Minimally invasive surgery for colorectal cancer: past, present, and future

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.

The perioperative dynamics of IL-7 following robot-assisted and open colorectal surgery

Interleukin-7 is critical for T-cell development and displays antimicrobial and antitumor properties. It is referred to as a “critical enhancer of protective immunity”. However, there is no information on interleukin-7 dynamics following colorectal surgery. Moreover, although robot-assisted surgery is gaining popularity, data on the immune response to it is almost non-existent. In this prospective non-randomized case-control study we found interleukin-7 dynamics to differ following robot-assisted and open approach and to affect postoperative immunity. Linear increases were seen in the robotic group while a cubic pattern with a maximum at 8 h in the open one. Low preoperative interleukin-7 was associated with developing surgical site infection. In turn, higher preoperative interleukin-7 was associated with preserved immune function: less pronounced drop in lymphocyte count and higher Δlymphocyte/Δneutrophil ratio in patients undergoing robotic surgery. The changes in other cytokines, namely, interleukin-12(p70), TNFα, interferon-γ, and interleukin-10 were independently associated with interleukin-7 dynamics. In turn, relative changes in interleukin-7 were independent predictors of changes in interferon-γ, key cytokine of favourable Th1 immune response. Taken together, we demonstrated different perioperative dynamics of interleukin-7, which may contribute to favourable outcomes following robotic colorectal surgery including lower incidence of surgical site infections, milder surgery-induced lymphopenia, and beneficial interferon-γ dynamics.

Needlescopic surgery for left-sided colorectal cancer

PURPOSE

Laparoscopic surgery has become the standard for colorectal cancers, but more minimally invasive surgery is continuously pursued. In June 2011, our institution started needlescopic surgery (NS). The aims of this study are to describe this technique and to investigate its feasibility for left-sided colorectal cancer surgery.

METHODS

From June 2011 to June 2013, 105 sigmoid colon and upper/middle rectal cancer patients underwent NS in our institution, involving one 5-mm port and three 3-mm ports, with the exception of an umbilical 12-mm port. A 10-mm scope is used through the umbilical 12-mm port, which will be extended to a small skin incision for specimen extraction. After dissection of the left colon, a 5-mm scope is inserted through the right lower 5-mm port and a linear stapler is inserted through the umbilical 12-mm port for rectal transection. The specimen is then extracted through umbilical incision, and the anastomosis is carried out by the double-staple technique.

RESULTS

TNM staging is stage 0/I/II/III/IV = 0/31/32/31/11. Fifty-one patients underwent sigmoidectomy and 54 patients underwent anterior resection. There was no conversion to open surgery, but one patient required a change to a 5-mm port from one of the 3-mm ports. Mean operating time was 193 min and mean estimated blood loss was 12 ml. There were ten (9 %) postoperative complications: two anastomotic leaks requiring reoperation, two anastomotic hemorrhages, and one wound infection. There was no mortality.

CONCLUSIONS

NS for left-sided colorectal cancer was a technically and oncologically feasible technique for selected patients.

Minimally invasive surgery for rectal cancer

Rectal cancer remains a common and complex surgical problem. There is growing evidence that minimally invasive surgery (MIS) can provide ideal care for patients with rectal cancer. This review examines the short- and long-term benefits to MIS for rectal cancer, as well as the current techniques available, and how wider adoption of these techniques may be performed.

Supporting the wider use of laparoscopy in the treatment of ovarian masses

Patients with ovarian masses which have a moderate risk of malignancy are frequently treated by open laparotomy, despite the Royal College of Obstetricians and Gynaecologists (RCOG) guidance indicating that laparoscopic oophorectomy may be performed in selected cases. The reluctance to perform laparoscopic surgery in these cases is normally due to the perception that survival is affected if the mass is subsequently diagnosed as being malignant, the risk of rupture impacting on FIGO stage and the need for additional staging surgery. However, there is no good evidence to support these views. Preoperative diagnosis of ovarian masses is limited and thus a significant number of patients are subjected to open surgery, where they may have benefitted from the advantages of laparoscopic surgery. We argue that in the absence of a definitive preoperative test, there are advantages to the laparoscopic approach in patients who have a moderate risk of malignancy and further high level evidence should be encouraged in this field.