgical outcomes of the first 100 elective laparoscopic CRC resections performed at a newly established tertiary care cancer center in Peshawar, Pakistan.

MATERIALS AND METHODS

Data were prospectively collected for CRC resections performed between April 2021 and February 2022. The study included patients above 18 years of age with biopsy-proven CRC. Surgical procedures were performed by two dedicated colorectal surgeons trained in minimally invasive surgery. Patient demographics, pre-operative factors, intraoperative parameters, and post-operative outcomes were systematically recorded and analyzed.

RESULTS

Among the 100 cases included in the study, laparoscopic colorectal surgeries were successfully performed without any conversions to open surgery. The mean age of the study population was 52.5 years, with a male-to-female ratio of 2:1. The majority of cases were colon (48%) and anorectal cancers (52%). The mean lymph node yield was 18.29 (range 6-49). Only one patient required a re-look laparoscopy for a pelvic hematoma, and overall mortality was reported at 1%.

CONCLUSION

Laparoscopic colorectal surgery is a safe and effective treatment option for elective colorectal operations with minimal post-operative complications and favorable short-term outcomes.

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).

Progress of near-infrared-II fluorescence in precision diagnosis and treatment of colorectal cancer

Colorectal cancer is a malignant tumour with high incidence and mortality worldwide; therefore, improving the early diagnosis of colorectal cancer and implementing a targeted "individualized treatment" strategy is of great concern. NIR-II fluorescence imaging is a large-depth, high-resolution optical bioimaging tool. Around the NIR-II window, researchers have developed a variety of luminescent probes, imaging systems, and treatment methods with colorectal cancer targeting capabilities, which can be visualized and image-guided in clinical surgery. This article aims to overcome the difficulties in diagnosing and treating colorectal cancer. The present review summarizes the latest results on using NIR-II fluorescence for targeted colorectal cancer imaging, expounds on the application prospects of NIR-II optical imaging for colorectal cancer, and discusses the imaging-guided multifunctional diagnosis and treatment platforms.

A prospective phase II clinical trial/IDEAL Stage 2a series of single-port robotic colorectal surgery for abdominal and transanal cases

AIM

Slow laparoscopy adoption accelerated the uptake of robotic surgery. However, the current robotic platforms have limitations in transanal applications and multiple port sites. The da Vinci single-port (SP) robot is currently used on trial for colorectal surgery, and broad assessment of outcomes is needed. We aimed to report findings of a phase II clinical trial of SP robotic colorectal surgery.

METHODS

A sequentially reported prospective case series was performed on patients using SP robotics at a tertiary referral centre from 1 October 2018 to 31 August 2021. Cases were stratified into abdominal and transanal cohorts. Demographics, intra-operative variables and 30-day postoperative outcomes were evaluated. Univariate analysis was performed, with statistical process control for the docking process. Main outcomes were conversion rates, morbidity, mortality and point of standardization of docking.

RESULTS

In all, 133 patients were included: 93 (69.92%) abdominal and 40 (30.08%) transanal. The main diagnosis was rectal cancer (n = 59) and the procedure performed a robotic transanal abdominal transanal radical proctosigmoidectomy (n = 30). There were no conversions to open surgery. Two abdominal (2.15%) and three transanal cases (7.50%) were converted to laparoscopy. All colorectal adenocarcinomas had negative margins, proper lymph node harvest and complete mesorectal excision, as appropriate. Docking became a standardized process at cases 34 (abdominal) and 23 (anorectal). After surgery, bowel function returned on mean day 2 (abdominal) and 1 (transanal). The morbidity rate was 15.05% (abdominal) and 27.50% (transanal). There were two major morbidities in each cohort. Overall, there were three (2.65%) readmissions, one reoperation and no mortality.

CONCLUSIONS

Single-port robotics is feasible for all types of colorectal procedures, with good clinical and oncological outcomes. With this development in colorectal surgery, further studies can develop best practices with this novel technology.

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.

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.

Minimally invasive colectomies can be performed with similar outcomes to open counterparts for colorectal cancer emergencies: a propensity score matching analysis utilizing ACS-NSQIP

PURPOSE

The safety and feasibility of minimally invasive surgery (MIS) in the setting of colorectal cancer emergencies have been debated. We sought to compare postoperative outcomes of MIS with open techniques in the setting of colorectal cancer emergencies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

We included patients undergoing colectomy for colorectal cancer emergency between 2012 and 2019 "2012-2019" from the ACS-NSQIP dataset. We compared short-term morbidity, mortality, short-term oncological outcomes, and secondary outcomes for MIS vs open colectomies using propensity score matching. We then evaluated the trends of MIS versus open colectomies using linear regression analysis.

RESULTS

We examined a total of 5544 patients (open n = 4070; MIS n = 1474) and included 1352 patients for our postoperative outcome analyses after propensity score matching 1:1 (open n = 676; MIS n = 676). Within the matched cohort, mortality was significantly higher in the open group (open 6.95% vs MIS 3.99%, OR 1.8, p = 0.023). Anastomotic leak rates were comparable between the  two groups (open 4.46% vs MIS 4.02%, OR 1.12, p = 0.787). Pulmonary complications were significantly higher after open surgery (open 10.06% vs MIS 4.73%, OR 2.25, p < 0.001). Rates of ileus were significantly higher amongst open patients (open 29.08% vs MIS 19.94%, p < 0.001). Patients stayed on average 1 day longer in the hospital after open surgery (p < 0.001). Rates of MIS for early tumors (N0 and T1/T2, n = 289) did not significantly change over 7 years (p = 0.597, rate = - 0.065%/year); however, utilization of MIS for late tumors (N1 or T3/T4, n = 4359) increased by 2.06% per year (p < 0.001).

CONCLUSIONS

This study demonstrates that MIS was associated with superior postoperative outcomes compared to open surgery without compromising oncological outcomes in patients undergoing emergency colectomy for colon cancer. Within the matched cohort, MIS was associated with lower rates of mortality, pulmonary complications, ileus, and shorter postoperative length of stay.

Surgical site infection after intracorporeal and extracorporeal anastomosis in laparoscopic left colectomy for colon cancer: a multicenter propensity score-matched cohort study

BACKGROUND

Intracorporeal anastomosis (IA) is associated with reduced surgical site infection (SSI) and other postoperative complications in laparoscopic right colectomy (LRC). However, evidence is inadequate for IA in laparoscopic left colectomy (LLC). This study aimed to determine the effect of IA and extracorporeal anastomosis (EA) on SSI and other short-term postoperative complications in LLC.

METHODS

In this retrospective multicenter propensity score-matched (PSM) cohort study, we enrolled consecutive patients who underwent LLC with IA (TLLC/IA) and laparoscopic-assisted left colectomy with EA (LALC/EA) at two medical centers between January 2015 and September 2021. Propensity score matching with a 1:2 ratio was employed. The primary outcome was SSI occurrence. Secondary outcomes were operating time, intraoperative hemorrhage, other postoperative complications, and pathological outcomes.

RESULTS

Overall, 574 and 99 patients received LALC/EA and TLLC/IA, respectively. After PSM, 84 patients with TLLC/IA were matched with 141 patients with LALC/EA. Thirty patients (13.3%) patients experienced SSI (17.0% in LALC/EA vs 7.1% in TLLC/IA). IA was associated with a reduced risk of overall SSI and superficial/deep SSI compared with EA after PSM, with OR of 0.375 (95% CI, 0.147-0.959, P = 0.041). and 0.148 (95% CI, 0.034-0.648, P = 0.011), respectively. Multivariate analysis of unmatched patients indicated similar results. In the analysis of secondary outcomes, LALC/EA may have a shorter operating time (absolute mean difference - 13.41 [95% CI, - 23.76 to - 3.06], P = 0.002) and a higher risk of intraoperative hemorrhage (absolute risk difference 4.96 [95% CI, - 0.09 to 9.89], P = 0.048).

CONCLUSIONS

IA in LLC is associated with a reduced risk of overall SSI and superficial/deep SSI. However, it may require a longer operating time.

Right Colectomy with Intracorporeal Anastomosis: A European Multicenter Propensity Score Matching Retrospective Study of Robotic Versus Laparoscopic Procedures

BACKGROUND

This study aimed to compare the short- and long-term outcomes of robotic (RRC-IA) versus laparoscopic (LRC-IA) right colectomy with intracorporeal anastomosis using a propensity score matching (PSM) analysis based on a large European multicentric cohort of patients with nonmetastatic right colon cancer.

METHODS

Elective curative-intent RRC-IA and LRC-IA performed between 2014 and 2020 were selected from the MERCY Study Group database. The two PSM-groups were compared for operative and postoperative outcomes, and survival rates.

RESULTS

Initially, 596 patients were selected, including 194 RRC-IA and 402 LRC-IA patients. After PSM, 298 patients (149 per group) were compared. There was no statistically significant difference between RRC-IA and LRC-IA in terms of operative time, intraoperative complication rate, conversion to open surgery, postoperative morbidity (19.5% in RRC-IA vs. 26.8% in LRC-IA; p = 0.17), or 5-yr survival (80.5% for RRC-IA and 74.7% for LRC-IA; p = 0.94). R0 resection was obtained in all patients, and > 12 lymph nodes were harvested in 92.3% of patients, without group-related differences. RRC-IA procedures were associated with a significantly higher use of indocyanine green fluorescence than LRC-IA (36.9% vs. 14.1%; OR: 3.56; 95%CI 2.02-6.29; p < 0.0001).

CONCLUSION

Within the limitation of the present analyses, there is no statistically significant difference between RRC-IA and LRC-IA performed for right colon cancer in terms of short- and long-term outcomes.

Usefulness of the endoscopic surgical skill qualification system for laparoscopic colectomy for transverse colon cancer: a Japanese multicenter analysis

PURPOSE

Laparoscopic colectomy for transverse colon cancer (TCC) can be technically demanding due to the anatomical complexity of the region. In Japan, the Endoscopic Surgical Skill Qualification System (ESSQS) was established to improve the skill of laparoscopic surgeons and further develop surgical teams. We examined the safety and feasibility of laparoscopic colectomy for TCC and evaluated the effects of the Japanese ESSQS in facilitating this approach.

METHODS

We retrospectively reviewed 136 patients who underwent laparoscopic colectomy for TCC between April 2016 and December 2021. Patients were divided into an ESSQS-qualified surgeon group (surgery performed by an ESSQS-qualified surgeon, n = 52) and a non ESSQS-qualified surgeon (surgery performed by a non ESSQS-unqualified surgeon, n = 84). Clinicopathological and surgical features were compared between groups.

RESULTS

Postoperative complications occurred in 37 patients (27.2%). The proportion of patients who developed postoperative complications was lower in the ESSQS-qualified surgeon group (8.0%) than that in the non ESSQS-qualified surgeon group (34.5%; p < 0.017). Multivariate analysis revealed "Operation by ESSQS-qualified surgeon surgeon" (odds ratio (OR) 0.360, 95% confidence interval (CI) 0.140-0.924; p = 0.033), blood loss (OR 4.146, 95% CI 1.688-10.184; p = 0.002), and clinical N status (OR 4.563, 95% CI 1.814-11.474; p = 0.001) as factors independently associated with postoperative complications.

CONCLUSION

The present multicenter study confirmed the feasibility and safety of laparoscopic colectomy for TCC and revealed that ESSQS-qualified surgeon achieved better surgical outcomes.

The impact of laparoscopic, open, extended right, and left colectomy on clinical outcomes of splenic flexure colon cancer: A meta-analysis

BACKGROUND

Surgical intervention is the recommended line for the management of colon cancer. The aim of this study was to evaluate the impact of different surgical techniques (laparoscopic, open, extended right, and left colectomy) on clinical outcomes such as mortality, postoperative complications, operation and hospitalization time, and oncological factors.

METHODS

A total of 15 studies have been included in the current study. The outcomes of these studies were analyzed using a random-effect model and it was used to calculate the mean difference with 95% confidence intervals to quantify the impact of open, laparoscopic, extended right, and left colectomy. Inclusion criteria included studies in which subjects undergo splenic flexure colon cancer surgery with 2 comparable different surgical techniques.

RESULTS

Laparoscopic splenic flexure colon cancer surgery showed a significant beneficial impact on the length of hospital stay (P < .001), the volume of blood loss during surgery (P < .001), postoperative complications (P < .001), and time to an oral diet (P < .001). On the other hand, there was no significance regarding anastomotic leakage, infection of the surgical site, and operation time. Regarding the comparison between extended right colectomy (ERC) and lift colectomy (LC), analysis findings showed a significant (P = .001) higher efficacy of ERC in harvested number of lymph nodes compared with LC. On the other hand, there was no significant difference for the rest of the parameters. The neoadjuvant therapy as an influencing factor on postoperative outcome showed a beneficial impact regarding the overall survival rate.

CONCLUSION

Laparoscopic splenic flexure colon cancer surgery showed a significant beneficial impact compared with open surgery as proved by clinical outcomes. On the other hand, ERC and LC resulted in similar findings except for harvested lymph nodes, results were in favor of ERC.

Robotic colorectal resection in combination with a multimodal enhanced recovery program - results of the first 100 cases

PURPOSE

In Germany, colorectal robot-assisted surgery (RAS) has found its way and is currently used as primary technique in colorectal resections at our clinic. We investigated whether RAS can be extensively combined with enhanced recovery after surgery (ERAS®) in a large prospective patient group.

METHODS

Using the DaVinci Xi surgical robot, all colorectal RAS from 09/2020 to 01/2022 were incorporated into our ERAS® program. Perioperative data were prospectively recorded using a data documentation system. The extent of resection, duration of the operation, intraoperative blood loss, conversion rate, and postoperative short-term results were analyzed. We documented the postoperative duration of Intermediate Care Unit (IMC) stay and major and minor complications according to the Clavien-Dindo classification, anastomotic leak rate, reoperation rate, hospital-stay length, and ERAS® guideline adherence.

RESULTS

One hundred patients (65 colon and 35 rectal resections) were included (median age: 69 years). The median durations of surgery were 167 min (colon resection) and 246 min (rectal resection). Postoperatively, four patients were IMC-treated (median stay: 1 day). In 92.5% of the colon and 88.6% of the rectum resections, no or minor complications occurred postoperatively. The anastomotic leak rate was 3.1% in colon and 5.7% in rectal resection. The reoperation rate was 7.7% (colon resection) and 11.4% (rectal resection). The hospital stay length was 5 days (colon resection) and 6.5 days (rectal resection). The ERAS® guideline adherence rate was 88% (colon resection) and 82.6% (rectal resection).

CONCLUSION

Patient perioperative therapy per the multimodal ERAS® concept is possible without any problems in colorectal RAS, leading to low morbidity and short hospital stays.

Conversion to Open Surgery During Minimally Invasive Right Colectomy for Cancer: Results from a Large Multinational European Study

Background: The risk of conversion to open surgery is inevitably present during any minimally invasive colorectal surgical procedure. Conversions have been associated with adverse postoperative and oncologic outcomes. No previous study has evaluated the specific causes and consequences of conversion during a minimally invasive right colectomy (MIS-RC). Materials and Methods: We analyzed the Minimally invasivE surgery for oncologic Right ColectomY (MERCY) study database including patients who underwent laparoscopic or robotic RC because of colon cancer between 2014 and 2020. Descriptive analyses were performed to determine the different reasons for conversion. Uni- and multivariate logistic regressions were run to identify potential variables associated with this outcome. Cox regression analyses were used to evaluate the impact of conversion on tumor recurrence. Results: Over a total of 1574 MIS-RC, 120 (7.6%) were converted to open surgery. The main reasons for conversion were procedural difficulties related to adherences from previous abdominal surgical procedures (39.2%), or owing to large tumor size or infiltration of adjacent structures (26.7%). Only 16.7% of the conversions were caused by intraoperative medical or surgical complications. Converted patients required longer operative times and developed more postoperative complications, both overall (39.2% versus 27.5%; P = .006) and severe ones (13.3% versus 8.3%; P = .061). Male gender (odds ratio [OR] = 1.89 [95% confidence interval: 1.31-2.71]), obesity (OR = 1.99 [1.4-2.83]), prior abdominal surgery (OR = 1.68 [1.19-2.37]), and pT4 cancers (OR = 4.04 [2.86-5.69]) were independently associated with conversion. Conversion to open surgery was not significantly associated with tumor recurrence (hazard ratios = 1.395 [0.724-2.687]). Conclusions: Although conversion to open surgery during MIS-RC for cancer is associated with worsened postoperative outcomes, it seems not to impact on the oncologic prognosis.

The influence of socioeconomic aspects and hospital case volume on survival in colorectal cancer in Saxony, Germany

BACKGROUND

Colorectal cancer (CRC) is one of the most common types of cancer in Western civilization and responsible for a high number of yearly deaths. Long-term outcome is influenced by many factors, potentially including socioeconomic aspects like income, education, and employment. Furthermore, annual surgical case volume plays a major role in achieving good oncological results. In our retrospective study, we evaluated the effect of socioeconomic deprivation and hospital volume on overall survival (OS) in the federal state of Saxony, Germany.

METHODS

All patients with CRC who underwent surgery in Saxony, Germany between 2010 and 2020 and were living in Saxony at the time of diagnosis were included in our retrospective analysis. Uni- and multivariate analyses were conducted considering age, sex, tumor localization, UICC tumor stage, surgical approach (open/laparoscopic), number of resected lymph nodes, adjuvant chemotherapy, year of surgery, and hospital case volume. In addition, our model was adjusted for social disparity using the German Index of Socioeconomic Deprivation (GISD).

RESULTS

A total of 24,085 patients were analyzed (15,883 with colon cancer and 8,202 with rectal cancer). Age, sex, UICC tumor stage and tumor localization were distributed as expected for CRC. Median overall survival time was 87.9 months for colon cancer and 110.0 months for rectal cancer. Univariate analysis revealed laparoscopic surgery (colon and rectum P < 0.001), high case volume (rectum: P = 0.002) and low levels of socioeconomic deprivation (colon and rectum P < 0.001) to be significantly associated with better survival. In multivariate analyses, the associations of laparoscopic surgery (colon: HR = 0.76, P < 0.001; rectum: HR = 0.87, P < 0.01), and mid-low to mid-high socioeconomic deprivation (colon: HR = 1.18-1.22, P < 0.001; rectum: HR = 1.18-1.36, P < 0.001-0.01) remained statistically significant. Higher hospital case volume was associated with better survival only in rectal cancer (HR = 0.89; P < 0.01).

CONCLUSION

In Saxony, Germany, better long-term survival after CRC surgery was associated with low socioeconomic deprivation, laparoscopic surgery and partly with high hospital case volume. Thus, there is a need to reduce social differences in access to high-quality treatment and prevention and increase hospital patient volume.

Overall survival comparing laparoscopic to open surgery for right-sided colon cancer: propensity score inverse probability weighting population study

BACKGROUND

This retrospective cohort study reports on overall survival and short-term complications, comparing laparoscopic to open resection for right-sided colon cancers. It is one of the largest studies in the field with generalizable population-level results.

METHOD

This study on right sided colon cancers used prospectively collected administrative data linked to a death registry over 5 years from 2014 to 2018. Exclusion criteria were private patients, patients aged less than 10 years, synchronous and metachronous cancers. Propensity score weighting was used to balance cohorts and Cox proportional hazards regression was used to assess the hazard of death. In addition, logistic regression analysis was used to assess secondary outcomes. For completeness, unweighted data was similarly analysed.

RESULTS

There were 3603 patients identified for the analysis: 1729 open patients and 1874 laparoscopic patients. Cox proportional hazards regression analysis of the weighted data showed no evidence of a statistically significant effect of laparoscopic surgery compared to open surgery on overall survival for right-sided colon cancers (HR 0.86, 95% CI 0.71-1.04, P = 0.112). The weighted data showed lower odds of prolonged length of stay, return to theatre and discharge destination other than home in the laparoscopic cohort compared to the open cohort. There was no difference in inpatient mortality. Unweighted results were similar.

CONCLUSION

This study validates the use of laparoscopic surgery for right-sided colon cancer, showing similar long-term overall survival and inpatient mortality compared to open surgery. It is superior to open surgery for the short-term outcomes of LOS, return to theatre and discharge destination other than home.

Long-term oncological outcomes for minimally invasive surgery versus open surgery for colon cancer-a population-based nationwide study with a non-inferiority design

AIM

The study aimed to compare 5-year overall survival in a national cohort of patients undergoing curative abdominal resection for colon cancer by minimally invasive surgery (MIS) or by the open (OPEN) technique.

METHODS

All patients diagnosed between 2010 and 2016 in Sweden with pathological Union International Contre le Cancer Stages I-III colon cancer localized in the caecum, ascending colon, hepatic flexure or sigmoid colon and those who underwent curative right sided hemicolectomy, sigmoid resection or high anterior resection by MIS or OPEN were included. Patients were identified in the Swedish Colorectal Cancer Registry from which all data were retrieved. The analyses were performed as intention-to-treat and the relationship between surgical technique (MIS or OPEN) and overall mortality within 5 years was analysed. For the primary research question a non-inferiority hypothesis was assumed with a statistical power of 90%, a one-side type I error of 2.5% and a non-inferiority margin of 2%. For the secondary analyses, multilevel survival regression models with the patients matched by propensity scores were employed, adjusted for patient- and tumour-related variables.

RESULTS

A total of 11 605 pathological Union International Contre le Cancer Stages I-III patients were included with 3297 MIS (28.4%) and 8308 OPEN (71.6%) and were followed until 31 December 2020. The primary analysis demonstrated superiority for MIS compared to OPEN. The multilevel survival regression analyses confirmed that 5-year overall survival was higher in MIS with a hazard ratio of 0.874 (95% confidence interval 0.791-0.965), and if excluding pT4 the outcome was similar, with a hazard ratio of 0.847 (95% confidence interval 0.756-0.948).

CONCLUSION

This observational study demonstrated that MIS was favourable to OPEN with regard to 5-year overall survival. These results support the use of laparoscopic colon cancer surgery in routine practice.

Minimally Invasive Compared to Open Colorectal Cancer Resection for Older Adults: A Population-based Analysis of Long-term Functional Outcomes

OBJECTIVE

We sought to compare long-term healthcare dependency and time-at-home between older adults undergoing minimally invasive surgery (MIS) for colorectal cancer (CRC) and those undergoing open resection.

BACKGROUND

Although the benefits of MIS for CRC resection are established, data specific to older adults are lacking. Long-term functional outcomes, central to decision-making in the care for older adults, are unknown.

METHODS

We performed a population-based analysis of patients ≥70years old undergoing CRC resection between 2007 to 2017 using administrative datasets. Outcomes were receipt of homecare and "high" time-at-home, which we defined as years with ≤14 institution-days, in the 5years after surgery. Homecare was analyzed using time-to-event analyses as a recurrent dichotomous outcome with Andersen-Gill multivariable models. High timeat-home was assessed using Cox multivariable models.

RESULTS

Of 16,479 included patients with median follow-up of 4.3 (interquartile range 2.1-7.1) years, 7822 had MIS (47.5%). The MIS group had lower homecare use than the open group with 22.3% versus 31.6% at 6 months and 14.8% versus 19.4% at 1 year [hazard ratio 0.87,95% confidence interval (CI) 0.83-0.92]. The MIS group had higher probability ofhigh time-at-home than open surgery with 54.9% (95% CI 53.6%-56.1%) versus 41.2% (95% CI 40.1%-42.3%) at 5years (hazard ratio 0.71, 95% CI 0.68-0.75).

CONCLUSIONS

Compared to open surgery, MIS for CRC resection was associated with lower homecare needs and higher probability of high time-at-home in the 5 years after surgery, indicating reduced long-term functional dependence. These are important patient-centered endpoints reflecting the overall long-term treatment burden to be taken into consideration in decision-making.

Does 3D laparoscopic video technology affect long-term survival in right hemicolectomy for cancer compared to standard 2D? A propensity score study

BACKGROUND

There are few studies focused on the short-term results of laparoscopic right hemicolectomy performed with 2D (two-dimension) or 3D (three-dimension) video technology and none on the oncologic effects. The aim of the study was to assess the long-term results of laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis using 3D or 2D video in patients with right colon cancer with at least three years of oncologic follow-up.

METHODS

Data from patients undergoing laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis for cancer in an 11-year period (June 2008-June 2019) and ≥ 3 years of follow-up were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons.

RESULTS

111 patients were included in the study: 56 (50.5%) in the 3D group and 55 (49.5%) in the 2D group. Tumor stage and number of lymph nodes harvested were similar. Overall and disease-free survival were not different in the two groups. Local recurrence occurred in none of the patients, and distant metachronous metastases were similar in the two groups. A propensity score weighting approach was used to account for potential confounding related to patients' nonrandom allocation to the 2 groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach.

CONCLUSIONS

Laparoscopic 3D technology allows similar oncological results as 2D vision in LRH with intracorporeal anastomosis. Larger prospective randomized studies might confirm these results in the long-term follow-up.

Advantage of laparoscopic surgery in patients with generalized obesity operated for colorectal malignancy: A retrospective cohort study

Background

Because of the progression of minimally invasive surgery skills and obesity in colorectal surgery, we aimed to evaluate the short-term outcomes of colorectal cancer resections in patients with generalized obesity at a single teaching hospital with mature surgical techniques and training programs.

Methods

A total of 537 patients were diagnosed with CRC and had a body mass index ≥30 kg/m2 between January 2009 and December 2019 at a single institution. 265 patients underwent open surgery and 272 patients underwent laparoscopic surgery. Data were analysed to explore the independent risk factors for postoperative complications.

Results

The laparoscopic group had less blood loss (73 ± 128 vs. 148 ± 290 ml, p < 0.001) and a shorter postoperative hospital stay (10.8 ± 17.1 vs. 11.7 ± 6.8 days, p < 0.001) than the open group. The number of harvested lymph nodes did not significantly differ between the two groups (30.9 ± 18.3 vs. 30.2 ± 15.3, p = 0.981). Although anastomotic leakage was significantly higher in the laparoscopic group (1.5% vs. 4.8%, p = 0.030), there were also similar overall postoperative morbidity and mortality rates between the open and laparoscopic groups for CRC patients with generalized obesity who underwent surgery.

Conclusion

Laparoscopic surgery can reduce blood loss, decrease the length of hospital stay, obtain a similar number of harvested lymph nodes, and achieve an acceptable conversion rate for CRC patients with generalized obesity. We suggest that laparoscopic surgery could become a standard method for CRC treatment in patients with generalized obesity.

[Transanal specimen extraction after left-sided laparoscopic colectomy: a systematic review and meta-analysis]

OBJECTIVE

To compare the short-term results after left-sided laparoscopic colectomy with transanal and transabdominal specimen extraction.

MATERIAL LAND METHODS

We selected 998 appropriate manuscripts and subsequently excluded 995 ones due to exclusion criteria. Thus, the meta-analysis was based on 3 randomized trials in accordance with PRISMA recommendations.

RESULTS

A total of 353 patients were enrolled in meta-analysis including 169 resections with transanal specimen extraction and 184 surgeries with transabdominal extraction. Overall risk of postoperative complications (OR=0.60; 95% CI 0.31-1.14; p=0.12) including anastomotic leakage (OR=1.83; 95% CI 0.43-7.89; p=0.42) was similar in both groups. At the same time, severity of pain syndrome (mean difference = -2.35; 95% CI -2.51-2.19), time to the first flatus discharge (mean difference = -0.92; 95% CI -0.99-0.85) and postoperative hospital stay (mean difference = -1.5; 95% CI -2.03-0.98) were significantly lower in the group of transanal extraction (p<0.00001).

CONCLUSION

Transanal specimen extraction in left-sided laparoscopic colectomy does not increase overall risk of postoperative complications. In addition, the NOSE technique has some advantages in short-term results compared to procedures with transabdominal specimen extraction.

Urogenital dysfunction after laparoscopic surgery for rectal or sigmoid colon cancer

BACKGROUND/OBJECTIVE

Urogenital dysfunction is a common complication after surgery for sigmoid colon or rectal cancers and may result from various causes. Herein, we evaluated urogenital dysfunction and the associated factors after laparoscopic surgery at different follow-up times.

METHODS

We conducted a prospective study on 91 patients who were diagnosed with sigmoid colon and rectal cancers and underwent laparoscopic surgery during 2014-2016. Voiding and male and female sexual dysfunctions following surgery were evaluated by the International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5), and Female Sexual Function Index-6 (FSFI-6), respectively. Urogenital function was compared at pre-surgery and 3 and 12 months postoperatively, and factors associated with urogenital dysfunction were identified.

RESULTS

The overall urinary function after surgery was better when compared to that at pre-surgery; however, there was deterioration in both male and female sexual functions. The mean preoperative IPSS, IIEF-5, and FSFI-6 scores were 9.35, 12.18, and 6.09, respectively. The mean differences among IPSS, IIEF-5, and FSFI-6 at 12 months postoperatively and pre-surgery were -3.08 (95% confidence interval [CI] -4.77 to -1.40), -2.57 (95% CI -4.33 to -0.80), and -2.58 (95% CI -4.73 to 0.42), respectively. Multivariate analysis demonstrated that age ≤60 years (odds ratio 4.22) and postoperative complications (odds ratio 2.77) were correlated with erectile dysfunction.

CONCLUSION

Voiding function improved after laparoscopic surgery in both sigmoid colon and rectal cancer patients. However, sexual function in both male and female patients was worse. Age ≤60 years and postoperative complications were strongly associated with male sexual dysfunction.

Impact of operation duration on postoperative outcomes of minimally-invasive right colectomy

AIM

Operation time (OT) is a key operational factor influencing surgical outcomes. The present study aimed to analyse whether OT impacts on short-term outcomes of minimally-invasive right colectomies by assessing the role of surgical approach (robotic [RRC] or laparoscopic right colectomy [LRC]), and type of ileocolic anastomosis (i.e., intracorporal [IA] or extra-corporal anastomosis [EA]).

METHODS

This was a retrospective analysis of the Minimally-invasivE surgery for oncological Right ColectomY (MERCY) Study Group database, which included adult patients with nonmetastatic right colon adenocarcinoma operated on by oncological RRC or LRC between January 2014 and December 2020. Univariate and multivariate analyses were used.

RESULTS

The study sample was composed of 1549 patients who were divided into three groups according to the OT quartiles: (1) First quartile, <135 min (n = 386); (2) Second and third quartiles, 135-199 min (n = 731); and (3) Fourth quartile ≥200 min (n = 432). The majority (62.7%) were LRC-EA, followed by LRC-IA (24.3%), RRC-IA (11.1%), and RRC-EA (1.9%). Independent predictors of an OT ≥ 200 min included male gender, age, obesity, diabetes, use of indocyanine green fluorescence, and IA confection. An OT ≥ 200 min was significantly associated with an increased risk of postoperative noninfective complications (AOR: 1.56; 95% CI: 1.15-2.13; p = 0.004), whereas the surgical approach and the type of anastomosis had no impact on postoperative morbidity.

CONCLUSION

Prolonged OT is independently associated with increased odds of postoperative noninfective complications in oncological minimally-invasive right colectomy.

Minimally invasive colorectal surgery learning curve

The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon’s experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.

Postoperative circulating tumor DNA detection is associated with the risk of recurrence in patients resected for a stage II colorectal cancer

Circulating tumor DNA (ctDNA) is reported to be promising in localized colorectal cancer (CRC). The present study aimed to retrospectively evaluate the impact of ctDNA in patients with a resected stage II CRC from the PROGIGE 13 trial with available paired tumor and blood samples. A group of recurrent patients were matched one-to-one with nonrecurrent patients according to sex, tumor location, treatment sequence, and blood collection timing. CtDNA was analyzed by digital PCR according to NGS of tumors. Disease-free survival (DFS) and overall survival (OS) were analyzed based on ctDNA, and the risks of recurrence and death were determined. A total of 134 patients were included, with 67 patients in each group. At least one alteration was identified in 115/134 tumors. Postoperative ctDNA was detected in 10/111 (9.0%) informative samples and was detected more frequently in the recurrent group (16.7% versus 1.8%; p = 0.02). The median DFS of ctDNA+ versus ctDNA- patients was 16.8 versus 54 months (p = 0.002), respectively, and the median OS was 51.3 versus 69.5 months (p = 0.03), respectively. CtDNA was associated with recurrence (ORa = 11.13, p = 0.03) and death (HRa = 3.15, p = 0.01). In conclusion, the presence of postoperative ctDNA is associated with both recurrence and survival in stage II CRC.

Laparoscopic vs. open colectomy for T4 colon cancer: A meta-analysis and trial sequential analysis of prospective observational studies

Background

To evaluate short- and long-term outcomes of laparoscopic colectomy (LC) vs. open colectomy (OC) in patients with T4 colon cancer.

Methods

Three authors independently searched PubMed, Web of Science, Embase, Cochrane Library, and Clinicaltrials.gov for articles before June 3, 2022 to compare the clinical outcomes of T4 colon cancer patients undergoing LC or OC.

Results

This meta-analysis included 7 articles with 1,635 cases. Compared with OC, LC had lesser blood loss, lesser perioperative transfusion, lesser complications, lesser wound infection, and shorter length of hospital stay. Moreover, there was no significant difference between the two groups in terms of 5-year overall survival (5y OS), and 5-year disease-free survival (5y DFS), R0 resection rate, positive resection margin, lymph nodes harvested ≥12, and recurrence. Trial Sequential Analysis (TSA) results suggested that the potential advantages of LC on perioperative transfusion and the comparable oncological outcomes in terms of 5y OS, 5y DFS, lymph nodes harvested ≥12, and R0 resection rate was reliable and no need of further study.

Conclusions

Laparoscopic surgery is safe and feasible in T4 colon cancer in terms of short- and long-term outcomes. TSA results suggested that future studies were not required to evaluate the 5y OS, 5y DFS, R0 resection rate, positive resection margin status, lymph nodes harvested ≥12 and perioperative transfusion differences between LC and OC.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022297792.

The Senhance Surgical System in Colorectal Surgery: A Systematic Review

The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m²) were included. The most common indication for surgery was colorectal cancer (n = 180, 80.7%) and the most common operation was anterior resection (n = 72, 32.3%). Meta-analyses demonstrated a pooled total operative time of 229.8 min (95% CI 189.3-270.4, I² = 0%), console time of 141.3 min (95% CI 106.5-176.1, I² = 0%), and docking time of 10.8 min (95% CI 6.4-15.2, I² = 0%). The pooled EBL was 37.0 mL (95% CI 24.7-49.2, I² = 20%). Overall, there were nine (4.0%) conversions to laparoscopy/laparotomy. The Senhance Surgical System has an acceptable safety profile, reasonable docking and console times, low conversion rates, and an affordable case cost across a variety of colorectal surgeries. Further prospective, comparative trials with other robotic surgical platforms are warranted.

Medium-term oncological outcomes of totally laparoscopic colectomy with intracorporeal anastomosis for right-sided and left-sided colon cancer: propensity score matching analysis

Background

This retrospective study aimed to compare long-term oncological outcomes between laparoscopic-assisted colectomy (LAC) with extracorporeal anastomosis (EA) and totally laparoscopic colectomy (TLC) with intracorporeal anastomosis (IA) for colon cancers, including right- and left-sided colon cancers.

Methods

Patients with stage I–III colon cancers who underwent elective laparoscopic colectomy between January 2013 and December 2017 were analyzed retrospectively. Patients converted from laparoscopic to open surgery and R1/R2 resection were excluded. Propensity score matching (PSM) analysis (1:1) was performed to overcome patient selection bias.

Results

A total of 388 patients were reviewed. After PSM, 83 patients in the EA group and 83 patients in the IA group were compared. Median follow-up was 56.5 months in the EA group and 55.5 months in the IA group. Estimated 3-year overall survival (OS) did not differ significantly between the EA group (86.6%; 95% confidence interval (CI), 77.4–92.4%) and IA group (84.8%; 95%CI, 75.0–91.1%; P = 0.68). Estimated 3-year disease-free survival (DFS) likewise did not differ significantly between the EA group (76.4%; 95%CI, 65.9–84.4%) and IA group (81.0%; 95%CI, 70.1–88.2%; P = 0.12).

Conclusion

TLC with IA was comparable to LAC with EA in terms of 3-year OS and DFS. TLC with IA thus appears to offer an oncologically feasible procedure.

Oncological outcomes of open, laparoscopic and robotic colectomy in patients with transverse colon cancer

BACKGROUND

Literature concerning surgical management of transverse colon cancer is scarce, since many key trials excluded transverse colon cancer. The aim of this study was to evaluate clinical and oncological outcomes comparing open, laparoscopic and robotic transverse colon cancer resection.

METHODS

Consecutive patients who underwent elective surgery for transverse colon cancer between December 2005 and July 2021 were included. Data were kept in a prospective database approved by the institutional ethics committee. Primary outcome was overall and disease-free survival. Secondary outcomes included complications, operative time, length of stay and lymph node harvest. Statistical analysis was corrected for age and tumour localisation.

RESULTS

Two hundred and forty-six (38 robotic, 71 open and 137 laparoscopic resections) were recruited in this study. There were five conversions during laparoscopic procedures. Operative time was significantly shorter in robotic vs laparoscopic procedures (195 vs 238 min, p = 0.005) and length of stay was shorter in robotic vs laparoscopic and open group (7 vs 9 vs 15 days, p < 0.001). There was no difference in overall complications. R0 resections were similar. Lymph node harvest was highest in the robotic group vs. laparoscopic or open (32 vs. 29 vs. 21, p < 0.001). Overall survival was 97%, 85% and 60% (p < 0.001) and disease-free survival was 91%, 78% and 56% (p < 0.001) for the robotic, laparoscopic and open groups, respectively.

CONCLUSIONS

Minimally invasive surgery for transverse colon cancer is safe and offers good clinical and oncological outcomes. Robotic resection is associated with significantly shorter operating times, higher lymph node harvest, lower conversion rate and does not increase morbidity. Differences in disease-free and overall survival should be further explored in randomised controlled trials.

The Multidisciplinary Approach of Rectal Cancer: The Experience of "COMRE Group" Model

Background: Total mesorectal excision (TME) is the gold standard to treat locally advanced rectal cancer. This monocentric retrospective study evaluates the results of laparotomic, laparoscopic and robotic surgery in “COMRE GROUP” (REctalCOMmittee). Methods: 327 selected stage I-II-III patients (pts) underwent TME between November 2005 and April 2020 for low or middle rectal cancer; 91 pts underwent open, 200 laparoscopic and 36 robotic TME. Of these, we analyzed the anthropomorphic, intraoperative, anatomopathological parameters and outcome during the follow up. Results: The length of hospital stay was significantly different between robotic TME and the other two groups (8.47 ± 3.54 days robotic vs. 11.93 ± 5.71 laparotomic, p < 0.001; 8.47 ± 3.54 robotic vs. 11.10 ± 7.99 laparoscopic, p < 0.05). The mean number of harvested nodes was higher in the laparotomic group compared to the other two groups (19 ± 9 laparotomic vs. 15 ± 8 laparoscopic, p < 0.001; 19 ± 9 laparotomic vs. 15 ± 7 robotic, p < 0.05). Median follow-up was 52 months (range: 1−169). Overall survival was significantly shorter in the open TME group compared with the laparoscopic one (Chi2 = 13.36, p < 0.001). Conclusions: In the experience of the “COMRE” group, laparoscopic TME for rectal cancer is a better choice than laparotomy in a multidisciplinary context. Robotic TME has a significant difference in terms of hospital stay compared to the other two groups.

Laparoscopic versus open left hemicolectomy for left-sided colon cancer: protocol for a systematic review and meta-analysis

INTRODUCTION

Laparoscopic colectomy has been widely used clinically due to its minimally invasive advantages, and many studies have also demonstrated its safety and efficacy. However, the efficacy of laparoscopic left hemicolectomy remains unclear due to the differences in pathogenesis and surgical details between left and right colon cancers. Therefore, we plan to conduct a systematic review and meta-analysis to investigate whether laparoscopic techniques can be safely used in left hemicolectomy.

METHOD AND ANALYSIS

This meta-analysis protocol will be completed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. A systematic search was performed for all articles related to laparoscopic left hemicolectomy in PubMed, Web of Science, Medline, EMBASE and the Cochrane Library from inception to 5 November 2021. Article screening and data extraction were performed independently by two authors and cross-checked after completion. The literature to be included will use corresponding tools for bias risk assessment. Subgroup analyses and sensitivity analyses will be used to explore potential heterogeneity.

ETHICS AND DISSEMINATION

Because this systematic review is based on studies with published results and does not involve intervention in patients, no ethical review is required. The results of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022291526.

Immediate Adjuvant Chemotherapy in Non-Metastatic Colon Cancer: Phase I Trial Evaluating a Novel Treatment Protocol

BACKGROUND

The optimal timing of adjuvant chemotherapy (AC) in non-metastatic colon cancer is poorly defined. Delays in AC result in decreased survival. Effective cytotoxic treatments should be considered during the perioperative phase of care. The immediate adjuvant chemotherapy (IAC) concept intends to capitalize on the therapeutic benefits that can be achieved in the perioperative period. We aim to demonstrate that IAC is safe and tolerable.

PATIENT AND METHODS

Microsatellite stable invasive adenocarcinomas were treated with intravenous Leucovorin 20 mg/m2 and single dose of 5-Flurouracil 400mg/m2 at the time of surgery. High-risk stage II and stage III received the first dose of standard AC at 14 days after surgery. Serial measurements of blood-based biomarkers were measured. Quality of life (QOL) was measured using EORTC QLQ-C30.

RESULTS

Of the 20 patients recruited, 40% had final pathology of stage III, 40% stage II and 20% stage I. All patients received intra-operative chemotherapy with no associated morbidity. Median length of stay was 2 days (range of 2-4). There was no intraoperative morbidity with 5% (N = 1) grade 3 complication. AC was administered to 65% of patients. The median time to AC was 14 days (range 14-36). Overall quality of life and health scores were similar before surgery and at 30-day postoperatively (P < .05).

CONCLUSIONS

A protocol based on IAC starting at the time of surgical resection was found to be safe and feasible with no adverse effects on surgical morbidity or quality of life. Further prospective studies are needed to explore the oncologic benefit of this novel systemic treatment approach.

Long-term oncological outcomes in patients undergoing laparoscopic versus open surgery for colon cancer: A nationwide cohort study

AIM

To estimate the effect of laparoscopy versus laparotomy on recurrence status in patients undergoing intended curative resection for stage I-III colon cancer using nationwide data.

METHOD

A retrospective cohort study using prospectively collected nationwide quality assurance data on all patients undergoing elective, intended curative surgery for UICC stage I-III colon cancer in Denmark from 1 January 2010, through 31 December 2013. The association between laparoscopic versus open surgery and recurrence status was investigated using cause-specific hazard and subdistribution hazard models with death from any cause as a competing event.

RESULTS

In total, 4369 patients undergoing elective intended curative surgery for colon cancer were included in the analysis. Overall, 3243 (74.2%) patients underwent laparoscopic surgery. During a median follow-up time of 84 months, 1191 (27.2%) patients experienced recurrence, and 1304 (29.8%) patients died. The cause-specific hazard of recurrence following laparoscopic versus open surgery was HR_CS  = 1.08, 95% CI: 0.90-1.28, p = 0.422. The subdistribution hazard of recurrence following laparoscopic versus open surgery was HR_SD =0.99, 95% CI: 0.84-1.16, p = 0.880.

CONCLUSION

Elective laparoscopic resection for UICC stage I-III colon cancer is oncologically safe and comparable with open resection. These results confirm the external validity of previous RCTs in everyday clinical settings.

The MERCY Study Collaborating Group, de’Angelis N, Pattacini GC, Winter DC, Aisoni F, Bianchi G, Carcoforo P, Celentano V, Coccolini F, Di Saverio S, Frontali A, Denet C, Fuks D, Genova P, Guerrieri M, Kraft M, Lakkis Z, Antonot C, Vertier J, Le Roy B, Lupinacci RM, Martínez-Perez A, De Palma GD, Milone M, Orci L, Bartoletti S, O’Connell L, Ortenzi M, Paquet JC, Perrotto O, Petri R, Santangelo A, Scabini S, De Rosa R, Tonini V, Valverde A, Andolfi E, Pecchini F, Pellino G, Urbani A, Vidal L, Restivo A, Deidda S, Zorcolo L, Ris F, Espin E, Piccoli M. Predictors of surgical outcomes of minimally invasive right colectomy: the MERCY study

PURPOSE

The optimal approach for minimally invasive (MIS) right colectomy remains under debate. This study aimed to describe surgical trends in the treatment of nonmetastatic right colon cancer and to identify predictors of short-term surgical outcomes.

METHODS

A retrospective multicenter cohort study of Minimally-invasivE surgery for oncologic Right ColectomY (MERCY) was conducted on patients who underwent laparoscopic or robotic right colectomy between 2014 and 2020. Classification tree approach was used to describe the extracorporeal (EA) or intracorporeal (IA) anastomosis choice. Mixed-model regressions were used to identify patient- and surgery-related factors predictive of postoperative outcomes. A questionnaire was used to evaluate the surgeons' perspectives.

RESULTS

The MERCY database comprised 1870 patients; 87.2% underwent laparoscopy, and 68.1% received an EA. A clear surgical trend was noted, with an increasing rate of IA and robotic procedures after 2017. EA represented 41% of anastomoses in centers equipped with a robotic surgical system. Mixed-model regressions (on 1088 patients) showed that age, sex, BMI, comorbidity, robotics, IA, and conversion to open surgery were predictors of surgical outcomes. In particular, IA was a predictor of a shorter time to regular diet and fewer surgical site infections. Based on the questionnaire, IA was the preferred over EA by 72% of surgeons.

CONCLUSION

MIS continues to evolve, with an increasing number of IA being performed in the recent years and when using a robotic surgical system. Understanding the role of predictors of surgical outcomes may help surgeons personalize decision-making among the different MIS options to manage right colon cancer.

Early versus delayed defunctioning ileostomy closure after low anterior resection for rectal cancer: a meta-analysis and trial sequential analysis of safety and functional outcomes

PURPOSE

We performed a systematic review and meta-analysis with trial sequential analysis (TSA) to answer whether early closure of defunctioning ileostomy may be suitable after low anterior resection.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, up to October 2021, for RCTs comparing early closure (EC ≤ 30 days) and delayed closure (DC ≥ 60 days) of defunctioning ileostomy. The risk ratio (RR) with 95% CI was calculated for dichotomous variables and the mean difference (MD) with 95% CI for continuous variables. The GRADE methodology was implemented for assessing Quality of Evidence (QoE). TSA was implemented to address the risk of random error associated with sparse data and/or multiple testing.

RESULTS

Seven RCTs were included for quantitative synthesis. 599 patients were allocated to either EC (n = 306) or DC (n = 293). EC was associated with a higher rate of wound complications compared to DC (RR 2.56; 95% CI 1.33 to 4.93; P = 0.005; I2 = 0%, QoE High), a lower incidence of postoperative small bowel obstruction (RR 0.46; 95% CI 0.24 to 0.89; P = 0.02; I2 = 0%, QoE moderate), and a lower rate of stoma-related complications (RR 0.26; 95% CI 0.16 to 0.42; P < 0.00001; I2 = 0%, QoE moderate). The rate of minor low anterior resection syndrome (LARS) (RR 1.13; 95% CI 0.55 to 2.33; P = 0.74; I2 = 0%, QoE low) and major LARS (RR 0.80; 95% CI 0.59 to 1.09; P = 0.16; I2 = 0%, QoE low) did not differ between the two groups. TSA demonstrated inconclusive evidence with insufficient sample sizes to detect the observed effects.

CONCLUSION

EC may confer some advantages compared with a DC. However, TSA advocated a cautious interpretation of the results.

PROSPERO REGISTER ID

CRD42021276557.

Laparoscopic versus open colectomy for locally advanced T4 colonic cancer: meta-analysis of clinical and oncological outcomes

BACKGROUND

The aim of this study was to review the early postoperative and oncological outcomes after laparoscopic colectomy for T4 cancer compared with open surgery.

METHOD

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for any relevant clinical study comparing laparoscopic and open colectomy as treatment for T4 colonic cancer. The risk ratio (RR) with 95 per cent c.i. was calculated for dichotomous variables, and the mean difference (m.d.) with 95 per cent confidence interval for continuous variables. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was implemented for assessing quality of evidence (QoE).

RESULTS

Twenty-four observational studies (21 retrospective and 3 prospective cohort studies) were included, analysing a total of 18 123 patients: 9024 received laparoscopic colectomy and 9099 underwent open surgery. Laparoscopic colectomy was associated with lower rates of mortality (RR 0.48, 95 per cent c.i. 0.41 to 0.56; P < 0.001; I2 = 0 per cent, fixed-effect model; QoE moderate) and complications (RR 0.61, 0.49 to 0.76; P < 0.001; I2 = 20 per cent, random-effects model; QoE very low) compared with an open procedure. No differences in R0 resection rate (RR 1.01, 1.00 to 1.03; P = 0.12; I2 = 37 per cent, random-effects model; QoE very low) and recurrence rate (RR 0.98, 0.84 to 1.14; P = 0.81; I2 = 0 per cent, fixed-effect model; QoE very low) were found.

CONCLUSION

Laparoscopic colectomy for T4 colonic cancer is safe, and is associated with better clinical outcomes than open surgery and similar oncological outcomes.