Blood loss and transfusion after total mesorectal excision and conventional rectal cancer surgery

Robotic- vs laparoscopic-assisted proctectomy for locally advanced rectal cancer based on propensity score matching: Short-term outcomes at a colorectal center in China

BACKGROUND

Reports in the field of robotic surgery for rectal cancer are increasing year by year. However, most of these studies enroll patients at a relatively early stage and have small sample sizes. In fact, studies only on patients with locally advanced rectal cancer (LARC) and with relatively large sample sizes are lacking.

AIM

To investigate whether the short-term outcomes differed between robotic-assisted proctectomy (RAP) and laparoscopic-assisted proctectomy (LAP) for LARC.

METHODS

The clinicopathological data of patients with LARC who underwent robotic- or laparoscopic-assisted radical surgery between January 2015 and October 2019 were collected retrospectively. To reduce patient selection bias, we used the clinical baseline characteristics of the two groups of patients as covariates for propensity-score matching (PSM) analysis. Short-term outcomes were compared between the two groups.

RESULTS

The clinical features were well matched in the PSM cohort. Compared with the LAP group, the RAP group had less intraoperative blood loss, lower volume of pelvic cavity drainage, less time to remove the pelvic drainage tube and urinary catheter, longer distal resection margin and lower rates of conversion (P < 0.05). However, the time to recover bowel function, the harvested lymph nodes, the postoperative length of hospital stay, and the rate of unplanned readmission within 30 days postoperatively showed no difference between the two groups (P > 0.05). The rates of total complications and all individual complications were similar between the RAP and LAP groups (P > 0.05).

CONCLUSION

This retrospective study indicated that RAP is a safe and feasible method for LARC with better short-term outcomes than LAP, but we have to admit that the clinically significant of part of indicators are relatively small in the practical situation.

Chronic pain after rectal cancer surgery - development and validation of a scoring system

AIM

The aim was to develop and validate a scoring system for the assessment of chronic pain on quality of life (QoL) following surgical treatment of rectal cancer (RC).

METHOD

Patients diagnosed with RC between 2001 and 2014 in Denmark were evaluated for inclusion. Eligible patients were mailed questionnaires concerning pain and QoL. Questionnaire items were associated with QoL by odds ratio using regression analyses. The patients were randomized into a development group and a validation group. The most significant items were each assigned a score value based on multivariate-adjusted odds ratio. Validity was tested in the validation group using receiver operating characteristic curves and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 (EORTC QLQ-30).

RESULTS

A total of 1928 eligible patients completed the questionnaire; 1072 were randomized to the development group and 856 to the validation group. The calculated scores included the six most important questionnaire items giving a score range of 0-45 which identified three groups: no significant pain, minor pain syndrome and major pain syndrome. Our results suggest a significant correlation between QoL assessment and the presence of major pain.

CONCLUSION

We have developed and validated a reliable, QoL-based scoring system for chronic post-surgical pain following RC.

Intraoperative blood loss during surgical treatment of low-rectal cancer by abdominosacral resection is higher than during extra-levator abdominosacral amputation of the rectum

INTRODUCTION

Abdominosacral resection (ASR) usually required blood transfusions, which are virtually no longer in use in the modified abdominosacral amputation of the rectum (ASAR). The aim of this study was to compare the intra-operative bleeding in low-rectal patients subjected to ASR or ASAR.

MATERIAL AND METHODS

The study included low-rectal cancer patients subjected to ASR (n = 114) or ASAR (n = 46) who were retrospectively compared in terms of: 1) the frequency of blood transfusions during surgery and up to 24 h thereafter; 2) the volume of intraoperative blood loss (ml of blood transfused) during surgery and up to 24 h thereafter; 3) hemoglobin concentrations (Hb) 1, 3 and 5 days after surgery; 4) the duration of hospitalization.

RESULTS

Blood transfusions were necessary in 107 ASR patients but in none of those subjected to ASAR (p < 0.001). Median blood loss in the ASR group was 800 ml (range: 100-4500 ml). The differences between the groups in median Hb determined 1, 3 and 5 days following surgery were insignificant. The proportions of patients with abnormal values of Hb, however, were significantly higher in the ASR group on postoperative days 1 and 3 (day 1: 71.9% vs. 19.6% in the ASAR group, p = 0.025; day 3: 57.% vs. 13.0%, p = 0.009). Average postoperative hospitalization in ASR patients was 13 days compared to 9 days in the ASAR group (p = 0.031).

CONCLUSIONS

Abdominosacral amputation of the rectum predominates over ASR in terms of the prevention of intra- and postoperative bleeding due to the properly defined surgical plane in low-rectal cancer patients.

Colorectal surgery and its impact on male sexual function

The quality of functional outcome has become increasingly important in view of improvement in prognosis with colorectal cancer patients. Sexual dysfunction remains a common problem after colorectal cancer treatment, despite the good oncologic outcomes achieved by expert surgeons. Although radiotherapy and chemotherapy contribute, surgical nerve damage is the main cause of sexual dysfunction. The autonomic nerves are in close contact with the visceral pelvic fascia that surrounds the mesorectum. The concept of total mesorectal excision (TME) in rectal cancer treatment has led to a substantial improvement of autonomic nerve preservation. In addition, use of laparoscopy has allowed favorable results with regards to sexual function. The present paper describes the anatomy and pathophysiology of autonomic pelvic nerves, prevalence of sexual dysfunction, and the surgical technique of nerve preservation in order to maintain sexual function.

Voiding dysfunction after total mesorectal excision in rectal cancer

Purpose

The aim of this study was to assess the voiding dysfunction after rectal cancer surgery with total mesorectal excision (TME).

Methods

This was part of a prospective study done in the rectal cancer patients who underwent surgery with TME between November 2006 and June 2008. Consecutive uroflowmetry, post-voided residual volume, and a voiding questionnaire were performed at preoperatively and postoperatively.

Results

A total of 50 patients were recruited in this study, including 28 male and 22 female. In the comparison of the preoperative data with the postoperative 3-month data, a significant decrease in mean maximal flow rate, voided volume, and post-voided residual volume were found. In the comparison with the postoperative 6-month data, however only the maximal flow rate was decreased with statistical significance (P=0.02). In the comparison between surgical methods, abdominoperineal resection patients showed delayed recovery of maximal flow rate, voided volume, and post-voided residual volume. There was no significant difference in uroflowmetry parameters with advances in rectal cancer stage.

Conclusions

Voiding dysfunction is common after rectal cancer surgery but can be recovered in 6 months after surgery or earlier. Abdominoperineal resection was shown to be an unfavorable factor for postoperative voiding. Larger prospective study is needed to determine the long-term effect of rectal cancer surgery in relation to male and female baseline voiding condition.

Urinary and sexual dysfunction after rectal cancer treatment

In light of the improving prognosis for patients with rectal cancer, the quality of functional outcome has become increasingly important. Despite the good functional results achieved by expert surgeons, large multicenter studies show that urogenital dysfunction remains a common problem after rectal cancer treatment. More than half of patients experience a deterioration in sexual function, consisting of ejaculatory problems and impotence in men and vaginal dryness and dyspareunia in women. Urinary dysfunction occurs in one-third of patients treated for rectal cancer. Surgical nerve damage is the main cause of urinary dysfunction. Radiotherapy seems to have a role in the development of sexual dysfunction, without affecting urinary function. Pelvic autonomic nerves are especially at risk in cases of low rectal cancer and during abdominoperineal resection. Data concerning nerve damage during laparoscopic surgery for resection of rectal cancer are awaited. Structured education of surgeons with regard to pelvic neuroanatomy, and systematic registration of identified nerves, could well be the key to improving functional outcome for these patients. Meanwhile, patients should be informed of all associated risks before their operation, and their functional status should be evaluated before and after surgery.

Risk factors for indications of intraoperative blood transfusion among patients undergoing surgical treatment for colorectal adenocarcinoma

CONTEXT: Identification of risk factors for requiring transfusions during surgery for colorectal cancer may lead to preventive actions or alternative measures, towards decreasing the use of blood components in these procedures, and also rationalization of resources use in hemotherapy services. This was a retrospective case-control study using data from 383 patients who were treated surgically for colorectal adenocarcinoma at "Fundação Pio XII", in Barretos-SP, Brazil, between 1999 and 2003. OBJECTIVE: To recognize significant risk factors for requiring intraoperative blood transfusion in colorectal cancer surgical procedures. METHODS: Univariate analyses were performed using Fisher's exact test or the chi-squared test for dichotomous variables and Student's t test for continuous variables, followed by multivariate analysis using multiple logistic regression. RESULTS: In the univariate analyses, height (P = 0.06), glycemia (P = 0.05), previous abdominal or pelvic surgery (P = 0.031), abdominoperineal surgery (P<0,001), extended surgery (P<0.001) and intervention with radical intent (P<0.001) were considered significant. In the multivariate analysis using logistic regression, intervention with radical intent (OR = 10.249, P<0.001, 95% CI = 3.071-34.212) and abdominoperineal amputation (OR = 3.096, P = 0.04, 95% CI = 1.445-6.623) were considered to be independently significant. CONCLUSION: This investigation allows the conclusion that radical intervention and the abdominoperineal procedure in the surgical treatment of colorectal adenocarcinoma are risk factors for requiring intraoperative blood transfusion.

Postoperative morbidity following chemoradiation for locally advanced low rectal cancer

BACKGROUND

Postoperative morbidity remains a significant clinical problem and may alter long-term outcome particularly after neoadjuvant chemoradiation in patients with locally advanced low rectal cancer. The aim of the present study was to identify a potential long-term effect of postoperative morbidity.

METHODS

Analysis of prospectively collected data of 90 consecutive patients who underwent neoadjuvant chemoradiation and curative mesorectal excision for locally advanced (cT3/4, Nx, M0/1) adenocarcinoma of the mid and lower third of the rectum during a 7-year period (1996-2002).

RESULTS

Major postoperative complications occurred in 17.8% and minor complications in 26.6% of patients. Hospital mortality and 30-day mortality was 0%. Infectious complications were seen in 34.5%. The leading causes of infectious complications were anastomotic leakage and perineal wound infection. Postoperative morbidity was statistically significantly associated with gender (P < 0.05), pre-therapeutic haemoglobin level (P < 0.05), ASA score (P < 0.05), hospitalisation (P < 0.001) and clinical long-time course (P < 0.01). Moreover, early postoperative morbidity was proven as an independent prognostic factor concerning disease-free (P < 0.05) and overall survival (P < 0.05).

CONCLUSION

Early postoperative morbidity in patients with preoperative chemoradiation due to locally advanced low rectal cancer is demonstrated as an independent prognosticator. Gender, pre-therapeutic haemoglobin level and ASA score indicate patients at risk for early postoperative complications and may therefore serve as predictive features.

One hundred years of curative surgery for rectal cancer: 1908-2008

In 1908, William Ernest Miles published his article in the Lancet, introducing the basis of modern rectal cancer surgery. He established the basis for curative cancer treatment by combining the knowledge of anatomy and biological behaviour with improved surgical options as a result of better anaesthesiological techniques. Miles' contribution comprised the introduction of the concept of lymphatic spread of cancer cells and his consequent radical surgical resection, removing all primary lymph nodes en bloc. Miles' concept has dominated the minds of surgeons throughout the 20th century and his abdominoperineal resection has been the golden standard for several decades. However, his concept of downward spread of rectal cancer was proven wrong, which initiated the historical shift from radical abdominoperineal resection to the use of sphincter-saving surgery. Since the introduction of total mesorectal excision, abdominoperineal excision has been performed in only a minority of patients. Further improvement in surgical technique consisted of autonomic nerve preservation, improving functional outcome. From a historical overview, it can be concluded that the management of rectal cancer has been progressed tremendously over the past 100 years, mainly because of an increased understanding of the pathology and natural history of the disease, which has been initiated by Miles.