Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery. Ann Surg. 2010;252:84-89. [PMID: 20562603 DOI: 10.1097/sla.0b013e3181e45b66]

Assessing and managing frailty in emergency laparotomy: a WSES position paper

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

Outcomes following open versus laparoscopic multi-visceral resection for locally advanced colorectal cancer: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to compare morbidity, mortality, oncological safety, and survival outcomes after laparoscopic multi-visceral resection (MVR) of the locally advanced primary colorectal cancer (CRC) compared with open surgery.

MATERIALS AND METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic and open surgery in patients with locally advanced CRC undergoing MVR were selected. The primary endpoints were peri-operative morbidity and mortality. Secondary endpoints were R0 and R1 resection, local and distant disease recurrence, disease-free survival (DFS), and overall survival (OS) rates. RevMan 5.3 was used for data analysis.

RESULTS

Ten comparative observational studies reporting a total of 936 patients undergoing laparoscopic MVR (n = 452) and open surgery (n = 484) were identified. Primary outcome analysis demonstrated a significantly longer operative time in laparoscopic surgery compared with open operations (P = 0.008). However, intra-operative blood loss (P<0.00001) and wound infection (P = 0.05) favoured laparoscopy. Anastomotic leak rate (P = 0.91), intra-abdominal abscess formation (P = 0.40), and mortality rates (P = 0.87) were comparable between the two groups. Moreover the total number of harvested lymph nodes, R0/R1 resections, local/distant disease recurrence, DFS, and OS rates were also comparable between the groups.

CONCLUSION

Although inherent limitations exist with observational studies, the available evidence demonstrates that laparoscopic MVR in locally advanced CRC seems to be a feasible and oncologically safe surgical option in carefully selected cohorts.

Combining staged laparoscopic colectomy with robotic completion proctectomy and ileal pouch–anal anastomosis (IPAA) in ulcerative colitis for improved clinical and cosmetic outcomes: a single-center feasibility study and technical description

Robotic proctectomy has been shown to lead to better functional outcomes compared to laparoscopic surgery in rectal cancer. However, in ulcerative colitis (UC), the potential value of robotic proctectomy has not yet been investigated, and in this indication, the operation needs to be adjusted to the total colectomy typically performed in the preceding 6 months. In this study, we describe the technique and analyze outcomes of a staged laparoscopic and robotic three-stage restorative proctocolectomy and compare the clinical outcome with the classical laparoscopic procedure. Between December 2016 and May 2021, 17 patients underwent robotic completion proctectomy (CP) with ileal pouch–anal anastomosis (IPAA) for UC. These patients were compared to 10 patients who underwent laparoscopic CP and IPAA, following laparoscopic total colectomy with end ileostomy 6 months prior by the same surgical team at our tertiary referral center. 27 patients underwent a 3-stage procedure for refractory UC (10 in the lap. group vs. 17 in the robot group). Return to normal bowel function and morbidity were comparable between the two groups. Median length of hospital stay was the same for the robotic proctectomy/IPAA group with 7 days [median; IQR (6–10)], compared to the laparoscopic stage II with 7.5 days [median; IQR (6.25–8)]. Median time to soft diet was 2 days [IQR (1–3)] vs. 3 days in the lap group [IQR 3 (3–4)]. Two patients suffered from a major complication (Clavien–Dindo ≥ 3a) in the first 90 postoperative days in the robotic group vs. one in the laparoscopic group. Perception of cosmetic results were favorable with 100% of patients reporting to be highly satisfied or satisfied in the robotic group. This report demonstrates the feasibility of a combined laparoscopic and robotic staged restorative proctocolectomy for UC, when compared with the traditional approach. Robotic pelvic dissection and a revised trocar placement in staged proctocolectomy with synergistic use of both surgical techniques with their individual advantages will likely improve overall long-term functional results, including an improved cosmetic outcome.

Changing patterns of multidisciplinary team treatment, early mortality, and survival in colorectal cancer

Background

This study reports early mortality and survival from colorectal cancer in relation to the pattern of treatments delivered by the multidisciplinary team (MDT) meeting at a high-volume institution in England over 14 years.

Methods

All patients diagnosed with colorectal cancer and discussed during MDT meetings from 2003 to 2016 at a single institution were reviewed. Three time intervals (2003–2007, 2008–2012, and 2013–2016) were compared regarding initial surgical management (resection, local excision, non-resection surgery, and no surgery), initial oncological therapy, 90-day mortality, and crude 2-year survival for the whole cohort. Sub-analyses were performed according to age greater or less than 80 years.

Results

The MDT managed 4617 patients over 14 years (1496 in the first interval and 1389 in the last). Over this time, there was a reduction in emergency resections from 15.5 per cent to 9.0 per cent (P < 0.0001); use of oncological therapies increased from 34.6 per cent to 41.6 per cent (P < 0.0001). The 90-day mortality after diagnosis of colorectal cancer dropped from 14.8 per cent to 10.7 per cent (P < 0.001) and 2-year survival improved from 58.6 per cent to 65 per cent (P < 0.001). Among patients aged 80 years or older (425 and 446, in the first and last intervals respectively) there was, in addition, a progressive increase in ‘no surgery’ rate from 33.6 per cent to 50.2 per cent (P < 0.0001) and a reduction in elective resections from 42.4 per cent to 33.9 per cent (P = 0.010). The 90-day mortality after elective resection fell from 10.0 per cent (18 of 180) to 3.3 per cent (5 of 151; P = 0.013).

Conclusions

Survival from colorectal cancer improved significantly over 14 years. Among patients aged ≥80 years, major changes in the type of treatment delivered were associated with a decrease in postoperative mortality.

Keep Them on the Table: Outcomes Are Improved After Minimally Invasive Colectomy Despite Longer Operative Times in Patients With High-Risk Colon Cancer

BACKGROUND

For high-risk patients, traditional surgical dogma advises open operations, with short operative times, to "get them off the table" instead of longer minimally invasive surgery approaches.

OBJECTIVE

The aim of this study was to compare postoperative outcomes in patients with high-risk colon cancer undergoing elective longer minimally invasive surgery operations compared with shorter open operations.

DESIGN

Retrospective comparative cohort study.

SETTINGS

Interventions were performed in hospitals participating in the national surgical database.

PATIENTS

The National Surgical Quality Improvement Program database was used to identify patients with colon cancer with ASA class 3 to 4 undergoing right and sigmoid colectomy between 2012 and 2017.

MAIN OUTCOME MEASURES

Thirty-day postoperative outcomes were compared between short open and long minimally invasive groups.

RESULTS

A total of 3775 patients were identified as having undergone long minimally invasive right colectomy and short open right colectomy (33% open, 67% minimally invasive surgery), and 1042 patients were identified as having undergone long minimally invasive sigmoid colectomy and short open sigmoid colectomy (36% open, 64% minimally invasive). Patients undergoing long minimally invasive right colectomy had significantly lower rates of overall morbidity, severe adverse events, mortality, superficial surgical site infections, and wound disruptions, as well as discharge to a higher level of care and shorter length of stay ( p < 0.05). Patients undergoing long minimally invasive sigmoid colectomy had decreased rates of overall morbidity, severe adverse events, and length of stay, as well as discharge to a higher level of care compared with the patients undergoing short open sigmoid colectomy ( p < 0.05).

LIMITATIONS

This study was limited by the retrospective nature and standardized outcome measures.

CONCLUSIONS

In high-risk patients undergoing colectomy for colon cancer, outcomes were worse with shorter open compared with longer minimally invasive surgery operations. Focus should shift from getting patients "off the table" faster to longer, but safer, minimally invasive surgery in high-risk patients. See Video Abstract at http://links.lww.com/DCR/B642 .

MANTNGALOS SOBRE LA MESA HAY MEJORES RESULTADOS DESPUS DE COLECTOMA MNIMAMENTE INVASIVA A PESAR DE TIEMPOS QUIRRGICOS MS PROLONGADOS EN PACIENTES CON CNCER DE COLON DE ALTO RIESGO

ANTECEDENTES:Para los pacientes de alto riesgo, el dogma quirúrgico tradicional aconseja operaciones abiertas, con tiempos quirúrgicos cortos, con el fin de "sacarlos de la mesa" en lugar de enfoques quirúrgicos mínimamente invasivos más prolongados.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios en pacientes electivos de cáncer de colon de alto riesgo sometidos a operaciones de cirugía mínimamente invasiva más prolongadas en comparación con operaciones abiertas más cortas.DISEÑO:Los resultados posoperatorios de pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha o sigmoidea se compararon en un análisis multivariado. Se comparó el grupo de colectomía derecha abierta corta (tiempo operatorio <116 minutos) y colectomía derecha mínimamente invasiva larga (tiempo operatorio> 132 minutos). También se compararon la colectomía sigmoidea abierta corta (tiempo operatorio <127 minutos) y la colectomía sigmoidea mínimamente invasiva larga (tiempo operatorio> 161 minutos).ESCENARIO:Las intervenciones se realizaron en hospitales participantes en la base de datos quirúrgica nacional.PACIENTES:La base de datos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica se utilizó para identificar a los pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha y sigmoidea entre 2012-2017.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados posoperatorios a los treinta días entre el grupo de procedimientos abiertos cortos y el de mínimamente invasivos largos.RESULTADOS:Se identificó un total de 3.775 pacientes sometidos a colectomía derecha mínimamente invasiva larga y colectomía derecha abierta corta (33% abierta, 67% cirugía mínimamente invasiva) y se identificaron 1042 pacientes sometidos a colectomía sigmoidea mínimamente invasiva larga y colectomía sigmoidea abierta corta (36% abierta, 64% mínimamente invasiva). Los pacientes con colectomía derecha larga mínimamente invasiva tuvieron significativamente menor morbilidad general, eventos adversos graves, mortalidad, infecciones superficiales del sitio quirúrgico, dehiscencia de herida, alta a un nivel más alto de atención y estadía más corta ( p <0.05). Los pacientes con colectomía sigmoidea mínimamente invasiva prolongada tuvieron menor morbilidad general, eventos adversos graves, duración de la estadía y alta a un nivel más alto de atención en comparación con los pacientes con colectomía sigmoidea abierta corta ( p <0.05).LIMITACIONES:Este estudio estuvo limitado por la naturaleza retrospectiva y las medidas de resultado estandarizadas.CONCLUSIONES:En los pacientes de alto riesgo sometidos a colectomía por cáncer de colon, los resultados fueron peores con operaciones abiertas más cortas en comparación con operaciones mínimamente invasivas más largas. El enfoque debe pasar de hacer que los pacientes "salgan rápido de la mesa quirúrgica" a una cirugía mínimamente invasiva más prolongada pero más segura, en pacientes de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B642 . (Traducción-Dr. Jorge Silva Velazco ).

Colorectal resection in end-stage renal disease (ESRD) patients: experience from a single tertiary center

BACKGROUND

End-stage renal disease (ESRD) and renal replacement therapy (RRT) are important risk factors for post-operative morbidity and mortality but remains poorly reported in colorectal surgery. This study aims to evaluate postoperative outcomes of ESRD patients under RRT undergoing colorectal resection.

METHODS

All ESRD patients under RRT who underwent colorectal resection between 2006 and 2019 were retrospectively reviewed. Perioperative outcomes were analysed, such as risk factors of postoperative complications.

RESULTS

Forty-two patients were analysed, including 27 emergency and 15 elective surgeries. The most frequent indication was acute colonic ischemia for emergency and malignancy for elective procedures. Laparoscopic approach was used in 12 patients (29%), without difference between elective and emergency groups. Postoperative severe complications rate (including deaths) was 50% (21/42), including 56% (15/27) and 40% (6/15) in emergency and elective groups, respectively (p = .334). Anastomotic leak was observed in 3 of the 23 patients (13%) undergoing digestive anastomosis, (1 in emergency and 2 in elective groups, p = .246). The postoperative mortality rate was 29%, not significantly different between groups. The median hospital stay was 14.5 days (8-42). At univariate analysis, history of cardiac event (p = .028) and open approach (p = .040) were associated with severe complications, and ASA score >3 (p = .043), history of cardiac event (p = .001) and diabetes (p = .030) associated with mortality.

CONCLUSIONS

Colorectal surgery in ESRD patient exposes to high risk of morbidity and mortality, even in the elective setting, especially in patients with comorbidities like cardiac event and diabetes. Careful patient selection and closed management is required in such fragile patients.

Robotic surgery for colorectal cancer in the Octogenarians

BACKGROUND

We evaluated the short-term outcomes of robotic colorectal cancer surgery in octogenarian patients, focussing on postoperative morbidity and survival.

METHODS

All patients ≥80 years in a prospective colorectal cancer database undergoing robotic curative colorectal cancer resection were included. Patient demographics, intraoperative findings, postoperative and oncological outcomes were recorded. Patients were further subdivided into two groups named: old (OG 80-85 years) and very old (VOG ≥ 86 years).

RESULTS

Fifty-eight consecutive patients were included (median age, 83 years; male, 53.4%; median BMI, 26.5). Median total operative time was 230 min, median blood loss 20 ml, median length of stay 7 days. Major complications were seen in 12% of patients; and the 90-day mortality rate was 1.7%. Complete R0 resection achieved in 93% of cases, average lymph node harvest was 22. Overall and disease-free survival was 81% and 87.3%, respectively (median follow-up 24.5 months). We noticed a trend towards more advanced lesion staging in the VOG, but only N2 stage was significant (p = 0.03). There was a statistically significant difference in overall survival in favour of the OG (p = 0.024).

CONCLUSIONS

Robotic surgery is feasible in octogenarian patients undergoing curative colorectal cancer resection and is associated with good post-operative outcomes and overall survival.

The Trends in Adoption, Outcomes, and Costs of Laparoscopic Surgery for Colorectal Cancer in the Elderly Population

BACKGROUND

The elderly constitute the majority of both colorectal cancer and surgical volume. Despite established safety and feasibility, laparoscopy may remain underutilized for colorectal cancer resections in the elderly. With proven benefits, increasing laparoscopy in elderly colorectal cancer patients could substantially improve outcomes. Our goal was to evaluate utilization and outcomes for laparoscopic colorectal cancer surgery in the elderly.

METHODS

A national inpatient database was reviewed for elective inpatient resections for colorectal cancer from 2010 to 2015. Patients were stratified into elderly (≥ 65 years) and non-elderly cohorts (< 65 years), then grouped into open or laparoscopic procedures. The main outcomes were trends in utilization by approach and total costs, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models were used to control for differences across platforms, adjusting for patient demographics, comorbidities, and hospital characteristics.

RESULTS

Laparoscopic adoption for colorectal cancer in the elderly increased gradually until 2013, then declined, with simultaneously increasing rates of open surgery. Laparoscopy significantly improved all primary outcomes compared to open surgery (all p < 0.01). From the adjusted analysis, laparoscopy reduced complications by 30%, length of stay by 1.99 days, and total costs by $3276/admission. Laparoscopic patients were 34% less likely to be readmitted; when readmitted, the episodes were less expensive when index procedure was laparoscopic.

CONCLUSION

The adoption of laparoscopy for colorectal cancer surgery in the elderly is slow and even declining recently. In addition to the clinical benefits, there are reduced overall costs, creating a tremendous value proposition if use can be expanded.

PRECIS

This national contemporary study shows the slow uptake and recent decline in adaption of laparoscopic surgery for colorectal cancer in the elderly, despite the benefits in clinical outcomes and costs found. This data can be used to target education, regionalization, and quality improvement efforts in this expanding population.

Enhanced recovery after surgery in colon and rectal surgery: identification of predictive variables of failure in a monocentric series including 733 patients

To identify factors associated with early deviation and delayed discharge within an Enhanced Recovery after Surgery (ERAS) pathway. This is a retrospective review of prospectively collected data of consecutive patients who underwent laparoscopic or open colorectal surgery and managed with a standardized ERAS pathway between April 2015 and October 2018. ERAS items were assessed within 48 h after surgery. Patients with early complications were excluded. The influence of factors on length of stay was calculated by univariate and multivariate analysis. A binary logistic regression was used to model a predicting score. Seven hundred and thirty-three patients met the inclusion criteria. Multivariate analysis showed that age ≥ 75 years (P = 0.02), ASA score ≥ 3 (P = 0.03), open surgery or conversion to open (P = 0.001), non-compliance with the intra-operative balanced fluid therapy (P = 0.049), failure to early removal of the urinary catheter (P = 0.001), to discontinue IV fluid (P = 0.02) and to early mobilization (P = 0.001) were independently associated with ERAS failure. The generated score had a specificity of 84% and a positive predictive value of 72%. Patients who would have a length of stay longer than the median for each surgical procedure were properly identified (Area under ROC Curve = 0.753, P < 0.001). The delayed discharge could be predicted at 48 h from the intervention. The ability of the model to weight the specific role of each statistically significant variable might be a useful tool to identify the most frail patients.

Short- and long-term outcomes of laparoscopic surgery for colorectal cancer in the elderly aged over 80 years old versus non-elderly: a retrospective cohort study

Background

Recently, colorectal cancer has increased in elderly patients worldwide, with laparoscopic colorectal surgery increasing in elderly patients with colorectal cancer. However, whether laparoscopic colorectal surgery is an optimal procedure for colorectal cancer in the elderly remains unclear. This study aimed to verify safety and curability of laparoscopic colorectal surgery in elderly patients ≥80 years old.

Methods

Patients undergoing curative colorectal surgery from 2006 to 2014 were enrolled and classified into the laparoscopic surgery in elderly patients aged ≥80 years (LAC-E) group, open surgery in elderly patients (OC-E) group, and laparoscopic surgery in non-elderly patients (LAC-NE) group. Short- and long-term outcomes were compared between these groups.

Results

The LAC-E, OC-E, and LAC-NE groups comprised 85, 25, and 358 patients, respectively. Intraoperative blood loss and incidence of postoperative complications were significantly lower in the LAC-E versus OC-E group (97 vs. 440 mL, p < .01 and 14% vs. 32%, p < .05, respectively). Long-term outcomes were not different between these two groups. Operation time was significantly shorter in the LAC-E versus LAC-NE group (249 vs. 288 min, p < .01). Intraoperative blood loss and postoperative complications were similar between the groups. Although the 5-year overall survival rate in the LAC-E group was lower than that in the LAC-NE group (64% vs. 80%, p < .01), there was no difference in 5-year disease-specific survival between the groups.

Conclusion

Laparoscopic colorectal surgery is technically and oncologically safe for colorectal cancer in the elderly as well as the non-elderly and can be an optimal procedure for colorectal cancer in the elderly.

Indications for laparoscopic surgery for older rectal cancer patients with comorbidities

PURPOSE

Given the lack of safety studies concerning laparoscopic surgery for rectal cancer in patients ≥ 80 years old with comorbidities, we sought to investigate this in the current study.

METHODS

Between 2012 and 2019, 24 patients ≥ 80 years old underwent laparoscopic surgery for rectal cancer without preoperative treatment. These patients were divided into those with [comorbidity(+) group, n = 13] and without [comorbidity(-) group, n = 11] comorbidities. The preoperative nutritional status and ASA classification, postoperative complications, time to oral diet, and length of hospital stay were evaluated in each group.

RESULTS

In the comorbidity(+)/comorbidity(-) groups, the average age was 85.9/84.1 years old, respectively. The major comorbidities were heart disease including atrial fibrillation and valvular disorder. The average PNI and CONUT scores in the comorbidity(+)/comorbidity(-) groups were 44.7/44.2 an 3.1/2.2, respectively. Planned surgical procedures were completed in all patients. Postoperative complications occurred in 2/3 cases in the comorbidity(+)/comorbidity(-) groups, respectively, and the average time to oral diet was 3.8/3.7 days, while the average length of hospitalization after surgery was 15.2/16.5 days, respectively. In the comorbidity(+) group, there was no exacerbation of comorbidities in any cases.

CONCLUSION

The safety of laparoscopic surgery is acceptable among older rectal cancer patients with comorbidities.

Laparoscopic vs open surgery for colorectal cancer patients with high American Society of Anesthesiologists classes

INTRODUCTION

Laparoscopic surgery has become popular for colorectal cancer treatment in recent years. However, its success rate even among high-risk patients remains debatable. The present study aims to compare the short- and long-term outcomes between laparoscopic and open surgeries in the American Society of Anesthesiologists (ASA) classes 3 and 4 patients with colorectal cancer.

METHODS

This was a single-center, retrospective, cohort study performed at a university hospital, with 78 patients suffering from colorectal cancer who underwent surgery in ASA classes 3 and 4 as respondents. Patient and tumor characteristics, operative outcomes, and prognoses were factors compared between the open and laparoscopic groups.

RESULTS

Compared with the open group, laparoscopic group had longer operation time (median 287.5 vs 204.5 minutes, P = .001), less operative blood loss (median 40 vs 240 mL, P = .020), and fewer postoperative complications (24% vs 55%, P = .011). In addition, operative approach (open vs laparoscopic) served as an independent factor for the occurrence of postoperative complications [HR = 3.963 (1.344-12.269), P = .013]. In terms of overall survival and recurrence-free survival (P = .171 and .087, respectively), no significant difference was found between the two groups.

CONCLUSION

Laparoscopic surgery is thus associated with more favorable short-time outcomes and could be adopted as treatment even for colorectal cancer ASA class 3 and 4 patients.

Results of laparoscopic resection in high-risk rectal cancer patients

PURPOSE

Obesity, neoadjuvant-radiotherapy, tumour proximity to the anal verge and previous abdominal surgery are factors that might increase the intra-operative difficulty of laparoscopic rectal cancer surgery. However, whether patients with these 'high-risk' characteristics are subject to worse short- or long-term outcomes is debated. The aim of this study is to examine the short- and long-term clinical and oncological outcomes of patients receiving laparoscopic rectal surgery with any of these high-risk characteristics and compare them with patients that do not possess any of these high-risk features.

METHODS

For the purpose of this study data from consecutive patients receiving laparoscopic rectal cancer resections between 2006 and 2016 from two centres were analysed. High-risk patients were defined as patients with either one of the following characteristics: BMI ≥ 30, neoadjuvant chemoradiotherapy, tumour < 8 cm from the anal verge and previous abdominal surgery.

RESULTS

A total of 313 patients were identified (227 high risk, 86 low risk). Short-term outcomes were similar between the two groups with the exception of blood loss and length of stay, which were higher in the high-risk group (10 vs 2.5 ml, p = 0.045; 7 vs 5 days, p = 0.001). There were no statistically significant differences in 5-year overall survival (79.7% vs 79.8%, p = 0.757), disease-free survival (76.8% vs 69.3%, p = 0.175), distant disease-free interval (84.8% vs 79.7%, p = 0.231) and local recurrence-free interval (100%, 97.4%, p = 0.162) between the two groups.

CONCLUSION

Similar short- and long-term outcomes can be achieved in high-risk and low-risk patients receiving laparoscopic rectal surgery. The presented data support the suitability of laparoscopic surgery for this group of patients.

Laparoscopic Surgery Is Safe and Beneficial in True Functional High-Risk Patients with Colorectal Cancer: Utilization of Cardiopulmonary Exercise Test

Background: Patients with colorectal cancer deemed to be high-risk may be denied an elective laparoscopic resection due to subjective reasons. A comparison of the 30-day outcomes in true functional high-risk patients who underwent either open or laparoscopic colorectal resection was undertaken. Materials and Methods: A retrospective cohort of all functional high-risk patients as assessed by cardiopulmonary exercise test between July 2015 and April 2018 were identified. Anaerobic threshold of <11 mL/kg/minute was used as a physiologic indicator to determine a high-risk patient. Adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was ensured. P values were computed via two-sided Fisher's exact test, and the exact Mann-Whitney U-test. Forest plots for relative risks with 95% confidence intervals were displayed on a log scale. Results: One hundred forty-six patients were identified as high-risk. Outcomes demonstrated a trend to laparoscopic benefit in all Clavien-Dindo grades of postoperative complications, but especially in severe complications of grades 3-4 (3.5% versus 10.2%). Readmissions demonstrated a trend to laparoscopic surgery benefit (7% versus 11.8%), as did mortality (1.7% versus 3.4%). The rate of surgery-site complications was higher after open surgery (42.1% versus 22.4%, P = .0201). Wound infections were observed more frequently after open surgery (12.5% versus 1.72%, P = .0280). The estimated risk of all-grade complications was significantly higher after open anterior rectal resection (63.0% versus 29.6%, P = .0281) and there was significantly shorter stay after laparoscopic right colectomy (5 v. 7 days, P = .0490). Conclusions: Laparoscopic approach for colorectal resections in high-risk patients is safe and beneficial compared to open surgery, especially in patients undergoing laparoscopic resection of the rectum and right colon.

Prospective multicenter study of reduced port surgery combined with transvaginal specimen extraction for colorectal cancer resection

PURPOSE

The relevance of transvaginal specimen extraction (TVSE) combined with reduced port surgery (RPS) remains unknown. This study investigated the feasibility of TVSE with RPS according to short-term outcomes and cosmesis.

METHODS

This prospective multicenter study enrolled ten patients at three institutions. For the semi-quantification of each parameter, we administered questionnaires to assess pain (visual analogue scale), subjective/objective wound healing esthetics [photo series questionnaires (PSQ)], and quality of life (QOL).

RESULTS

No operative complications occurred, except one case of urinary tract infection, which was promptly cured with antibiotics. On day 0, pain was rated at 2.3 ± 0.67 at rest and 4.9 ± 0.82 during sneezing; these ratings gradually declined over time. The PSQ showed that the patient ratings of wound esthetics after TVSE were not inferior to ratings from patients after conventional laparoscopy or single incision laparoscopic surgery, and they were significantly higher than the patient ratings of wounds after laparotomy (P < 0.05). The QOL scores showed that, in comparison to before surgery, after surgery, patients reported significant deterioration of their physical function (96.67 ± 1.49 vs. 87.33 ± 2.71), emotional function (93.33 ± 2.72 vs. 86.67 ± 2.22), fatigue (7.78 ± 3.72 vs. 26.67 ± 8.31), and pain (6.67 ± 3.69 vs. 18.33 ± 4.61).

CONCLUSION

TVSE with RPS for colorectal cancer was feasible and was associated with a low degree of postoperative pain.

Comparison of Oncologic Outcomes in Laparoscopic versus Open Surgery for Non-Metastatic Colorectal Cancer: Personal Experience in a Single Institution

The oncologic merits of the laparoscopic technique for colorectal cancer surgery remain debatable. Eligible patients with non-metastatic colorectal cancer who were scheduled for an elective resection by one surgeon in a medical institution were randomized to either laparoscopic or open surgery. During this period, a total of 188 patients received laparoscopic surgery and the other 163 patients received the open approach. The primary endpoint was cancer-free five-year survival after operative treatment, and the secondary endpoint was the tumor recurrence incidence. Besides, surgical complications were also compared. There was no statistically significant difference between open and laparoscopic groups regarding the average number of lymph nodes dissected, ileus, anastomosis leakage, overall mortality rate, cancer recurrence rate, or cancer-free five-year survival. Even though performing a laparoscopic approach used a significantly longer operation time, this technique was more effective for colorectal cancer treatment in terms of shorter hospital stay and less blood loss. Meanwhile, fewer patients receiving the laparoscopic approach developed postoperative urinary tract infection, wound infection, or pneumonia, which reached statistical significance. For non-metastatic colorectal cancer patients, laparoscopic surgery resulted in better short-term outcomes, whether in several surgical complications and intra-operative blood loss. Though there was no significant statistical difference in terms of cancer-free five-year survival and tumor recurrence, it is strongly recommended that patients undergo laparoscopic surgery if not contraindicated.

Can We Increase the Resection Rate by Minimally Invasive Approach? Experience from 100 Minimally Invasive Esophagectomies

Background

Whether we can increase the resection rate of esophageal cancer by minimally invasive esophagectomy (MIE) is unknown. The aim was to report the number and results of MIE in high-risk patients considered unsuitable for open surgery and compare these results to other operated patients and to high-risk patients not undergoing surgery.

Methods

At Central Finland Central Hospital, between September 2012 and July 2018, the number of operated MIEs was 100. Of these, 10 patients were prospectively considered unfit for open approach. Nineteen additional high-risk patients with operable disease were ruled out of surgery. The short- and long-term outcomes of these 3 groups were compared.

Results

In patients eligible for any approach (n=90), MIE only (n=10), and no surgery (n=19), WHO performance status Grade 0 was observed in 66.7%, 20.0%, and 5.3%, respectively; stair climbing with ≥4 stairs was successfully completed in 77.8%, 50%, and 36.8%, respectively. Between any approach and MIE only groups, rate of major complications (Clavien-Dindo ≥3a) was 6.7% vs. 50.0% (p<0.001) without a difference in median hospital stay (9 vs. 10 days, p=0.542). Readmission rates were 4.4% vs. 30.0% (p=0.003). Survival rates were 100% vs. 80% (p<0.001) at 90-days, 91.5% vs. 66.7% (p=0.005) at 1-year, and 68.9% vs. 53.3% (p=0.024) at 3-years, respectively. In comparison between MIE only and no surgery groups, these survival rates from day of diagnosis were 80% vs. 100%, 68.6% vs. 67.1%, and 45.7% vs. 32.0% (p=0.290), respectively.

Conclusions

By operating patients unsuitable for open approach with MIE, the resection rate increased 11.1%. These high-risk patients had, however, higher early morbidity and reduced long-term survival compared to other operated patients. Though there seems to be long-term benefit of surgery compared to nonsurgical patients, we have to be cautious when offering surgery to those considered unfit for open surgery.

Comparison of short-term and long-term efficacy of laparoscopic and open gastrectomy in high-risk patients with gastric cancer: a propensity score-matching analysis

BACKGROUND

To determine whether laparoscopic surgery can be used in high-risk patients with gastric cancer.

METHODS

The clinicopathological data of 3743 patients with primary gastric adenocarcinoma, collected from January 2007 to December 2014, were retrospectively analyzed. Patients who had ≥ 1 of the following conditions were defined as high-risk patients: (1) age ≥ 80 years; (2) BMI ≥ 30 kg/m2; (3) ASA (American Society of Anesthesiologists) grade ≥ 3; or (4) clinical T stage 4 (cT4). Propensity score matching (PSM) was used to reduce confounding bias; then, we compared the short-term and long-term efficacy of laparoscopic gastrectomy (LG) with open gastrectomy (OG) in high-risk patients with gastric cancer.

RESULTS

A total of 1296 patients were included in PSM. After PSM, no significant difference in clinicopathological data was observed between the LG group (n = 341) and the OG group (n = 341). The operative time (181.70 vs. 266.71 min, p < 0.001) and blood loss during the operation (68.11 vs. 225.54 ml, p < 0.001) in the LG group were significantly lower than those in the OG group. In the LG and OG groups, postoperative complications occurred in 39 (11.4%) and 63 (18.5%) patients, respectively, p = 0.010. Multivariate analysis showed that laparoscopic surgery was an independent protective factor against postoperative complications (p = 0.019). The number of risk factors was an independent risk factor for postoperative complications (p = 0.021). The 5-year overall survival rate in the LG group was comparable to that in the OG group (55.0 vs. 52.0%, p = 0.086). Hierarchical analysis further confirmed that the LG and OG groups exhibited comparable survival rates among patients with stages cI, pI, cII, pII, cIII, and pIII (all p > 0.05).

CONCLUSIONS

For high-risk patients with gastric cancer, LG not only exhibits better short-term efficacy than OG but also has a comparable 5-year survival rate to OG.

Decrease of Sphincter Preserving Length Lowers the Postoperative Genital Function for Patients With Rectal Cancer

BACKGROUND AND OBJECTIVE

With the increase in sphincter preserving rate of rectal cancer (RC) cancer, postoperative quality-of-life, such as genital dysfunction, has become a major issue in the patient management. In this study, we proposed a measurement, namely, the sphincter preserving length (SPL), and investigated the relationship between SPL and postoperative genital function and survival in RC patients.

METHODS

A total of 536 male patients who had a diagnosis of RC and underwent sphincter preserving rectal resection in the Sixth Affiliated Hospital of Sun Yat-sen University and the First Affiliated Hospital of Sun Yat-sen University between October 1997 and December 2013 were included in our study. SPL was defined as the distance between the lowest edge of the tumor to dentate line. Postoperative genital function was evaluated by erection function and ejaculation function. Five-year survival status was extracted from the hospital database.

RESULTS

Larger SPL was significantly associated with poorer postoperative erection and ejaculation function. For a SPL of 7.25 cm, the sensitivity and specificity of the diagnosis of erection dysfunction was 68.6% and 68.8%, respectively. The corresponding sensitivity and specificity for the diagnosis of ejaculation dysfunction was 70.9% and 75.7%, respectively. SPL was also negatively associated with survival rate. Compared with lower anterior resection, patients with lower RC who underwent local resection or draw-out colon-anal anastomosis had better postoperative genital function.

CONCLUSIONS

SPL might be a useful measurement to assess the risk of postoperative genital dysfunction and survival status and an indicator for initiation of early preventative treatment in patients with RC.

Risk factors for postoperative pneumonia in elderly patients with colorectal cancer: a sub-analysis of a large, multicenter, case-control study in Japan

PURPOSE

Postoperative pneumonia affects the length of stay and mortality after surgery in elderly patients with colorectal cancer (CRC). We aimed to determine the risk factors of postoperative pneumonia in elderly patients with CRC, and to evaluate the impact of laparoscopic surgery on elderly patients with CRC.

METHODS

We retrospectively investigated 1473 patients ≥ 80 years of age who underwent surgery for stage 0-III CRC between 2003 and 2007. Using a multivariate analysis, we determined the risk factors for pneumonia occurrence from each baseline characteristic.

RESULTS

Among all included patients, 26 (1.8%) experienced postoperative pneumonia, and restrictive respiratory impairment, obstructive respiratory impairment, history of cerebrovascular events, and open surgery were determined as risk factors (odds ratio [95% confidence interval], 2.78 [1.22-6.20], 2.71 [1.22-6.30], 3.60 [1.37-8.55], and 3.57 [1.22-15.2], respectively). Furthermore, postoperative pneumonia was more frequently accompanied by increasing cumulative numbers of these risk factors (area under the receiver operating characteristic curve = 0.763).

CONCLUSIONS

Laparoscopic surgery may be safely performed in elderly CRC patients, even those with respiratory impairment and a history of cerebrovascular events.

Treatment of Elderly Patients with Colorectal Cancer

Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths worldwide. As society ages, the number of elderly patients with CRC will increase. The percentage of patients with right-sided colon cancer and the incidence of microsatellite instability are higher in elderly than in younger patients with CRC. Moreover, the higher incidence of comorbid diseases in elderly patients indicates the need for less invasive treatment strategies. For example, care should be taken in performing additional surgery after endoscopic submucosal dissection for elderly patients with high-risk T1 CRC. Minimally invasive surgery, such as laparoscopic colectomy, would be preferable for elderly patients with CRC. Chemotherapy for elderly patients requires careful monitoring for adverse events. The aim of this review is to summarize the clinicopathological features of CRC in elderly patients, optical surgical strategies, including endoscopic and laparoscopic resection, and chemotherapeutic strategies, including postoperative adjuvant chemotherapy and systemic chemotherapy for unresectable CRC.

Robotic vs laparoscopic rectal surgery in high-risk patients

AIM

Laparoscopic rectal surgery is associated with a steep learning curve and high conversion rate despite progress in equipment design and consistent practice. The robotic system has shown an advantage over the laparoscopic approach due to stable three-dimensional views, improved dexterity and better ergonomics. These factors make the robotic approach more favourable for rectal surgery. The aim of this study was to compare the perioperative outcomes of laparoscopic and robotic rectal cancer surgery in high-risk patients.

METHOD

A prospectively collected dataset for high-risk patients who underwent rectal cancer surgery between May 2013 and November 2015 was analysed. Patients with any of the following characteristics were defined as high risk: a body mass index ≥30, male gender, preoperative chemoradiotherapy, tumour <8 cm from the anal verge and previous abdominal surgery.

RESULTS

In total, 184 high-risk patients were identified: 99 in the robotic group and 85 in the laparoscopic group. Robotic surgery was associated with a significantly higher sphincter preservation rate (86% vs 74%, P = 0.045), shorter operative time (240 vs 270 min, P = 0.013) and hospital stay (7 vs 9 days, P = 0.001), less blood loss (10 vs 100 ml, P < 0.001) and a smaller conversion rate to open surgery (0% vs 5%, P = 0.043) compared with the laparoscopic technique. Reoperation, anastomotic leak rate, 30-day mortality and oncological outcomes were comparable between the two techniques.

CONCLUSION

Robotic surgery in high-risk patients is associated with higher sphincter preservation, reduced blood loss, smaller conversion rates, and shorter operating time and hospital stay. However, further studies are required to evaluate this notion.

Colorectal cancer surgery in the very elderly patient: a systematic review of laparoscopic versus open colorectal resection

INTRODUCTION

Colorectal cancer is the second most common cause of death from neoplastic disease in men and third in women of all ages. Globally, life expectancy is increasing, and consequently, an increasing number of operations are being performed on more elderly patients with the trend set to continue. Elderly patients are more likely to have cardiovascular and pulmonary comorbidities that are associated with increased peri-operative risk. They further tend to present with more locally advanced disease, more likely to obstruct or have disseminated disease. The aim of this review was to investigate the feasibility of laparoscopic colorectal resection in very elderly patients, and whether there are benefits over open surgery for colorectal cancer.

METHODS

A systematic literature search was performed on Medline, Pubmed, Embase and Google Scholar. All comparative studies evaluating patients undergoing laparoscopic versus open surgery for colorectal cancer in the patients population over 85 were included. The primary outcomes were 30-day mortality and 30-day overall morbidity. Secondary outcomes were operating time, time to oral diet, number of retrieved lymph nodes, blood loss and 5-year survival.

RESULTS

The search provided 1507 citations. Sixty-nine articles were retrieved for full text analysis, and only six retrospective studies met the inclusion criteria. Overall mortality for elective laparoscopic resection was 2.92% and morbidity 23%. No single study showed a significant difference between laparoscopic and open surgery for morbidity or mortality, but pooled data analysis demonstrated reduced morbidity in the laparoscopic group (p = 0.032). Patients undergoing laparoscopic surgery are more likely to have a shorter hospital stay and a shorter time to oral diet.

CONCLUSION

Elective laparoscopic resection for colorectal cancer in the over 85 age group is feasible and safe and offers similar advantages over open surgery to those demonstrated in patients of younger ages.

Oncologic outcomes following laparoscopic colon cancer resection for T4 lesions: a case-control analysis of 7-years' experience

BACKGROUND

According to many Societies' guidelines, patients presenting with clinical T4 colorectal cancer should conventionally be approached by a laparotomy. Results of emerging series are questioning this attitude.

METHODS

We retrospectively analysed the oncologic outcomes of 147 patients operated on between June 2008 and September 2015 for histologically proven pT4 colon cancers. All patients were treated with curative intent, either by a laparoscopic or open "en bloc" resection.

RESULTS

Median operative time, blood loss and hospital length of stay were significantly reduced in the laparoscopic group. Postoperative surgical complication rate and 30-day mortality did not significantly differ between the two groups ( p = 0.09 and p = 0.99, respectively). R1 resection rate and lymph nodes harvest, as well, did not remarkably differ when comparing the two groups. In the laparoscopic group, conversion rate was 19%. Long-term outcomes were not affected in patients who had undergone conversion. Five-year overall survival and disease-free survival did not significantly differ between the two groups (44.6% and 40.3% vs. 39.4% and 38.9%). Locally advanced stages (IIIB-IIIC) and R1 resections were detected as independent prognostic factors for overall survival.

CONCLUSION

Laparoscopic approach might be safe and acceptable for locally advanced colon cancer and does not jeopardize the oncologic results. Conversion to open surgery should be a part of a strategy as it does not seem to adversely affect perioperative and long-term outcomes. We consider laparoscopy, in expert hands, the last diagnostic tool and the first therapeutic approach for well-selected locally advanced colon cancers. Larger prospective studies are needed to widely assess this issue.

Toward standardization of laparoscopic resection for colorectal cancer in developing countries: A step by step module

BACKGROUND

Despite the proven benefits, laparoscopic colorectal surgery is still underutilized among surgeons especially in developing countries. Also a steep learning is one of the causes of its limited adoption.

OBJECTIVE

To explore the learning curve of single surgeon experience in laparoscopic colectomy and feasibility of implementing a well standardized step by step operative technique to overcome the beginning technical obstacles.

PATIENTS AND METHODS

This prospective study included 50 patients with carcinoma of the left colon and rectum recruited from the department of surgical oncology at National Cancer Institute, Cairo University in the period 2012-2016. All the procedures were performed through laparoscopic approach. Intra and post-operative data were recorded and analyzed.

RESULTS

The mean age was 49.7±10.6years (range: 33-74years). They were 29 males and 21 females. The mean operation time was 180min (range 100-370min), and the mean blood loss was 350ml (60-600ml). Six patients (12%) were converted to a laparotomy. The median lymph nodes harvest was 12 (range 7-25). The mean time of passing flatus after surgery was 2days (1-4days) and the mean time of passing stools was 3.3days (2-5) days. The median hospitalization period after surgery was 4days (3-12). 5 patients (10%) had postoperative morbidity, major morbidity occurred in one patient.

CONCLUSION

Laparoscopic colorectal surgery for colorectal cancer is safe and oncologically sound, standardized well-structured laparoscopic technique masters the procedure even in early learning curve setting.

Enhanced recovery programme following laparoscopic colorectal resection for elderly patients

BACKGROUND

The aim of this study was to investigate the feasibility and safety of an enhanced recovery programme (ERP) in patients aged ≥75 years who undergo laparoscopic surgery for colorectal cancer.

METHODS

Patients were divided into two groups according to perioperative management: the ERP group (Group A, n = 94) and the conventional perioperative care group (Group B, n = 157). The postoperative outcomes were compared between two groups.

RESULTS

There were no differences in terms of age, gender, American Society of Anesthesiologists score, operative time or blood loss between two groups. Postoperative return of gastrointestinal function was significantly faster in Group A compared to Group B, including time to first flatus (2 versus 3 days, P < 0.001), first stool (3 versus 4 days, P = 0.001) and oral intake (1 versus 4 days, P < 0.001). Group A was associated with lower overall postoperative complication rate (26.6% versus 44.6%, P = 0.004) and general complication rate (14.9% versus 31.2%, P = 0.004). The median postoperative hospital stay was 6 days in Group A and 8 days in Group B (P < 0.001), respectively.

CONCLUSIONS

ERP following laparoscopic colorectal resection for elderly patients is associated with faster postoperative recovery, shorter postoperative hospital stay and fewer complications compared with conventional perioperative care.

Laparoscopic surgery for colorectal cancer in patients over 80 years of age: the morbidity outcomes

Purpose

The aim of this study was to compare the outcomes between patients under 60 years of age and older patients over 80 years of age who underwent laparoscopic colorectal surgery with colorectal cancer.

Methods

A retrospective analysis of 519 colorectal patients who underwent laparoscopic colorectal surgery for colorectal adenocarcinoma between January 2007 and December 2012 was collected and categorized into 2 groups of patients, those under 60 years of age (n = 404) and those over 80 years of age (n = 115).

Results

The group of patients over 80 years of age had a significantly higher ASA physical status classification (P < 0.001), more preoperative comorbidities (P < 0.001), had a tendency towards more tumors in a colonic location (P = 0.034), and more advanced American Joint Committee on Cancer TNM stage (P = 0.001). A higher proportion of right hemicolectomy and abdominoperineal resection was performed and more transfusions were required in the group of patients over 80 years of age (P = 0.002 and P = 0.001, respectively). There were no significant differences in operative time, conversion rate, resection margins, and numbers of harvested lymph nodes, hospital stay, and morbidity between the 2 groups. No postoperative mortality was found in the present study. The 3-year DFS for over 80 years age group and under 60 years age group were 73.5% and 73.9%, respectively (P = 0.770).

Conclusion

Laparoscopic colorectal surgery was effective and safe for elderly patients over 80 years of age and resulted in postoperative outcomes similar to those in younger patients. The postoperative morbidity after laparoscopic colorectal cancer surgery was not increased in over 80 years of age.

Patient Body Image and Satisfaction with Surgical Wound Appearance After Reduced Port Surgery for Colorectal Diseases

BACKGROUND

The use of reduced port surgery (RPS) is increasing in the field of colorectal surgery. It is considered to offer advantages over conventional multiport surgery (MPS) in terms of decreased invasiveness and superior cosmesis. However, to date there has been no study that evaluates patient satisfaction after undergoing RPS for colorectal diseases. Herein, we present a questionnaire-based study to address this issue.

METHODS

Questionnaires were sent by mail to 216 patients who underwent RPS and 145 who underwent MPS. Patient's satisfaction with cosmesis and body image after colorectal surgery was assessed using a validated Body Image Questionnaire (BIQ) and Photo Series Questionnaire (PSQ).

RESULTS

A total of 76.9 % (166/216) of the RPS patients and 70.3 % (102/145) of the MPS patients returned the questionnaires. BIQ scores gradually improved after surgery, and were more positive overall in the RPS group compared to the MPS group. RPS patients marked significantly better PSQ scores than MPS patients (P < 0.05). In RPS subset analysis, patients with single port surgery (SPS) rated better PSQ scores than patients with SPS with additional port insertion (P < 0.05).

CONCLUSION

We find that RPS, especially SPS, enhances patient satisfaction by reducing abdominal wall trauma. This new advantage of RPS may prove valuable in its consideration as an option in laparoscopic colorectal surgery.

Clinically suspected T4 colorectal cancer may be resected using a laparoscopic approach

Background

The role of laparoscopic resection in patients with clinically suspicious T4 colorectal cancer remains controversial. The aim of this study was to compare the long-term and oncologic outcomes of laparoscopic resection and the open approach in clinical T4 colorectal cancer.

Methods

Two hundred ninety-three consecutive patients undergoing curative surgery for colorectal cancer suspected to be T4 by computed tomography and/or magnetic resonance imaging were reviewed.

Results

Despite clinical suspicion of T4 disease in all cases, concordance with pathologic determination of T4 was only 37.9 %. Of the 71 patients in the laparoscopic group, four (5.6 %) were converted to the open technique. Patients in the laparoscopic group had significantly lower estimated blood loss (p < 0.001), fewer days to first flatus (p = 0.001), shorter length of hospital stay (p < 0.001), and fewer adverse events (14.1 % versus 31.5 %, p = 0.004). After a median follow-up of 36 months, 5-year disease-free survival was not significantly different between the two groups (81.8 % in laparoscopic versus 73.9 % in open surgery, p = 0.433). The clinical factors that predicted T4 staging on pathologic examination were found to be male sex (p = 0.038), preoperative carcinoembryonic antigen status (p = 0.021), clinical N status (p = 0.046), and clinical cancer perforation (p = 0.004).

Conclusions

Laparoscopic colorectal resection for T4 colorectal cancer has perioperative and long-term oncologic outcomes similar to those of the open approach when performed by an experienced surgeon.

Clinical outcomes of the very elderly undergoing enhanced recovery programmes in elective colorectal surgery

Introduction Enhanced recovery programmes (ERPs) have been shown to improve short-term outcomes after major colorectal surgery. Benefits of the ERP in patients who are very elderly (VE) are less well understood. We aimed to evaluate the role of the ERP in the VE population, which for the purpose of this study was defined as any patient aged 75 years or over. Methods A prospectively compiled database was used to identify all patients aged ≥75 years who underwent elective colorectal resection in our unit between January 2011 and September 2012. These data were analysed to study the short-term outcomes in these patients and compared with those of patients aged <75 years. Results Overall, 352 patients underwent elective surgery during this period; 106 were identified as VE. The median length of stay (LOS) in the VE group was 7 days (5 days in non-VE group; p=0.002). Two-thirds (62%) underwent laparoscopic surgery. The median LOS of VE patients undergoing laparoscopic surgery was 6 days (11 days for open surgery; p=0.003). A third (33%) of the VE cohort was discharged by day 5. Of these patients, 85% underwent laparoscopic surgery. There was no statistical difference in overall complication rates (VE vs non-VE). Conclusions Accepting that some VE patients may stay in hospital for longer, this study supports our current policy of including everyone in the ERP regardless of age. Patients undergoing laparoscopic surgery appear to benefit, with a shorter LOS. Further large scale trials are required to support the results of this study and to identify long-term outcomes.

Open Surgery Against Laparoscopic Surgery for Mid-Rectal or Low-Rectal Cancer of Male Patients: Better Postoperative Genital Function of Laparoscopic Surgery

PURPOSE

To evaluate retrospectively the postoperative genital function, the local recurrence, and the survival rate impacted by laparoscopic or open surgery for rectal cancer (RC) in male patients.

METHODS

A total of 398 male RC patients after laparoscopic or open total mesorectal excision (TME) of rectomy (205 patients in the TME with laparoscopy group, and 193 patients in the control group) were included in our study, between October 1997 and December 2013. Postoperative genital function, local recurrence, and the 5-year survival rate were analyzed, retrospectively.

RESULTS

The rate of erection dysfunction was lower in the laparoscopic group (60.0%) than in the open group (82.4%, P<0.05); the rate of ejaculation dysfunction in the laparoscopic group (56.6%) was also lower than in the open group (82.4%, P<0.05). No significant difference was found regarding the local recurrence (P=0.87) and the survival rate (P=0.17). Interestingly, for patients with preoperative obstruction, the survival rate was lower in the laparoscopy group compared with the control group (P=0.002).

CONCLUSIONS

Laparoscopic surgery should be recommended for mid-RC or low-RC patients to preserve the postoperative genital function. However, for patients with preoperative obstruction, laparoscopy surgery was not recommended.

Open compared with laparoscopic complete mesocolic excision with central lymphadenectomy for colon cancer: a systematic review and meta-analysis

AIM

Several studies report improved survival in colon cancer with use of extended lymphadenectomy techniques (ELTs), such as D3 lymphadenectomy or complete mesocolic excision. The noninferiority of laparoscopic versus open techniques has already been established in D2 resections. The aim of this study was to compare the safety and efficacy of open and laparoscopic approaches for ELTs in colon cancer.

METHOD

Major databases, including PubMed, Scopus and the Cochrane library, were searched using defined inclusion and exclusion criteria, and relevant data were extracted. The Cochrane and Newcastle-Ottawa tools were used for critical appraisal and quality assessment. Meta-analysis with various subgroup analyses were undertaken, and clinical and statistical heterogeneity, along with publication bias, were also assessed.

RESULTS

One randomized and seven case-control trials were included. All studies were found to be of low methodological quality with some external validity issues. There was no difference in short-term mortality [OR = 2.16 (95% CI: 0.73-6.41); P = 0.16], anastomotic leakage, ileus or deep-sited infection/abscess. There was a trend for longer operative time [weighted mean difference (WMD) = -30.88 (95% CI: -62.38 to 0.61); P = 0.05] and shorter length of hospital stay [WMD = 2.29 (95% CI: -0.39 to 4.98); P = 0.09] with the laparoscopic approach. Laparoscopic right hemicolectomy had a lower wound-infection rate [OR = 2.87 (95% CI: 1.38-5.98); P = 0.005] compared with the relevant open group. No statistically significant difference was found in overall survival [hazard ratio (HR) = 0.85 (95% CI: 0.69-1.06); P = 0.15], disease-free survival, local recurrence and distant metastases.

CONCLUSION

Based on the current evidence, the laparoscopic technique appears to be at least as safe as the open technique when used in performing ELTs for colonic cancer, with similar morbidity and oncological outcomes.

Single-port versus multi-port laparoscopic surgery for colon cancer in elderly patients

The safety of single-incision laparoscopic surgery (SLS) in elderly patients with colorectal cancer has not been established. The aim of the current study was to compare the outcomes of SLS and multi-port laparoscopic surgery (MLS) and to assess the feasibility of SLS in colorectal cancer patients aged ≥70 years. A retrospective case-control study of colon cancer patients undergoing elective surgical intervention between 2011 and 2014 was conducted. A total of 129 patients with colon cancer underwent surgery and were included in the analysis. Data regarding patient demographics, surgical variables, oncological outcomes and short-term outcomes were evaluated for statistical significance to compare MLS (n=79) and SLS (n=50) in colon cancer patients. No significant differences were observed in patient characteristics. No case required re-admission within 30 days post surgery. The mean surgery times were similar for the MLS and SLS groups when cases with left and right hemicolectomies were combined (207.7 and 215.9 min, respectively; P=0.47). In addition, overall perioperative outcomes, including blood loss, number of lymph nodes harvested, size of the surgical margin and complications, were similar between these groups. Thus, we suggest that SLS can be performed safely in elderly patients with colon cancer.

High mortality rates after nonelective colon cancer resection: results of a national audit

AIM

Colon cancer resection in a nonelective setting is associated with high rates of morbidity and mortality. The aim of this retrospective study is to identify risk factors for overall mortality after colon cancer resection with a special focus on nonelective resection.

METHOD

Data were obtained from the Dutch Surgical Colorectal Audit. Patients undergoing colon cancer resection in the Netherlands between January 2009 and December 2013 were included. Patient, treatment and tumour factors were analysed in relation to the urgency of surgery. The primary outcome was 30-day postoperative mortality.

RESULTS

The study included 30 907 patients. A nonelective colon cancer resection was performed in 5934 (19.2%) patients. There was a 4.4% overall mortality rate, with significantly more deaths after nonelective surgery (8.5% vs 3.4%, P < 0.001). Older patients, male patients and patients with high comorbidity, advanced tumours, perforated tumours, a tumour in the right or transverse colon and postoperative anastomotic leakage were at risk of postoperative death. In nonelective resections, a right-sided tumour and postoperative anastomotic leakage were associated with high mortality.

CONCLUSION

Nonelective colon cancer resection is associated with high mortality. In particular, right-sided resections and patients with tumour perforation are at particularly high risk. The optimization of patients prior to surgery and expeditious operation after diagnosis might prevent the need for a nonelective resection.

Prognosis and postoperative genital function of function-preservative surgery of pelvic autonomic nerve preservation for male rectal cancer patients

Background

To retrospectively evaluate postoperative genital function, local recurrence rate and survival rate after total mesorectal excision (TME) combined with or without pelvic autonomic nerve preservation (PANP) in male patients with rectal cancer.

Methods

A total of 953 male patients with rectal cancer after TME (518 patients received TME combined with PANP [PANP group] and 434patients received TME alone [TME group]) were included. Assessments of postoperative genital function, local recurrence rate, and 5 year survival rate were collected.

Results

Rate of erection dysfunction in PANP group (41.9 %) was significantly lower than that in TME group (76.7 %, P < 0.05). Rate of ejaculation dysfunction in PANP group (42.5 %) was also significantly lower than that in TME group (67.3 %, P < 0.05). Local recurrence rate (P = 0.66) and survival rate (P = 0.26) did not differ between the two groups. For patients with preoperative obstruction, local recurrence rate was significantly higher (P = 0.01) and survival rate significantly lower (P = 0.03) in PANP group.

Conclusions

PANP surgery has significant advantage with respect to preservation of genital function and should be recommended as surgical treatment for rectal cancer patients. However, PANP surgery should be considered with caution in patients with preoperative obstruction in view of the poorer long-term outcomes in these patients.

Laparoscopic surgery for colorectal cancer is safe and has survival outcomes similar to those of open surgery in elderly patients with a poor performance status: subanalysis of a large multicenter case-control study in Japan

BACKGROUND

It remains controversial whether open or laparoscopic surgery should be indicated for elderly patients with colorectal cancer and a poor performance status.

METHODS

In those patients aged 80 years or older with Eastern Cooperative Oncology Group performance status score of 2 or greater who received elective surgery for stage 0 to stage III colorectal adenocarcinoma and had no concomitant malignancies and who were enrolled in a multicenter case-control study entitled "Retrospective study of laparoscopic colorectal surgery for elderly patients" that was conducted in Japan between 2003 and 2007, background characteristics and short-term and long-term outcomes for open surgery and laparoscopic surgery were compared.

RESULTS

Of the 398 patients included, 295 underwent open surgery and 103 underwent laparoscopic surgery. There were no significant differences in the baseline characteristics between open surgery and laparoscopic surgery patients, except for previous abdominal surgery and TNM stage. The median operation duration was shorter with open surgery (open surgery, 153 min; laparoscopic surgery, 202 min; P < 0.001), and less blood loss occurred with laparoscopic surgery (median open surgery, 109 g; median laparoscopic surgery, 30 g; P < 0.001). An operation duration of 180 min or more (odds ratio, 1.97; 95 % confidence interval, 1.17-3.37; P = 0.011) and selection of laparoscopic surgery (odds ratio, 0.41; 95 % confidence interval, 0.22-0.75; P = 0.003) were statistically significant in the multivariate analysis for postoperative morbidity. Moreover, laparoscopic surgery did not result in an inferior overall survival rate compared with open surgery (log-rank test P = 0.289, 0.278, 0.346, 0.199, for all-stage, stage 0-I, stage II, and stage III disease, respectively).

CONCLUSIONS

Laparoscopic surgery in elderly colorectal cancer patients with a poor performance status is safe and not inferior to open surgery in terms of overall survival.

Obese patients have similar short-term outcomes to non-obese in laparoscopic colorectal surgery

AIM: To determine whether obese patients undergoing laparoscopic surgery within an enhanced recovery program had worse short-term outcomes.

METHODS: A prospective study of consecutive patients undergoing laparoscopic colorectal resection was carried out between 2008 and 2011 in a single institution. Patients were divided in groups based on body mass index (BMI). Short-term outcomes including operative data, length of stay, complications and readmission rates were recorded and compared between the groups. Continuous data were analysed using t-test or one-way Analysis of Variance. χ² test was used to compare categorical data.

RESULTS: Two hundred and fifty four patients were included over the study period. The majority of individuals (41.7%) recruited were of a healthy weight (BMI < 25), whilst 50 patients were classified as obese (19.6%). Patients were matched in terms of the presence of co-morbidities and previous abdominal surgery. Obese patients were found to have a statistically significant difference in The American Society of Anesthesiologists grade. Length of surgery and intra-operative blood loss were no different according to BMI.

CONCLUSION: Obesity (BMI > 25) does not lead to worse short-term outcomes in laparoscopic colorectal surgery and therefore such patients should not be precluded from laparoscopic surgery.

Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study

BACKGROUND

Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, "learning curve" experience, implementing a well standardized operative technique and recovery protocol.

METHODS

The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed.

RESULTS

Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo-Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission.

CONCLUSION

Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.

A systematic review of outcome reporting in colorectal cancer surgery

AIM

Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered.

METHOD

Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies.

RESULTS

Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617).

CONCLUSION

Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.

Laparoscopic versus open surgery for colorectal cancer in elderly patients: a multicenter matched case-control study

BACKGROUND

The safety of laparoscopic surgery (LAP) in elderly patients with colorectal cancer has not been demonstrated. The aim of this study was to compare the outcomes of LAP and open surgery (OP) and estimate the feasibility of LAP in colorectal cancer patients aged ≥ 80 years.

METHODS

We conducted a propensity scoring matched case-control study of colon and rectal cancer patients aged ≥ 80 years using data from 41 hospitals between 2003 and 2007. A total of 1,526 colon cancer patients and 282 rectal cancer patients underwent surgery and were included in the analysis. The primary end point was 3-year overall survival (OS). Secondary end points included disease-free survival (DFS), cancer-specific survival (CSS), and postoperative complications.

RESULTS

LAP and OP were compared in 804 colon cancer patients (402 pairs) and 114 rectal cancer patients (57 pairs) after all covariates were balanced, and no significant differences were observed, except for tumor size in colon cancer. OS, DFS, and CSS did not differ between the groups for either colon cancer (P = 0.916, 0.968, and 0.799, respectively) or rectal cancer (P = 0.765, 0.519, and 0.950, respectively). In colon cancer cases, LAP was associated with fewer morbidities than was OP (24.9 vs. 36.3 %, P < 0.001); no such difference was observed for rectal cancer patients (47.4 vs. 40.4 %, P = 0.450).

CONCLUSIONS

LAP is an acceptable alternative to OP in elderly patients with colorectal cancer.

Two-day hospital stay after laparoscopic colorectal surgery under an enhanced recovery after surgery (ERAS) pathway

Background

The present study aims to examine the feasibility and safety of a two-day hospital stay after laparoscopic colorectal resection (LCR) under an enhanced recovery after surgery (ERAS) pathway.

Methods

Between 2003 and 2010, 882 consecutive patients undergoing LCR were analyzed. Patients were grouped and analyzed according to whether their hospital stay was 2 days (group A) or longer (group B). Demographic, surgical, and postoperative data were compared. To identify independent predictive factors related to a short hospital stay, a multivariate analysis was also performed.

Results

Group A represented 10.3 % of this series (91 patients). There were no differences regarding age, gender, BMI, ASA, and previous abdominal surgeries between groups. Group A had a lower incidence of rectal cancer and anterior resections than group B (6.6 vs. 17.7 % [p = 0.006] and 14.3 vs. 23.4 % [p = 0.048]), respectively, and a lower mean operative time (170 min vs. 192 min; p = 0.002). Group A had a lower overall morbidity rate than group B (5.5 vs. 16.9 %; p = 0.004) and a lower incidence of surgery-related complications (5.5 vs. 14.9 %; p = 0.001). The overall conversion rate was 10 % (only one patient in group A required conversion), and the difference in conversion rate between groups was statistically significant (1.2 vs. 10.7 %; p = 0.003). Group A had a lower readmission rate (0 vs. 4.9 %; p = 0.089). Multivariate analysis showed that conversion, postoperative morbidity, and rectal prolapse were independently associated with the length of hospital stay.

Conclusions

A two-day hospital stay after LCR is safe and feasible under an ERAS pathway, without compromising the readmission or complication rate.

Single-site laparoscopic colorectal surgery provides similar lengths of hospital stay and similar costs compared with standard laparoscopy: results of a retrospective cohort study

BACKGROUND

The present study sought to compare the length of stay (LOS) and hospital costs for elective single-site (SSL) and standard laparoscopic (SDL) colorectal resections performed at a tertiary referral center.

METHODS

An IRB-approved, retrospective cohort study of all elective SDL and SSL colorectal resections performed from 2008 to 2012 was undertaken. Patient charges and inflation adjusted hospital costs (US dollars) were compared with costs subcategorized by operating room expense, room and board, and pharmacy and radiology utilization.

RESULTS

A total of 149 SDL and 111 SSL cases were identified. Compared with SSL, SDL surgeries were associated with longer median operative times (SSL: 153 min vs. SDL: 189 min, p = 0.001); however, median operating room costs were similar (p > 0.05). Median postoperative LOS was similar for both groups (SSL: 3 days; SDL: 4 days; p > 0.05). There was no difference between SSL and SDL with respect to either total patient charges (SSL: $34,847 vs. SDL: $38,306; p > 0.05) or hospital costs (SSL: $13,051 vs. SDL: $12,703; p > 0.05). Median costs during readmission were lower for SSL patients (SSL: $3,625 vs. SDL: $6,203, p = 0.04).

CONCLUSIONS

SSL provides similar LOS as well as similar costs to both patients and hospitals compared with SDL, making it a cost-feasible alternative.

Laparoscopy for colorectal cancer

The laparoscopic approach for colorectal cancer resection has been evolved from an experimental procedure with oncological concerns to routine daily practice within a period of two decades. Numerous randomized controlled trials and meta-analyses have shown that laparoscopic resection results in faster recovery with similar oncological outcome compared to an open approach, both for colon and rectal cancer. Besides improved cosmesis, other long-term advantages seem to be less adhesion related small bowel obstruction and reduced incisional hernia rate. Adequate patient selection and surgical experience are of crucial importance. Experience can be gradually expanded step by step, by increasing the complexity of the procedure. A decision to convert should be made early in the procedure, because the outcome after a reactive conversion is worse than initial open resection or strategic conversion. The additive value of new techniques such as robotic surgery has to be proven in randomized studies including a cost-effectiveness assessment.