Long-term oncologic outcomes of laparoscopic versus open surgery for rectal cancer: a pooled analysis of 3 randomized controlled trials

Outcomes of Minimally Invasive Rectal Cancer Resection: Insights From a Resource-Limited Setting

BACKGROUND

Minimally invasive approaches for rectal cancer treatment are emerging as the standard of care. Robotic surgery is unfeasible across the country due to constrained resource allocation. This study aimed to assess the oncologic efficacy of laparoscopic resection for rectal cancer in a resource-limited setting.

METHODS

A propensity score-matched analysis was carried out to compare the oncological outcomes of laparoscopic and open rectal cancer resection at a high-volume tertiary cancer centre in South India.

RESULTS

Two hundred and twenty patients were included (110 patients in each group). The median follow-up was 93 months. There was no difference in positive circumferential resection margin between laparoscopic and open group (4.5% vs. 6.4%, p = 0.55), with a significantly better nodal yield in laparoscopic group. There was no significant difference between the laparoscopic and open groups in terms of local recurrence (5.1% vs. 8.3%, p = 0.12), 5-year disease-free survival (86% vs. 81%, p = 0.22, HR 0.699, 95% CI 0.353-1.27) or overall survival (85% vs. 76%, p = 0.21, HR 0.658, 95% CI 0.340-1.27). The mean cost between the two groups had no difference.

CONCLUSION

In a resource-limited setting with good expertise, laparoscopic surgery is an effective minimally invasive option that has good survival outcomes without imposing a financial burden on patients.

Long-Term Outcomes of Carbon Dioxide Insufflation in Thoracoscopic Esophagectomy After Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study

BACKGROUND

Thoracoscopic esophagectomy (TE) with carbon dioxide (CO2) insufflation is increasingly performed for esophageal cancer; however, there is limited evidence of the long-term outcomes of CO2 insufflation on postoperative survival.

OBJECTIVES

We investigated the long-term outcomes of TE with or without CO2 insufflation.

METHODS

We enrolled 182 patients who underwent TE for esophageal cancer between January 2003 and October 2013 and categorized them into two groups: with and without CO2 insufflation. The primary endpoint was five-year overall survival (5y-OS). Secondary endpoints included long-term outcomes, such as five-year relapse-free survival (5y-RFS) and five-year cancer-specific survival (5y-CSS), and short-term outcomes, such as surgical and non-surgical complications and reoperation within 30 days.

RESULTS

Follow-up until death or the five-year postoperative period was 98.9% (median follow-up duration was six years in survivors). After adjusting for age, sex, and yield pathologic tumor, node, and metastasis (TNM) stage, we found no significant differences in 5y-OS (HR 1.12, 95% CI 0.66-1.91), 5y-RFS (HR 1.12, 95% CI 0.67-1.83), or 5y-CSS rates (HR 1.00, 95% CI 0.57-1.75). For short-term outcomes, significant intergroup differences in operation time (p=0.02), blood loss (p<0.001), postoperative length of stay (p<0.001), and incidence of atelectasis (p=0.004) were observed. The results of the sensitivity analysis were similar to the main results.

CONCLUSIONS

In thoracoscopic procedures, CO2 insufflation significantly improved short-term outcomes, and it appears that the recurrence risk of esophageal cancer may not impact the long-term prognosis. While the influence of CO2 insufflation in thoracoscopic esophageal surgery remains unclear, our study suggests that the long-term prognosis is not compromised in other thoracic surgeries.

Perioperative and long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision: a retrospective study of 672 patients

Although there's growing information about the long-term oncological effects of robotic surgery for rectal cancer, the procedure is still relatively new. This study aimed to assess the long-term oncological results of total mesorectal excision (TME) performed laparoscopically versus robotically in the setting of rectal cancer. Restrospective analysis of a prospectively maintained database. A total of 489 laparoscopic (L-TME) and 183 robotic total mesorectal excisions (R-TME) were carried out by a single surgeon between 2013 and 2023. The groups were compared in terms of perioperative and long-term oncological outcomes. In the R-TME and L-TME groups, male sex predominated (75.4% and 57.3%, respectively), although the robotic group was significantly greater (p = 0.008). There was no conversion in R-TME group, whereas three (0.6%) converted to open surgery in L-TME group. The R-TME group had a statistically significant higher number of distal rectal tumors (85%) compared to the L-TME group (54.6%). Only three (1.7%) patients in the R-TME group received abdomineperineal resection (APR); in contrast, 25 (5%) patients in the L-TME group received APR (p < 0.001). For R-TME, the mean follow-up was 70.7 months (range 18-138) and for L-TME, it was 60 months (range 14-140). Frequency of completed mesorectum was significantly greater in R-TME group (98.9% vs 94.2%, p < 0.001). The 5 year overall survival rates for R-TME and L-TME groups were 89.6% and 88.7%, respectively. The 5 year disease-free survival for R-TME and L-TME groups were 84.1% and 81.1%, respectively. The local recurrences rates were 7.6% and 6.3%, respectively in R-TME and L-TME groups (p = 0.274). R-TME is characterized by no conversion and improved mesorectal integrity. R-TME had longer operation time. The long-term oncological outcomes were comparable between groups.

Laparoscopic rectal cancer resection yields comparable clinical and oncological results with shorter hospital stay compared to open access: a 5-year national cohort

PURPOSE

Although widely applied, the results following laparoscopic rectal resection (LRR) compared to open rectal resection (ORR) are still debated. The aim of this study was to assess clinical short- and long-term results as well as oncological resection quality following LRR or ORR for cancer in a 5-year national cohort.

METHODS

Data from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry were retrieved from January 2014 to December 2018 for patients who underwent elective resection for rectal cancer. Primary end point was 5-year overall survival. Secondary end points were local recurrence rates within 5 years, oncological resection quality, and short-term outcome measures.

RESULTS

A total of 1796 patients were included, of whom 1284 had undergone LRR and 512 ORR. There was no difference in 5-year survival rates between the groups after adjusting for relevant covariates with Cox regression analyses. Crude 5-year survival was 77.1% following LRR compared to 74.8% following ORR (p = 0.015). The 5-year local recurrence rates were 3.1% following LRR and 4.1% following ORR (p = 0.249). Length of hospital stay was median 8.0 days (quartiles 7.0-13.0) after ORR compared to 6.0 (quartiles 4.0-8.0) days after LRR. After adjusting for relevant covariates, estimated additional length of stay after ORR was 3.1 days (p < 0.001, 95% CI 2.3-3.9). Rates of positive resection margins and number of harvested lymph nodes were similar. There were no other significant differences in short-term outcomes between the groups.

CONCLUSION

LRR was performed with clinical and oncological outcomes similar to ORR, but with shorter hospital stay.

Impact of non-muscle cutting periumbilical transverse incision on the risk of incisional hernia as compared to midline incision during laparoscopic colon cancer surgery: a study protocol for a multi-centre randomised controlled trial

BACKGROUND

Minimally invasive surgery has become popular as a surgical approach for colorectal cancer because it has fewer complications related to the abdominal incision and perioperative complications. However, the incidence of incisional hernias in laparoscopic surgery has been reported to be similar to that in open surgery. We developed a new method, the non-muscle-cutting periumbilical transverse incision, for a small incision in laparoscopic colon cancer surgery. This study aims to evaluate the effectiveness of the non-muscle-cutting periumbilical transverse incision in comparison with the midline incision in reducing the incidence of an incisional hernia in patients undergoing laparoscopic colon cancer surgery.

METHODS

This is an open-label, multi-centre, parallel, superiority, and randomised trial. Altogether, 174 patients will be allocated in a 1:1 ratio to either the midline incision or the non-muscle-cutting periumbilical transverse incision group, after stratifying by the location of the tumour (right- or left-sided). The primary outcome of this study is the incidence of incisional hernias (both symptomatic and radiologic hernias) at 12 months after surgery. The secondary outcomes include operative outcomes, 30-day postoperative complications, pathological results, and patient-reported outcomes (short form-12 health survey questionnaire and body image questionnaire). Both primary (intention-to-treat) and secondary (as-treated principles) analyses will be performed for all outcomes. The statistical significance level was set at p < 0.05 (two-sided testing).

DISCUSSION

This trial may show that the non-muscle-cutting periumbilical transverse incision will reduce the incidence of incisional hernias compared to the midline incision.

TRIAL REGISTRATION

Clinical Research Information Service (CRiS) of Republic of Korea, KCT0006082 . Registered on April 12, 2021.

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.

Comparison of Survival Among Adults With Rectal Cancer Who Have Undergone Laparoscopic vs Open Surgery: A Meta-analysis

IMPORTANCE

Two large randomized clinical trials (RCTs) found that laparoscopic surgery failed to yield noninferior pathologic outcomes compared with open surgery for patients with rectal cancer. The results raised concerns regarding the effectiveness of the laparoscopic approach for patients with rectal cancer.

OBJECTIVE

To compare the long-term oncologic outcomes of laparoscopic and open surgery for patients with rectal cancer.

DATA SOURCES

PubMed, Web of Science, Embase, and Cochrane Central Register of Controlled Trials were searched from database inception to August 13, 2021. Studies published in English were retrieved.

STUDY SELECTION

The meta-analysis included RCTs that compared laparoscopic surgery with open surgery for patients with rectal cancer and reported the outcome of disease-free survival (DFS) or overall survival (OS). The following exclusion criteria were used: (1) non-RCTs, (2) studies without long-term survival outcomes of interest, and (3) studies that did not report Kaplan-Meier survival curves.

DATA EXTRACTION AND SYNTHESIS

This meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline for individual participant data development groups. Individual participant data on DFS and OS were extracted from the published Kaplan-Meier survival curves. One-stage and 2-stage meta-analyses were performed.

MAIN OUTCOMES AND MEASURES

Meta-analyses were conducted for DFS and OS. Hazard ratios (HRs) were used as effective measures.

RESULTS

Of 8471 records screened, 10 articles with 12 RCTs and 3709 participants were selected. The reconstructed survival curves for the combined population showed that the 5-year estimated DFS rates were 72.2% (95% CI, 69.4%-74.8%) for the laparoscopic group and 70.1% (95% CI, 67.0%-73.0%) for the open surgery group, and the 5-year estimated OS rates were 76.2% (95% CI, 73.8%-78.5%) for the laparoscopic group and 72.7% (95% CI, 69.8%-75.3%) for open surgery group. In 1-stage meta-analyses, DFS had a nonsignificant HR of 0.92 (95% CI, 0.80-1.06; P = .26), which suggested that DFS in the laparoscopic and open surgery groups was comparable; however, OS was significantly better in the laparoscopic group (HR, 0.85; 95% CI, 0.74-0.97; P = .02). The results were confirmed by 2-stage meta-analyses and were validated by sensitivity analysis with large RCTs.

CONCLUSIONS AND RELEVANCE

A similar DFS but significantly better OS were found for patients who have undergone laparoscopic surgery compared with open surgery for rectal cancer. These findings address concerns regarding the effectiveness of laparoscopic surgery and support the routine use of laparoscopic surgery for patients with rectal cancer.

Application of Transumbilical Laparoscopic Surgery on Low/Ultralow Rectal Cancer for Anal Sphincter Preservation

Background: Rectal cancer is a common malignant tumor in the gastrointestinal tract. This work compares the effects of transumbilical laparoscopic surgery (TULS) and laparoscopic-assisted surgery on the anus-preserving effect of low/ultralow rectal cancer. Materials and Methods: Eighty patients with rectal cancer admitted to our hospital from February 2011 to July 2016 were randomly selected and divided into the laparoscopic group and TULS group, 40 cases in each group, all underwent radical anorectal cancer radical surgery. Statistical analysis was performed on surgical-related indicators in the two groups. Results: Two patients converted to open surgery were excluded. Five patients were excluded because of radical abdomen perineal resection for rectal cancer. Six patients were converted to TULS from laparoscopic surgery. Sixty-seven patients in the experimental group successfully completed anus-sparing surgery, and none died during the operation. The compliance rate of the distance between the lower edge of the tumor and the incision edge of the specimen in the TULS group was better than that in the laparoscopic group (P < .05). There were no significant differences between the two groups in terms of surgical time, blood loss, number of lymph node dissections, functional time of voluntary defecation and postoperative complications, tumor-free recurrence rate at 3 years, and 3-year survival rate after surgery (P > .05). Conclusions: The TULS method is safe and feasible in low and ultralow rectal cancer surgery. It has more advantages than laparoscopic-assisted surgery for anus preservation.

Prognosis of laparoscopic surgery for colorectal cancer in middle-aged patients

Background

The prognosis of middle-aged patients with colorectal cancer (CRC) treated by laparoscopic resection (LR) is unclear. This study aimed to evaluate the survival outcomes of LR compared with open resection (OR) for middle-aged patients with CRC.

Patients and Methods

This retrospective cohort study used the data from a database of all consecutive colorectal resections performed between January 2009 and December 2017. Propensity score matching (PSM) was performed to handle the selection bias based on age, gender, body mass index, tumour location, AJCC stage and admission year. Univariate and multivariate COX regression model was used to identify risk factors of overall survival (OS) and disease-free survival (DFS).

Results

After PSM, 154 patients were included in each group. Compared with the OR group in the total cohort, there were better survival outcomes in the LR group for 5-year OS and 5-year DFS (both P < 0.001). These differences were observed for Stage II and III diseases and for all CRC, irrespective of location. The multivariate analysis showed that tumour ≥5 cm (hazard ratio [HR] = 1.750, 95% confidence interval [CI]: 1.026-2.986, P = 0.040), Stage III (HR = 14.092, 95% CI: 1.894-104.848, P = 0.010) and LR (HR = 0.300, 95% CI: 0.160-0.560, P < 0.001) were independently associated with OS. Pre-operative carcinoembryonic antigen ≥5 ng/ml (HR = 3.954, 95% CI: 1.363-11.473, P = 0.011), Stage III (HR = 6.206, 95% CI: 1.470-26.200, P = 0.013) and LR (HR = 0.341, 95% CI: 0.178-0.653, P = 0.001) were independently associated with DFS.

Conclusions

In middle-aged patients with CRC, LR achieves better survival than OR. Complications are similar, except for less blood loss and shorter post-surgical hospital stay with LR.

Laparoscopic versus open resection for rectal cancer: An individual patient data meta analysis of randomized controlled trials

BACKGROUND AND AIMS

The role of laparoscopic rectal cancer resection remains controversial. Thus, we aimed to conduct a one-stage meta-analysis with reconstructed patient-level data using randomized trial data to compare long-term oncologic efficacy of laparoscopic and open surgical resection for rectal cancer.

METHODS

Medline, EMBASE and Scopus were searched for articles comparing laparoscopic with open surgery for rectal cancer. Primary outcome was disease free survival (DFS) while secondary outcome was overall survival (OS). One-stage meta-analysis was conducted using patient-level survival data reconstructed from Kaplan-Meier curves with Web Plot Digitizer. Shared-frailty and stratified Cox models were fitted to compare survival endpoints.

RESULTS

Seven randomized trials involving 1767 laparoscopic and 1293 open resections for rectal cancer were included. There were no significant differences between both groups for DFS and OS with respective hazard ratio estimates of 0.91 (95% CI: 0.78-1.06, p = 0.241) and 0.86 (95% CI:0.73-1.02, p = 0.090). Sensitivity analysis for non-metastatic patients and patients with mid and lower rectal cancer showed no significant differences in OS and DFS between both surgical approaches. In the laparoscopic arm, improved DFS was noted for stage II (HR: 0.73, 95% CI:0.54-0.98, p = 0.036) and stage III rectal cancers (HR: 0.74, 95% CI:0.55-0.99, p = 0.041).

CONCLUSIONS

This meta-analysis concludes that laparoscopic rectal cancer resection does not compromise long-term oncologic outcomes compared with open surgery with potential survival benefits for a minimal access approach in patients with stage II and III rectal cancer.

Failure to rescue following proctectomy for rectal cancer: the additional benefit of laparoscopic approach in a nationwide observational study of 44,536 patients

BACKGROUND

There is growing evidence that failure to rescue (FTR) is an important factor of postoperative mortality (POM) after rectal cancer surgery and surgical approach modified post-operative outcomes. However, the impact of laparoscopy on FTR after proctectomy for rectal cancer remains unknown. The aim of this study was to compare the rates of postoperative complications and FTR after laparoscopy vs open proctectomy for cancer.

METHODS

All patients who underwent proctectomy for rectal cancer between 2012 and 2016 were included. FTR was defined as the 90-day POM rate among patients with major complications. Outcomes of patients undergoing open or laparoscopic rectal cancer surgery were compared after 1:1 propensity score matching by year of surgery, hospital volume, sex, age, Charlson score, neoadjuvant chemotherapy, tumor localization and type of anastomosis.

RESULTS

Overall, 44,536 patients who underwent proctectomy were included, 7043 of whom (15.8%) developed major complications. The rates of major complications, POM and FTR were significantly higher in open compared to laparoscopic procedure (major complications: 19.2% vs 13.7%, p < 0.001; POM: 5.4% vs 2.3%, p < 0.001; FTR: 13.6% vs 8.3%, p < 0.001; respectively). After matching, open and laparoscopic groups were comparable. Multivariate analysis showed that age, Charlson score, sphincter-preserving procedure and surgical approach were predictive factors for FTR. Open proctectomy was found to be a risk factor for FTR (OR 1.342, IC95% [1.066; 1.689], p = 0.012) compared to laparoscopic procedure.

CONCLUSION

When complications occurred, patients operated on by open proctectomy were more likely to die.

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

BACKGROUND

The role of laparoscopic rectal cancer surgery has been questioned owing to conflicting reports on pathological outcomes from recent RCTs. However, it is unclear whether these pathological markers and the surgical approach have an impact on oncological outcomes. This study assessed oncological outcomes of laparoscopic and open rectal cancer resections.

METHODS

A meta-analysis of RCTs was performed. Primary endpoints included oncological outcomes (disease-free survival (DFS), overall survival (OS), local recurrence). Secondary endpoints included surrogate markers for the quality of surgical resection.

RESULTS

Twelve RCTs including 3744 patients (2133 laparoscopic, 1611 open) were included. There was no significant difference in OS (hazard ratio (HR) 0.87, 95 per cent c.i. 0.73 to 1.04; P = 0.12; I2 = 0 per cent) and DFS (HR 0.95, 0.81 to 1.11; P = 0.52; I2 = 0 per cent) between laparoscopic and open rectal resections. There was no significant difference in locoregional (odds ratio (OR) 1.03, 95 per cent c.i. 0.72 to 1.48; P = 0.86; I2 = 0 per cent) or distant (OR 0.87, 0.70 to 1.08; P = 0.20; I2 = 7 per cent) recurrence between the groups. Achieving a successful composite score (intact mesorectal excision, clear circumferential resection margin and distal margin) was significantly associated with improved DFS (OR 0.55, 0.33 to 0.74; P < 0.001; I2 = 0 per cent). An intact or acceptable mesorectal excision (intact mesorectal excision with or without superficial defects) had no impact on DFS. Finally, a positive CRM was associated with worse DFS.

CONCLUSION

Well performed surgery (laparoscopic or open) achieves excellent oncological outcomes with very little difference between the two modalities. The advantage and benefit of minimally invasive surgery should be assessed on an individual basis.

Minimally Invasive Proctectomy for Rectal Cancer: A National Perspective on Short-term Outcomes and Morbidity

BACKGROUND

Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique.

METHODS

Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016-2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity.

RESULTS

A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups.

CONCLUSION

Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.

Early Experience With Transanal Total Mesorectal Excision Compared With Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Propensity Score-Matched Analysis

BACKGROUND

Laparoscopic total mesorectal excision is widely used for rectal cancers; however, it is sometimes challenging, especially in obese patients with low tumors, particularly after chemoradiotherapy. Transanal total mesorectal excision was developed to overcome these limitations in terms of visualization, dissection, and stapling.

OBJECTIVE

The purpose of this study was to compare the pathologic and early oncologic outcomes of the laparoscopic and transanal approaches.

DESIGN

This was a retrospective comparative study using propensity score-matched analysis.

SETTING

The study was conducted at a tertiary hospital specializing in oncology.

PATIENTS

In total, 722 inpatients who underwent total mesorectal excision for rectal cancer from January 2014 to December 2017 were included.

INTERVENTIONS

Laparoscopic (N = 514) and transanal (N = 208) total mesorectal excision were performed.

MAIN OUTCOME MEASURES

The primary outcome was pathologic outcome including circumferential and distal resection margin involvement. The secondary outcomes were intraoperative and postoperative complications and overall survival, recurrence-free survival, and local recurrence rates.

RESULTS

The 2 groups of the cohort had several differences; thus, we performed propensity score matching. The circumferential resection margin was involved in 13.4% and 12.9% of the laparoscopic and transanal groups (p = 0.88). The distal resection margin was involved in 1% and 3% of the laparoscopic and transanal groups (p = 0.28). Complete or nearly complete total mesorectal excision was 98.0% and 96.5% in the laparoscopic and transanal groups (p = 0.41). Postoperative complications with Clavien-Dindo grade III or higher did not differ significantly between groups (p = 0.54) but were significantly higher in patients with tumors <5 cm from the anal verge who underwent laparoscopy (laparoscopic group = 11.9%; transanal group = 1.7%; p = 0.04). There were no statistical differences in the 3-year overall survival, recurrence-free survival, or local recurrence rates between groups.

LIMITATIONS

This was a retrospective study design with a short follow-up period.

CONCLUSIONS

Early experience with the transanal approach showed similar pathologic outcomes as those of conventional laparoscopy; hence, it should be considered as a surgical option for lower rectal cancer. See Video Abstract at http://links.lww.com/DCR/B352. EXPERIENCIA TEMPRANA CON LA ESCISIÓN MESORRECTAL TOTAL TRANSANAL EN COMPARACIÓN CON LA ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA PARA EL CÁNCER DE RECTO: UN ANÁLISIS DE PUNTUACIÓN DE PROPENSIÓN: La escisión mesorrectal total laparoscópica se usa ampliamente para los cánceres rectales; Sin embargo, a veces es un desafío, especialmente en pacientes obesos con tumores bajos, particularmente después de la quimiorradioterapia. La escisión mesorrectal total transanal se desarrolló para superar estas limitaciones en términos de visualización, disección y grapado.Comparar los resultados patológicos y oncológicos precoces de los enfoques laparoscópico y transanal.estudio comparativo retrospectivo con puntaje de propensión-análisis emparejadoHospital terciario especializado en oncología.En total, se incluyeron 722 pacientes hospitalizados que se sometieron a una escisión mesorrectal total por cáncer rectal desde Enero de 2014 hasta Diciembre de 2017.Se realizó escisión mesorrectal total laparoscópica (n = 514) y transanal (n = 208).El resultado primario fue el resultado patológico, incluyendo el involucramiento del margen de resección circunferencial y distal. Los resultados secundarios fueron complicaciones intraoperatorias, postoperatorias y supervivencia general, supervivencia libre de recurrencia y tasas de recurrencia local.Los dos grupos de la cohorte tuvieron varias diferencias; así, realizamos un emparejamiento de puntuación de propensión. El margen de resección circunferencial estuvo involucrado en 13.4% y 12.9% de los grupos laparoscópico y transanal, respectivamente (p = 0.88). El margen de resección distal estuvo involucrado en 1% y 3% de los grupos laparoscópico y transanal, respectivamente (p = 0.28). La escisión mesorrectal total completa o casi completa fue de 98.0% y 96.5% en los grupos laparoscópico y transanal, respectivamente (p = 0.41). Las complicaciones postoperatorias con Clavien-Dindo grado ≥ III no difirieron significativamente entre los grupos (p = 0,54), pero fueron significativamente mayores en pacientes con tumores de < 5 cm del borde anal que se sometieron a laparoscopia (grupo laparoscópico, 11,9%; grupo transanal, 1,7%; p = 0,04). No hubo diferencias estadísticas en la supervivencia general a 3 años, la supervivencia libre de recurrencia y las tasas de recurrencia local entre los grupos.Diseño de estudio retrospectivo, corto período de seguimiento.La experiencia temprana con el enfoque transanal mostró resultados patológicos similares a los de la laparoscopia convencional; por lo tanto, debe considerarse como una opción quirúrgica para el cáncer rectal mas bajo. Consulte Video Resumen en http://links.lww.com/DCR/B352. (Traducción-Dr Yesenia Rojas-Khalil).

Impact of laparoscopic surgical experience on the learning curve of robotic rectal cancer surgery

BACKGROUND

Robotic surgery has advantages in terms of the ergonomic design and expectations of shortening the learning curve, which may reduce the number of patients with adverse outcomes during a surgeon's learning period. We investigated the differences in the learning curves of robotic surgery and clinical outcomes for rectal cancer among surgeons with differences in their experiences of laparoscopic rectal cancer surgery.

METHODS

Patients who underwent robotic surgery for colorectal cancer were reviewed retrospectively. Patients were divided into five groups by surgeons, and their clinical outcomes were analyzed. The learning curve of each surgeon with different volumes of laparoscopic experience was analyzed using the cumulative sum technique (CUSUM) for operation times, surgical failure (open conversion or anastomosis-related complications), and local failure (positive resection margins or local recurrence within 1 year).

RESULTS

A total of 662 patients who underwent robotic low anterior resection (LAR) for rectal cancer were included in the analysis. Number of laparoscopic LAR cases performed by surgeon A, B, C, D, and E prior to their first case of robotic surgery were 403, 40, 15, 5, and 0 cases, respectively. Based on CUSUM for operation time, surgeon A, B, C, D, and E's learning curve periods were 110, 39, 114, 55, and 23 cases, respectively. There were no significant differences in the surgical and oncological outcomes after robotic LAR among the surgeons.

CONCLUSIONS

This study demonstrated the limited impact of laparoscopic surgical experience on the learning curve of robotic rectal cancer surgery, which was greater than previously reported curves.

A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study

AIM

The oncological risk/benefit trade-off for laparoscopy in rectal cancer is controversial. Our aim was to compare laparoscopic vs open surgery for resection of rectal cancer, using unselected data from the public healthcare system of Catalonia (Spain).

METHODS

This was a multicentre retrospective cohort study of all patients who had surgery with curative intent for primary rectal cancer at Catalonian public hospitals from 2011 to 2012. We obtained follow-up data for up to 5 years. To minimize the differences between the two groups, we performed propensity score matching on baseline patient characteristics. We used multivariate Cox proportional hazards regression analyses to assess locoregional relapse at 2 years and death at 2 and 5 years.

RESULTS

Of 1513 patients with Stage I-III rectal cancer, 933 (61.7%) had laparoscopy (conversion rate 13.2%). After applying our propensity score matching strategy (2:1), 842 laparoscopy patients were matched to 517 open surgery patients. Multivariate Cox analysis of death at 2 years [hazard ratio (HR) 0.65, 95% CI 0.48, 0.87; P = 0.004] and 5 years (HR 0.61, 95% CI 0.5, 0.75; P < 0.001) and of local relapse at 2 years (HR 0.44, 95% CI 0.27, 0.72; P = 0.001) showed laparoscopy to be an independent protective factor compared with open surgery.

CONCLUSIONS

Laparoscopy results in lower locoregional relapse and long-term mortality in rectal cancer in unselected patients with all-risk groups included. Studies using long-term follow-up of cohorts and unselected data can provide information on clinically relevant outcomes to supplement randomized controlled trials.

Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis

BACKGROUND

The purpose of this meta-analysis is to evaluate the evidence available on the safety as well as effectiveness of robotic resection as compared to conventional laparoscopic surgery for rectal cancer.

MATERIAL AND METHODS

A comparison of laparoscopic and robotic surgical treatments for rectal cancer was collected. Eligible trials that analyzed probabilistic hazard ratios (HR) for endpoints of interest (including perioperative morbidity) and postoperative complications were included in our review.

RESULTS

A total of six studies were included based on the present inclusion criteria. The pooled data showed that R-TME appeared to have association with remarkable reduction in the postoperative morbidity rate as compared to L-TME. Moreover, R-TME was also linked to lower conversion, decreased lymph node number, and longer operation time compared with L-TME. However, there was no difference in hospital stay, positive range of circumferential resection and blood loss between the two study groups.

CONCLUSIONS

Robotic rectal cancer surgery provides favorable outcomes and is considered as a safe surgical technique in terms of postoperative oncological safety. Like laparoscopic TME surgery, robotic surgery may be a valid alternative and complementary approach with beneficial effects on minimally-invasive surgery.

Value of multi-disciplinary input into laparoscopic management of rectal cancer - An observational study

AIM

To assess the impact of multi-disciplinary teams (MDTs) management in optimising the outcome for rectal cancers.

METHODS

We undertook a retrospective review of a prospectively maintained database of patients with rectal cancers (defined as tumours ≤ 15 cm from anal verge) discussed at our MDT between Jan 2008 and Jan 2011. The data was validated against the national database to ensure completeness of dataset. The clinical course and follow-up data was validated using the institution’s electronic patient records. The data was analysed in terms of frequencies and percentages. Significance of any differences were analysed using χ² test. A Kaplan-Meier analysis was performed for overall survival and disease free survival.

RESULTS

Following appropriate staging, one hundred and thirty-three patients were suitable for potentially curative resections. Seventy two (54%) were upper rectal cancer (URC) - tumour was > 6 cm from the anal verge and 61 (46%) were lower rectal cancers (LRC) - lower extent of the tumour was palpable ≤ 6 cm. Circumferential resection margin (CRM) appeared threatened on pre-operative MRI in 19/61 (31%) patients with LRC requiring neo-adjuvant therapy (NAT). Of the 133 resections, 118 (89%) were attempted laparoscopically (5% conversion rate). CRM was positive in 9 (6.7%) patients; Median lymph node harvest was 12 (2-37). Major complications occurred in 8 (6%) patients. Median follow-up was 53 mo (0-82). The 90-d mortality was 2 (1.5%). Over the follow-up period, disease related mortality was 11 (8.2%) and overall mortality was 39 (29.3%). Four (3%) patients had local recurrence and 22 (16.5%) patients had distant metastases.

CONCLUSION

Management of rectal cancers can be optimized with multi-disciplinary input to attain acceptable long-term oncological outcomes even when incorporating a laparoscopic approach to rectal cancer resection.

Minimally invasive distal pancreatectomy

BACKGROUND

The first International conference on Minimally Invasive Pancreas Resection was arranged in conjunction with the annual meeting of the International Hepato-Pancreato-Biliary Association (IHPBA), in Sao Paulo, Brazil on April 19th 2016. The presented evidence and outcomes resulting from the session for minimally invasive distal pancreatectomy (MIDP) is summarized and addressed perioperative outcome, the outcome for cancer and patient selection for the procedure.

METHODS

A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to compare MIDP and open distal pancreatectomy. Patient selection was discussed based on plenary talks, panel discussions and a worldwide survey on MIDP.

RESULTS

Of 582 studies, 52 (40 observational and 12 case-matched) were included in the assessment for outcome for LDP (n = 5023) vs. ODP (n = 16,306) whereas 16 observational comparative studies were identified for cancer outcome. No randomized trials were identified. MIDP resulted in similar outcome to ODP with a tendency for lower blood loss and shorter hospital stay in the MIDP group.

DISCUSSION

Available evidence for comparison of MIDP to ODP is weak, although the number of studies is high. Observed outcomes of MIDP are promising. In the absence of randomized control trials, an international registry should be established.

Laparoscopic versus open surgery for rectal cancer: A meta-analysis of classic randomized controlled trials and high-quality Nonrandomized Studies in the last 5 years

OBJECTIVE

To present a meta-analysis of high-quality published reports comparing laparoscopic rectal resection (LRR) and open rectal resection (ORR) for rectal cancer.

METHODS

Studies that compared LRR and ORR and were published within the last 5 years were identified. All eligible randomized controlled trials (RCTs) and non-randomized comparative trials (NRCTs) were evaluated based on the Jadad score, the Cochrane risk of bias assessment tool and modified Methodological Indices for Nonrandomized Studies (MINORS). The mean differences (MD) and odds ratios (OR) were used to compare the operative time, blood loss, mortality, complications, harvested lymph nodes, hospital stay, distal resection margin, and circumferential resection margin. The risk ratio (RR) method was used to examine recurrence and survival.

RESULTS

Fourteen studies were identified and included 7 RCTs and 7 NRCTs and 4353 patients (2251 LRR, 2102 ORR). Although the operation time of the LRR group was obviously longer than that of the conventional surgery group (MD = 25.64, 95%CI = [5.17,46.10], P = 0.01), LRR was associated with fewer overall complications (OR = 0.67, 95%CI = [0.52,0.87], P = 0.002), less blood loss (MD = -66.49, 95%CI = [-88.31, -44.66], P < 0.00001), shorter postoperative hospital stays (OR = -1.26,95%CI = [-2.45, -0.07],P = 0.004) and shorter bowel function recovery times (MD = -0.93, 95%CI = [-1.27,-0.58], P < 0.00001). Moreover, the difference in the DRM was statistically clear (MD = 0.14, 95%CI = [0.02,0.27], P = 0.03). However, no significant differences between the LRR and ORR groups were observed in terms of the number of lymph nodes harvested, mortality, positive CRM, local and distal recurrence, or overall and disease-free survival.

CONCLUSIONS

This study indicates that there are no significant differences between LRR and ORR in terms of survival and pathological outcomes with the exception of the DRM. Moreover, this study suggests that LRR can be performed safely and elicits faster recovery times compared with conventional surgery.

Comparison of laparoscopic vs. open surgery for rectal cancer

This study was conducted to evaluate the safety of laparoscopic radical resection for rectal cancer. A total of 64 cases of rectal cancer patients undergoing radical surgery between January, 1998 and March, 2010 were collected. The patients were divided into the laparoscopic rectal surgery group (LS group, n=31) and the open surgery group (OS group, n=33). Operation time, postoperative recovery, complications and tumor-free survival rate were compared between the two groups. The inclusion criteria were as follows: Standard Karnofsky score >70 prior to surgery, definitive pathological diagnosis and complete clinical data. The exclusion criteria were concomitant tumors affecting survival. With the Dixon operation, the LS group had a longer operation time compared with the OS group (271.2±56.2 vs. 216.0±62.7 min, respectively; P=0.036), and an earlier time of oral intake (3.0±0.9 vs. 4.7±1.0 days, respectively; P=0.000). There were no significant differences between the LS and OS groups in terms of intraoperative blood loss, number of lymph nodes retrieved, duration of postoperative hyperthermia and hospitalization time (P>0.05). With the Miles operation, there were no obvious differences between the LS and OS groups regarding operation time, intraoperative blood loss, number of lymph nodes retrieved, time of oral intake, duration of postoperative hyperthermia and hospitalization time (P>0.05). Furthermore, there were no significant differences between the LS and OS groups with the Dixon or Miles operation in terms of 3-year tumor-free survival rate (P>0.05). Thus, laparoscopic surgery appears to be a safe and feasible option for the treatment of rectal cancer.

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.

Case-matched Comparison of Robotic Versus Laparoscopic Colorectal Surgery: Initial Institutional Experience

Robotic colorectal surgery is an emerging technique. In this study, we aimed to compare outcomes of robotic colorectal operations to laparoscopy. Patients undergoing robotic colorectal surgery between November 2010 and July 2013 were case matched to laparoscopic counterparts based on diagnosis and operation type. Perioperative and short-term postoperative outcomes were compared. There were 57 patients who underwent robotic colorectal surgery. American Society of Anaesthesiologists score was higher in patients who underwent robotic surgery (2 vs. 3, P=0.01). Blood loss (200 vs. 300 mL, P=0.27) and conversion rate to open surgery (6 vs. 5, P=0.75) were similar between the groups. Operating time was longer in robotic surgery (172 vs. 267 min, P<0.0001). Time to first bowel movement (3 vs. 3 d, P=0.38), hospital stay (5 vs. 6 d, P=0.22), and postoperative complications were comparable between the groups. In the early learning curve period, robotic colorectal surgery shows similar short-term outcomes with longer operating time compared with conventional laparoscopy.

Critical appraisal of laparoscopic vs open rectal cancer surgery

AIM: To evaluate the long-term clinical and oncological outcomes of laparoscopic rectal resection (LRR) and the impact of conversion in patients with rectal cancer.

METHODS: An analysis was performed on a prospective database of 633 consecutive patients with rectal cancer who underwent surgical resection. Patients were compared in three groups: Open surgery (OP), laparoscopic surgery, and converted laparoscopic surgery. Short-term outcomes, long-term outcomes, and survival analysis were compared.

RESULTS: Among 633 patients studied, 200 patients had successful laparoscopic resections with a conversion rate of 11.1% (25 out of 225). Factors predictive of survival on univariate analysis include the laparoscopic approach (P = 0.016), together with factors such as age, ASA status, stage of disease, tumor grade, presence of perineural invasion and vascular emboli, circumferential resection margin < 2 mm, and postoperative adjuvant chemotherapy. The survival benefit of laparoscopic surgery was no longer significant on multivariate analysis (P = 0.148). Neither 5-year overall survival (70.5% vs 61.8%, P = 0.217) nor 5-year cancer free survival (64.3% vs 66.6%, P = 0.854) were significantly different between the laparoscopic group and the converted group.

CONCLUSION: LRR has equivalent long-term oncologic outcomes when compared to OP. Laparoscopic conversion does not confer a worse prognosis.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Dealing with robot-assisted surgery for rectal cancer: Current status and perspectives

The laparoscopic approach for treatment of rectal cancer has been proven feasible and oncologically safe, and is able to offer better short-term outcomes than traditional open procedures, mainly in terms of reduced length of hospital stay and time to return to working activity. In spite of this, the laparoscopic technique is usually practised only in high-volume experienced centres, mainly because it requires a prolonged and demanding learning curve. It has been estimated that over 50 operations are required for an experienced colorectal surgeon to achieve proficiency with this technique. Robotic surgery enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, thus promising to overcome some of the technical difficulties associated with standard laparoscopy. It has high-definition three-dimensional vision, it translates the surgeon’s hand movements into precise movements of the instruments inside the patient, the camera is held and moved by the first surgeon, and a fourth robotic arm is available as a fixed retractor. The aim of this review is to summarise the current data on clinical and oncologic outcomes of robot-assisted surgery in rectal cancer, focusing on short- and long-term results, and providing original data from the authors’ centre.

Transanal rectal resection: an initial experience of 20 cases

AIM

Low anterior resection (LAR) can present a formidable surgical challenge, particularly for tumours located in the distal third of the rectum. Transanal total mesorectal excision (taTME) aims to overcome some of these difficulties. We report our initial experience with this technique.

METHOD

From June 2013 to September 2014, 20 selected patients underwent transanal rectal resection for various malignant and benign low rectal pathologies. All patients with rectal cancer were discussed at a multidisciplinary team meeting. Data were entered into a prospective managed international database.

RESULTS

Of the 20 patients (14 male), seventeen (85%) had rectal cancer lying at a median distance of 2 cm (range 0-7) from the anorectal junction. The operations performed included LAR (16). Abdominoperineal excision (2) and completion proctectomy (2), all of which were performed by a minimally invasive approach with three conversions. The mean operation time was 315.3 min. There were six postoperative complications of which two (10%) were Clavien-Dindo Grade IIIb (pelvic haematoma and a late contained anastomotic leakage). The median length of stay was 7 days. The TME specimen was intact in 94.1% of cancer cases. The mean number of harvested lymph nodes was 23.2. There was only one positive circumferential resection margin (tumour deposit; R1 rate 5.9%). One patient developed a distant recurrence (median follow-up 10 months, range 6-21).

CONCLUSION

TaTME was safe in this small series of patients. It is especially attractive in patients with a narrow and irradiated pelvis and a tumour in the lower third of the rectum. TaTME is technically demanding, but the good outcomes should prompt randomized studies and prospective registration of all taTME cases in an international registry.

Transanal total mesorectal excision: A valid option for rectal cancer?

Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current experience with TaTME. The limits and future developments are also explored. Although the experience with TaTME is still limited, it might be a promising alternative to laparoscopic TME, especially for difficult cases where laparoscopy is too demanding. The preliminary data on complications and short-term oncological outcomes are good, but also emphasize the importance of careful patient selection. Finally, there is a need for large-scale trials focusing on long-term outcomes and oncological safety before widespread adoption can be recommended.

Long-term oncologic outcomes of laparoscopic vs open surgery for stages II and III rectal cancer: A retrospective cohort study

AIM

To evaluate the 5-year survival after laparoscopic surgery vs open surgery for stages II and III rectal cancer.

METHODS

This study enrolled 406 consecutive patients who underwent curative resection for stages II and III rectal cancer between January 2000 and December 2009 [laparoscopic rectal resection (LRR), n = 152; open rectal resection (ORR), n = 254]. Clinical characteristics, operative outcomes, pathological outcomes, postoperative recovery, and 5-year survival outcomes were compared between the two groups.

RESULTS

Most of the clinical characteristics were similar except age (59 years vs 55 years, P = 0.033) between the LRR group and ORR group. The proportion of anterior resection was higher in the LRR group than that in the ORR group (81.6% vs 66.1%, P = 0.001). The LRR group had less estimated blood loss (50 mL vs 200 mL, P < 0.001) and a lower rate of blood transfusion (4.6% vs 11.8%, P = 0.019) compared to the ORR group. The pathological outcomes of the two groups were comparable. The LRR group was associated with faster recovery of bowel function (2.8 d vs 3.7 d, P < 0.001) and shorter postoperative hospital stay (11.7 d vs 13.7 d, P < 0.001). The median follow-up time was 63 mo in the LRR group and 65 mo in the ORR group. As for the survival outcomes, the 5-year local recurrence rate (16.0% vs 16.4%, P = 0.753), 5-year disease-free survival (DFS) rate (63.0% vs 63.1%, P = 0.589), and 5-year overall survival (OS) rate (68.1% vs 63.5%, P = 0.682) were comparable between the LRR group and the ORR group. Stage by stage, there were also no statistical differences between the LRR group and the ORR group in terms of the 5-year local recurrence rate (stage II: 6.3% vs 8.7%, P = 0.623; stage III: 26.4% vs 23.2%, P = 0.747), 5-year DFS rate (stage II: 77.5% vs 77.6%, P = 0.462; stage III: 46.5% vs 50.9%, P = 0.738), and 5-year OS rate (stage II: 81.4% vs 74.3%, P = 0.242; stage III: 53.9% vs 54.1%, P = 0.459).

CONCLUSION

LRR for stages II and III rectal cancer can yield comparable long-term survival while achieving short-term benefits compared to open surgery.

Factors associated with conversion from laparoscopic to open colectomy using the National Surgical Quality Improvement Program (NSQIP) database

AIM

Conversion rates from laparoscopic to open colectomy and associated factors are traditionally reported in clinical trials or reviews of outcomes from experienced institutions. Indications and selection criteria for laparoscopic colectomy may be more narrowly defined in these circumstances. With the increased adoption of laparoscopy, conversion rates using national data need to be closely examined. The purpose of this study was to use data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify factors associated with conversion of laparoscopic to open colectomy at a national scale in the United States.

METHOD

The ACS-NSQIP Participant Use Data Files for 2006-2011 were used to identify patients who had undergone laparoscopic colectomy. Converted cases were identified using open colectomy as the primary procedure and laparoscopic colectomy as 'other procedure'. Preoperative variables were identified and statistics were calculated using sas version 9.3. Logistic regression was used to model the multivariate relationship between patient variables and conversion status.

RESULTS

Laparoscopy was successfully performed in 41 585 patients, of whom 2508 (5.8%) required conversion to an open procedure. On univariate analysis the following factors were significant: age, body mass index (BMI), American Society of Anesthesiologists (ASA) class, presence of diabetes, smoking, chronic obstructive pulmonary disease, ascites, stroke, weight loss and chemotherapy (P < 0.05). The following factors remained significant on multivariate analysis: age, BMI, ASA class, smoking, ascites and weight loss.

CONCLUSION

Multiple significant factors for conversion from laparoscopic to open colectomy were identified. A novel finding was the increased risk of conversion for underweight patients. As laparoscopic colectomy is become increasingly utilized, factors predictive of conversion to open procedures should be sought via large national cohorts.

Short and long-term outcomes of robotic versus laparoscopic total mesorectal excision for rectal cancer: a case-matched retrospective study

The true benefits of robotic surgery are controversial, and whether robotic total mesorectal excision (R-TME) can be justified as a standard treatment for rectal cancer patients needs to be clarified. This case-matched study aimed to compare the postoperative complications and short- and long-term outcomes of R-TME and laparoscopic TME (L-TME) for rectal cancer.Among 1029 patients, we identified 278 rectal cancer patients who underwent R-TME. Propensity score matching was used to match this group with 278 patients who underwent L-TME.The mean follow-up period was similar between both groups (L-TME vs R-TME: 52.5 ± 17.1 vs 51.0 ± 13.1 months, P = 0.253), as were patient characteristics. The operation time was significantly longer in the R-TME group than in the L-TME group (361.6 ± 91.9 vs 272.4 ± 83.8 min; P < 0.001), whereas the conversion rate, length of hospital stay, and recovery of pain and bowel motility were similar between both groups. The rates of circumferential resection margin involvement and early complications were similar between both groups (L-TME vs R-TME: 4.7% vs 5.0%, P = 1.000; and 23.7% vs 25.9%, P = 0.624, respectively), as were the 5-year overall survival, disease-free survival, and local recurrence rates (93.1% vs 92.2%, P = 0.422; 79.6% vs 81.8%, P = 0.538; 3.9% vs 5.9%, P = 0.313, respectively).The oncologic quality, short- and long-term outcomes, and postoperative morbidity in the R-TME group were comparable with those in the L-TME group.

Minimally invasive versus open total mesorectal excision for rectal cancer: Long-term results from a case-matched study of 633 patients

BACKGROUND

This study compared the long-term oncologic outcomes of patients with rectal cancer who underwent either laparoscopic or robotic total mesorectal excision (TME) via minimally invasive surgery (MIS) to those patient who underwent open TME.

METHODS

This study was a retrospective, case-control study; patients in the 2 groups were matched according to age, sex, MIS vs open operation, body mass index, tumor location, pathologic TNM stage (ie, tumor-node-metastasis), neoadjuvant treatment, and adjuvant treatment.

RESULTS

A total of 633 patients (MIS, n = 211; open, n = 422) were assessed. The median follow-up period was 64 (2-124) months. Patient characteristics did not differ between the groups. Overall postoperative complication rates did not differ between the groups (16.0% [MIS]; 17.0% [open]; P = .76). Rates of the involvement of the circumferential resection margin did not differ between the groups (4.0% [MIS]; 5.0% [open]; P = .84). The 5-year overall survival, disease-specific survival, disease-free survival, and local recurrence rates were not different between the MIS and open groups (overall survival = 88.4% vs 85.3%, P = .23; disease-specific survival = 88.8% vs 87.4%, P = .53, disease-free survival = 80.7% vs 78.4%, P = .74; local recurrence = 5.7% vs 5.1%, P = .95). In subgroup analysis, no differences were found in terms of the long-term, oncologic outcomes, oncologic adequacy, and postoperative complications among 3 groups.

CONCLUSION

We found no differences in the oncologic outcomes between MIS and open surgery, suggesting that MIS for rectal cancer is a safe option for rectal cancer that does not increase the risk of serious complications.

Residual rectal mucosa after stapled vs. handsewn ileal J-pouch-anal anastomosis in patients with familial adenomatous polyposis coli (FAP)--a critical issue

INTRODUCTION

Restorative proctocolectomy has become the standard surgical procedure for familial adenomatous polyposis (FAP) patients. The use of stapler devices has initiated a controversial discussion concerning the ileal pouch-anal reconstruction. Some authors advocate a handsewn anastomosis after transanal mucosectomy. A double-stapled anastomosis leads to better functional results but seems to bear a higher risk of residual rectal mucosa with dysplasia and adenomas. The present study systematically analyses the rate of residual rectal mucosa after restorative proctocolectomy and handsewn vs. stapled anastomosis.

PATIENTS AND METHODS

One hundred FAP patients after restorative proctocolectomy undergoing regular follow-up at our outpatient clinic were included in the study. Proctoscopy with standardised biopsy sampling was performed.

RESULTS

Of the 100 patients, 50 had undergone a stapled and 50 a handsewn anastomosis. Median follow-up was 146.1 months (handsewn) vs. 44.8 months (stapled) (P < 0.0001). Eighty-seven patients received a proctoscopy with standardised biopsy sampling. Thirteen patients had been diagnosed with residual rectal mucosa before. Sixty-three patients (63 %) showed remaining rectal mucosa (42 (66.6 %) stapler, 21 (33.3 %) handsewn, P < 0.0001). Patients after stapled anastomosis had higher rates of circular rectal mucosa seams, while small mucosa islets predominated in the handsewn group. The rate of rectal adenomas was significantly higher in the stapler group (21 vs. 10, P = 0.02).

CONCLUSION

Rectal mucosa, especially wide mucosa seams, as well as rectal adenomas are found significantly more often after a stapled than after a handsewn anastomosis. As the follow-up interval in the stapler group was significantly shorter, the impact of these findings may still be underestimated.

New developments in colorectal surgery

PURPOSE OF REVIEW

Surgical management of diseases of the colon and rectum continues to evolve. This review examines the recent publications that have led to or may lead to changes in practice in this field.

RECENT FINDINGS

We identified and reviewed the recent publications in the areas of colon, rectal, and anal cancers; inflammatory bowel disease; incontinence; diverticulitis; hemorrhoids; fistulas; and quality improvement initiatives.

SUMMARY

New technologies and novel questions have changed practice and will improve patient outcomes. Multiinstitutional studies, ideally randomized, continue to be essential to answer the questions that will lead to identification of best practices.

Is the learning curve of robotic low anterior resection shorter than laparoscopic low anterior resection for rectal cancer?: a comparative analysis of clinicopathologic outcomes between robotic and laparoscopic surgeries

As robotic surgery was developed with ergonomic designs, there are expectations that the technical advantages of robotic surgery can shorten the learning curve. However, there is no comparative study, so far, to evaluate the learning curve between robotic and laparoscopic rectal cancer surgeries. Therefore, the aim of this study is to compare the learning curve of robotic low anterior resection (LAR) with laparoscopic LAR for rectal cancer.Patients who underwent robotic or laparoscopic LAR by a single surgeon were compared retrospectively (robot n = 89 vs laparoscopy n = 89). Cumulative sum (CUSUM) was used to evaluate the learning curve. The patients were divided into phase 1 (initial learning curve period) and phase 2 (post-learning curve period). The perioperative clinicopathologic characteristics were compared by phases and surgical procedures.According to CUSUM, the learning curve of robotic LAR was the 44th case and laparoscopic LAR was the 41st case. The learning phases were divided as follows: phase 1 (cases 1-41) versus phase 2 (cases 42-89) in the laparoscopic group, and phase 1 (cases 1-44) versus phase 2 (cases 45-89) in the robotic group. Comparison between phase 1 and phase 2 in each type of surgery showed no significant difference for the perioperative outcomes. Comparison between robotic and laparoscopic surgeries in each phase showed similar perioperative results. Pathologic outcomes were not significantly different in both procedures and phases.The learning curve of robotic LAR for rectal cancer was similar to laparoscopic LAR, and the clinicopathologic outcomes were similar in both the procedures.

Patient-reported genitourinary dysfunction after laparoscopic and open rectal cancer surgery in a randomized trial (COLOR II)

BACKGROUND

This article reports on patient-reported sexual dysfunction and micturition symptoms following a randomized trial of laparoscopic and open surgery for rectal cancer.

METHODS

Patients in the COLOR II randomized trial, comparing laparoscopic and open surgery for rectal cancer, completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-CR38 questionnaire before surgery, and after 4 weeks, 6, 12 and 24 months. Adjusted mean differences on a 100-point scale were calculated using changes from baseline value at the various time points in the domains of sexual functioning, sexual enjoyment, male and female sexual problems, and micturition symptoms.

RESULTS

Of 617 randomized patients, 385 completed this phase of the trial. Their mean age was 67·1 years. Surgery caused an anticipated reduction in genitourinary function after 4 weeks, with no significant differences between laparoscopic and open approaches. An improvement in sexual dysfunction was seen in the first year, but some male sexual problems persisted. Before operation 64·5 per cent of men in the laparoscopic group and 55·6 per cent in the open group reported some degree of erectile dysfunction. This increased to 81·1 and 80·5 per cent respectively 4 weeks after surgery, and 76·3 versus 75·5 per cent at 12 months, with no significant differences between groups. Micturition symptoms were less affected than sexual function and gradually improved to preoperative levels by 6 months. Adjusting for confounders, including radiotherapy, did not change these results.

CONCLUSION

Sexual dysfunction is common in patients with rectal cancer, and treatment (including surgery) increases the proportion of patients affected. A laparoscopic approach does not change this.

REGISTRATION NUMBER

NCT00297791 (http://www.clinicaltrials.gov).

Successful total shift from multiport to single-port laparoscopic surgery in low anterior resection of colorectal cancer

OBJECTIVE

To assess the possibility of using single-port low anterior resection (LAR) in place of conventional laparoscopic LAR.

BACKGROUND

Though single-port LS is gradually evolving, the application of single-port LS techniques in LAR have been viewed with skepticism due to technical difficulties.

METHODS

Data from patients who had undergone either conventional laparoscopic LAR (n = 49) or single-port LAR (n = 67) for colorectal cancers between March 2006 and March 2013 were analyzed retrospectively.

RESULTS

In single-port LAR group, oncologic outcomes were satisfactory with respect to attainment of lymph nodes (23.4 ± 15.3) and surgical margins (proximal cut margin: 7.1 ± 4.6 cm, distal cut margin: 7.7 ± 5.7 cm). Single-port LAR showed acceptable clinical outcomes manifested by comparable outcomes of post-operative analgesics requirement and length of hospital stay, and by low incidence of post-operative complications (conventional laparoscopic LAR group: 30.6% vs. single-port LAR group: 14.9%; P < 0.01). Operative time was comparable between groups (conventional laparoscopic LAR group: 309 ± 93 min vs. single-port LAR group: 277 ± 106 min; P = 0.097). Throughout a series of 67 consecutive single-port LARs, no conversion to multiport or open surgery was occurred.

CONCLUSION

This study shows that single-port LAR is both safe and feasible for use in resection of colorectal cancer when performed by surgeons who are trained in conventional laparoscopic technique. If further and more extensive studies support our results, then single-port LAR can be an acceptable alternative to conventional laparoscopic LAR for treatment of colorectal cancer.

Safety of laparoscopic colorectal surgery in a low-volume setting: review of early and late outcome

Background. There is increasing evidence suggesting that the laparoscopic technique is the treatment of choice for large bowel resection, including for malignancy. The purpose of the study was to assess whether general surgeons, with particular skills in advanced laparoscopy, can adequately provide safe laparoscopic colorectal resections in a low-volume setting. Methods. A retrospective review of prospectively collected case series of all laparoscopic colorectal resections performed under the care of a single general surgeon is presented. The primary endpoint was postoperative clinical outcome in terms of morbidity and mortality. Secondary endpoints were adequacy of surgical margins and number of lymph nodes harvested for colorectal cancer cases. Results. Seventy-three patients underwent 75 laparoscopic resections between March, 2003, and May, 2011. There was no elective mortality and the overall 30-day postoperative morbidity was 9.3%. Conversion and anastomotic leakage rates were both 1.3%, respectively. None of the malignant cases had positive margins and the median number of lymph nodes retrieved was 17. Conclusions. Our results support the view that general surgeons with advanced skills in minimally invasive surgery may safely perform laparoscopic colorectal resection in a low-volume setting in carefully selected patient cases.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.