Short-term and long-term outcomes of robotic rectal surgery-from the real word data of 1145 consecutive cases in China

Outcomes in robotic-assisted compared to laparoscopic-assisted colorectal surgery in a newly established colorectal tertiary center: a retrospective comparative cohort study

The robotic platform matches or surpasses laparoscopic surgery in postoperative results. However, limited date and slow adoption are noticed in the middle east. We aimed to report outcomes of robotic and laparoscopic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare it to larger more experienced centers. Retrospective review of prospectively collected data between 2021 and 2023 of 107 patients who had robotic-assisted or laparoscopic-assisted colorectal surgery was included in the study. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and the quality of oncological specimen. Of 107 patients, 57 were in the robotic and 50 were in the laparoscopic surgery groups. Overall, there were no significant differences in overall morbidity (46.8 vs. 53.2%, p = 0.9), serious morbidity (10.5 vs. 8%, p = 0.7), or mortality (0 vs. 4%, p = 0.2). Regarding oncological outcomes, there were no significant difference between the two groups regarding the number of lymph node harvested (17.7 ± 6.9 vs 19.0 ± 9.7, p = 0.5), R0 resections (92.7 vs. 87.1%, p = 0.5), and the rate of complete mesorectal excision (92.7 vs. 71.4%, p = 0.19). The study found that the robotic group had an 86% reduction in conversion rate to open surgery compared to the laparoscopic group, despite including more obese and physically dependent patients (OR = 0.14, 95% CI 0.03-0.7, p = 0.01). Robotic surgery appears to be a safe and effective as laparoscopic surgery in smaller colorectal surgery programs led by fellowship-trained robotic surgeons, with outcomes comparable to those of larger programs.

How to use the Surveillance, Epidemiology, and End Results (SEER) data: research design and methodology

In the United States (US), the Surveillance, Epidemiology, and End Results (SEER) program is the only comprehensive source of population-based information that includes stage of cancer at the time of diagnosis and patient survival data. This program aims to provide a database about cancer incidence and survival for studies of surveillance and the development of analytical and methodological tools in the cancer field. Currently, the SEER program covers approximately half of the total cancer patients in the US. A growing number of clinical studies have applied the SEER database in various aspects. However, the intrinsic features of the SEER database, such as the huge data volume and complexity of data types, have hindered its application. In this review, we provided a systematic overview of the commonly used methodologies and study designs for retrospective epidemiological research in order to illustrate the application of the SEER database. Therefore, the goal of this review is to assist researchers in the selection of appropriate methods and study designs for enhancing the robustness and reliability of clinical studies by mining the SEER database.

Evaluation of an established colorectal robotic programme at an NHS district general hospital: audit of outcomes and systematic review of published data

INTRODUCTION

Robotic-assisted surgery (RAS) offers potential advantages over traditional surgical approaches. This study aimed to assess outcomes from a district general hospital (DGH) robotic colorectal programme against published data.

MATERIALS AND METHODS

The robotic programme was established following simulator, dry/wet lab training, and proctoring. We performed a case series analysing technical, patient, and oncological outcomes extracted from a prospective database of colorectal RAS cases (2015-2022). A registered systematic review (PROSPERO CRD42022300773; PubMed, Web of Science, EMBASE) of single-centre colorectal series from established robotic centres (n>200 cases) was completed and compared to local data using descriptive summary statistics. Risk of bias assessment was performed using an adapted version of the Cochrane ROBINS-I tool.

RESULTS

Two hundred thirty-two RAS cases were performed including 122 anterior resections, 56 APERs, 19 rectopexies, and 15 Hartmann's procedures. The median duration was 325 (IQR 265-400) min. Blood loss was < 100 ml in 97% of cases with 2 (0.9%) cases converted to open. Complications (Clavien-Dindo 3-5) occurred in 19 (8%) patients, with 3 (1.3%) deaths in < 30 days. Length of stay was 7 (IQR 5-11) days. In 169 rectal cancer cases, there were 9 (5.3%) cases with a positive circumferential or distal margin and lymph node yield of 17 (IQR 13-24). A systematic review of 1648 abstracts identified 13 studies from established robotic centres, totaling 4930 cases, with technical, patient, and oncological outcomes comparable to our own case series.

CONCLUSIONS

Outcomes from our robotic colorectal programme at a UK DGH are comparable with the largest published case series from world-renowned centres. Training and proctoring together with rolling audit must accompany the expansion of robotic surgery to safeguard outcomes.

Updating the Predictive Models for Mortality and Morbidity after Low Anterior Resection Based on the National Clinical Database

INTRODUCTION

We previously developed risk models for mortality and morbidity after low anterior resection using a nationwide Japanese database. However, the milieu of low anterior resection in Japan has undergone drastic changes since then. This study aimed to construct risk models for 6 short-term postoperative outcomes after low anterior resection, i.e., in-hospital mortality, 30-day mortality, anastomotic leakage, surgical site infection except for anastomotic leakage, overall postoperative complication rate, and 30-day reoperation rate.

METHODS

This study enrolled 120,912 patients registered with the National Clinical Database, who underwent low anterior resection between 2014 and 2019. Multiple logistic regression analyses were performed to generate predictive models of mortality and morbidity using preoperative information, including the TNM stage.

RESULTS

We developed new risk prediction models for the overall postoperative complication and 30-day reoperation rates for low anterior resection, which were absent from the previous version. The concordance indices for each endpoint were 0.82 for in-hospital mortality, 0.79 for 30-day mortality, 0.64 for anastomotic leakage, 0.62 for surgical site infection besides anastomotic leakage, 0.63 for complications, and 0.62 for reoperation. The concordance indices of all four models included in the previous version showed improvement.

CONCLUSION

This study successfully updated the risk calculators for predicting mortality and morbidity after low anterior resection using a model based on vast nationwide Japanese data.

Propensity score-matched analysis of the short-term outcomes of robotic versus laparoscopic surgery for rectal cancer

PURPOSE

The advantages of robot-assisted rectal surgery (RARS) over conventional laparoscope-assisted rectal surgery (LARS) remain controversial. This study was performed to compare the short-term outcomes of RARS and LARS.

METHODS

We retrospectively analyzed data of 207 patients who had undergone either RARS (n = 97) or LARS (n = 110) for rectal cancer (RC) from 2018 to 2020. A 1:1 matched propensity score-matched analysis was performed and the surgical outcomes of the two groups compared.

RESULTS

After matching, a well-balanced cohort of 136 patients was analyzed (n = 68 in each group), and there was no significant difference in the median operative time. The RARS group had less intraoperative blood loss than the LARS group. There were no significant differences in length of postoperative hospital stay or complication rate between the two groups. In the subgroup of lower RC, defined as the inferior edge of the tumor being within the rectum distal to the peritoneal reflection, the rate of sphincter preservation was higher in the RARS group (81.8% vs. 44.4%, p = 0.021).

CONCLUSION

This study shows that RARS is a safe and feasible approach for RC compared with LARS, RARS having the advantage of more often preserving the sphincter.

Clinical Safety and Effectiveness of Robotic-Assisted Surgery in Patients with Rectal Cancer: Real-World Experience over 8 Years of Multiple Institutions with High-Volume Robotic-Assisted Surgery

Simple Summary

The aim of this retrospective observational study was to evaluate perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) in hospitals with a high-volume of robotic-assisted surgeries. This study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions from December 2011 to June 2020. Compared with other studies, our results revealed the equivalent or superior perioperative and short-term oncological outcomes. Hence, RRS is an effective, safe, and feasible technique for patients with rectal cancers in high-volume hospitals.

Abstract

The perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) are unclear. This retrospective observational study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions in Taiwan. Of the 605 enrolled patients, 301 (49.75%), 176 (29.09%), and 116 (19.17%) had lower, middle, and upper rectal cancers, respectively. Low anterior resection (377, 62.31%) was the most frequent surgical procedure. Intraoperative blood transfusion was performed in 10 patients (2%). The surgery was converted to an open one for one patient (0.2%), and ten (1.7%) patients underwent reoperation. The overall complication rate was 14.5%, including 3% from anastomosis leakage. No deaths occurred during surgery and within 30 days postoperatively. The positive rates of distal resection margin and circumferential resection margin were observed in 21 (3.5%) and 30 (5.0%) patients, respectively. The 5-year overall and disease-free survival rates for patients with stage I–III rectal cancer were 91.1% and 86.3%, respectively. This is the first multi-institutional study in Taiwan with 605 patients from three high-volume hospitals. The overall surgical and oncological outcomes were equivalent or superior to those estimated in other studies. Hence, RRS is an effective and safe technique for rectal resection in high-volume hospitals.

Comparison between robotic‐assisted and laparoscopic sphincter‐preserving operations for ultra‐low rectal cancer

Aim

Sphincter‐preserving operations for ultra‐low rectal cancer include low anterior and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is used. We aimed to evaluate whether robotic‐assisted surgery is technically superior to laparoscopic surgery for ultra‐low rectal cancer. We compared the frequency of low anterior resection in cases of sphincter‐preserving operations.

Method

We investigated 183 patients who underwent sphincter‐preserving robotic‐assisted or laparoscopic surgery for ultra‐low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic‐assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses.

Results

Overall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic‐assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was done significantly more frequently in robotic‐assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (P = 0.04). Multivariate analyses showed that tumor distance from the anal verge (P < 0.01) and robotic‐assisted surgery (P = 0.02) were significantly associated with an increase in the performance of low anterior resection. The rate of postoperative complications or pathological results was similar between the groups.

Conclusion

Compared with laparoscopic surgery, robotic‐assisted surgery significantly increased the frequency of low anterior resection in sphincter‐preserving operations for ultra‐low rectal cancer. Robotic‐assisted surgery has technical superiority over laparoscopic surgery for ultra‐low rectal cancer treatment.

The double bipolar method for robotic total mesorectal excision in patients with rectal cancer

Although meta-analyses and systematic reviews have clarified the benefits of robotic surgery, few studies have focused on robotic rectal surgery (RRS) and the use of Endowrist® instruments. Therefore, we evaluated RRS using the double bipolar method (DBM) and compared its short-term outcomes with those of RRS using the single bipolar method (SBM). This study enrolled 157 consecutive patients and all procedures were performed by the same surgeon and recorded through short video clips. We analyzed the patient demographics and short-term clinical outcomes. Although this observational study has several limitations, the console time for total mesorectal excision using the DBM was significantly shorter than that using the SBM. Although the DBM did not demonstrate a specific learning curve, it was a safe and feasible procedure even for patients with advanced disease. Further studies are needed to evaluate the cost-effectiveness of the DBM.

Postoperative complications after robotic resection of colorectal cancer: An analysis based on 5-year experience at a large-scale center

BACKGROUND

As a common gastrointestinal malignancy, colorectal cancer (CRC) poses a serious health threat globally. Robotic surgery is one of the future trends in surgical treatment of CRC. Robotic surgery has several technical advantages over laparoscopic surgery, including 3D visualization, elimination of the fulcrum effect, and better ergonomic positioning, which together lead to better surgical outcomes and faster recovery. However, analysis of independent factors of postoperative complications after robotic surgery is still insufficient.

AIM

To analyze the incidence and risk factors for postoperative complications after robotic surgery in patients with CRC.

METHODS

In total, 1040 patients who had undergone robotic surgical resection for CRC between May 2015 and May 2020 were analyzed retrospectively. Postoperative complications were categorized according to the Clavien-Dindo (C-D) classification, and possible risk factors were evaluated.

RESULTS

Among 1040 patients who had undergone robotic surgery for CRC, the overall, severe, local, and systemic complication rates were 12.2%, 2.4%, 8.8%, and 3.5%, respectively. Multivariate analysis revealed that multiple organ resection (P < 0.001) and level III American Society of Anesthesiologists (ASA) score (P = 0.006) were independent risk factors for overall complications. Multivariate analysis identified multiple organ resection (P < 0.001) and comorbidities (P = 0.029) as independent risk factors for severe complications (C-D grade III or higher). Regarding local complications, multiple organ resection (P = 0.002) and multiple bowel resection (P = 0.027) were independent risk factors. Multiple organ resection (P < 0.001) and level III ASA score (P = 0.007) were independent risk factors for systemic complications. Additionally, sigmoid colectomy had a lower incidence of overall complications (6.4%; P = 0.006) and local complications (4.7%; P = 0.028) than other types of colorectal surgery.

CONCLUSION

Multiple organ resection, level III ASA score, comorbidities, and multiple bowel resection were risk factors for postoperative complications, with multiple organ resection being the most likely.

[Epidural block associated with improved long-term survival after surgery for colorectal cancer: A retrospective cohort study with propensity score matching]

OBJECTIVE

To investigate the effect of epidural anesthesia on the long-term prognosis of patients after selective colorectal cancer resection surgery.

METHODS

This was a retrospective cohort study and approved by local institution review board. Patients who underwent selective colorectal cancer resection surgery from August 2011 to December 2012 in Peking University First Hospital were enrolled. The patients were divided into general anesthesia (GA) group and combined epidural-general anesthesia (EGA) group according to anesthesia type. Primary outcome was patient's long-term survival status. Secondary outcome included the overall incidence of in-hospital complications and length of postoperative in-hospital stay. Propensity score was used to match cases between the two groups based on the probability of receiving EGA. Survival was analyzed by Kaplan-Meier analysis and compared by Log-rank test between the two groups. Multivariate Cox regression analysis was used to investigate the relationship between epidural anesthesia and other variables with long-term survival status.

RESULTS

A total of 264 patients were entered into final analysis, including 166 cases in GA group and 98 cases in EGA group. Mean age of the patients was (63.3±12.1) years and mean survival time was 47.2 (95%CI 45.7-48.7) months. Before the propensity score match, the mortality in EGA group was 16.9% (28/166) and 9.2% (9/98) in GA group. But comparison between the two groups had no statistical significance (P=0.091). After the propensity score match, 87 paired cases were matched and analyzed. The risk of long-term mortality in EGA group was lower than that of GA group by Kaplan-Meier analysis (5.7% vs.16.1%, HR=0.344, 95%CI 0.124-0.955, P=0.041). Mean survival time of EGA group was longer than that of GA group (50.3 months vs. 42.9 months, P=0.032). Multivariate Cox regression ana-lysis showed that EGA, in comparison with GA, was related with lower risk of long-term mortality (HR=0.326, 95%CI 0.117-0.909, P=0.032). Age (HR=1.042, 95%CI 1.001-1.085, P=0.046) and preoperative lymph node metastasis (HR=2.924, 95%CI 1.162-7.356, P=0.023) were also related with increased risk of long-term mortality.

CONCLUSION

Present study found that perioperative use of epidural anesthesia and analgesia was associated with improvement of the patient's long-term survival. Well-designed studies are needed to verify this hypothesis.

Single-docking robotic assisted proctectomy for rectal cancer below peritoneal reflection: a propensity score matching analysis

Background

The aim of this study was to compare the short and long-term outcomes of robotic assisted proctectomy (RP) and laparoscopic assisted proctectomy (LP) for rectal cancer below the peritoneal reflection using propensity score matching (PSM) analysis.

Methods

We evaluated the medical records of 200 patients who underwent proctectomy for rectal cancer below the peritoneal reflection through a robotic (n=81) or laparoscopic (n=119) approach between Jan 2015 and Dec 2017. The data were prospectively collected, and the patients were matched at a ratio of 1:1 according to age, sex, body mass index (BMI), previous abdominal surgeries, comorbidities, American Society of Anesthesiologist score (≤2/>2), and pathologic stage.

Results

After matching, each group included 74 patients. Compared to the LP group, the RP group showed shorter postoperative hospital stays (PHS) [7 (±2) vs. 9 (±2.3) d, P=0.003], shorter time to liquid diet [3 (±2) vs. 5 (±3) d, P<0.001], and shorter time to removal of catheter [6 (±2) vs. 7 (±2.3) d, p=0.014]. The operative expense was higher in the RP group [8,365 (±1,600) vs. 6,922 (±1,220) RMB, P<0.001]. The operation time, estimated blood loss, postoperative complications, and pathologic outcomes were similar between the two groups. No conversion to laparotomy, readmission, or mortality was observed in either group within 30 days after surgery. The 3-year disease-free survival (DFS) were 75.2% and 88.3% (P=0.070), and overall survival (OS) were 92.9% and 93.7% (P=0.810) in the RP and the LP groups, respectively and the risk of low anterior resection syndrome (LARS) was lower in the RP group (OR =0.304, 95% CI: 0.124–0.745, P=0.009).

Conclusions

Compared to LP, RP is worth recommending as it has long-term survival, faster postoperative recovery, and a lower risk of LARS in patients with rectal cancer below the peritoneal reflection.

Short-Term and Long-Term Outcomes in Mid and Low Rectal Cancer With Robotic Surgery

Objective

To investigate the risk factors for postoperative complications and anastomotic leakage after robotic surgery for mid and low rectal cancer and their influence on long-term outcomes.

Methods

A total of 641 patients who underwent radical mid and low rectal cancer robotic surgery at Zhongshan Hospital Fudan University from January 2014 to December 2018 were enrolled in this study. The clinicopathological factors of the patients were collected. The risk factors for short-term outcomes of complications and anastomotic leakage were analyzed, and their influences on recurrence and overall survival were studied.

Results

Of the 641 patients, 516 (80.5%) underwent AR or LAR procedures, while 125 (19.5%) underwent the NOSES procedure. Only fifteen (2.3%) patients had stoma diversion. One hundred and seventeen patients (17.6%) experienced surgical complications. Anastomotic leakage occurred in 44 patients (6.9%). Eleven patients (1.7%) underwent reoperation within 90 days after surgery. Preoperative radiotherapy did not significantly increase anastomotic leakage in our study (7.4% vs. 6.8%, P = 0.869). The mean postoperative hospital stay was much longer with complication (10.4 vs. 7.1 days, P<0.05) and leakage (12.9 vs. 7.4 days, P < 0.05). Multivariate analysis showed that male sex (OR = 1.855, 95% CI: 1.175–2.923, P < 0.05), tumor distance 5 cm from the anus (OR = 1.563, 95% CI: 1.016–2.404, P < 0.05), and operation time length (OR = 1.563, 95% CI: 1.009–2.421, P < 0.05) were independent risk factors for complications in mid and low rectal cancer patients. The same results for anastomotic leakage: male sex (OR = 2.247, 95% CI: 1.126–4.902, P < 0.05), tumor distance 5 cm from the anus (OR = 2.242, 95% CI: 1.197–4.202, P < 0.05), and operation time length (OR = 2.114, 95% CI: 1.127–3.968, P < 0.05). The 3-year DFS and OS were 82.4% and 92.6% with complication, 88.4% and 94.0% without complication, 88.6% and 93.1% with leakage, and 87.0% and 93.8% without leakage, respectively. The complication and anastomotic leakage showed no significant influences on long-term outcomes.

Conclusion

Being male, having a lower tumor location, and having a prolonged operation time were independent risk factors for complications and anastomotic leakage in mid and low rectal cancer. Complications and anastomotic leakage might have no long-term impact on oncological outcomes for mid and low rectal cancer with robotic surgery.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide. Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy (total mesorectal excision). This has traditionally been performed transabdominally through an open incision. Over the last thirty years, minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach. There are currently three resective modalities that complement the traditional open operation: (1) Laparoscopic surgery; (2) Robotic surgery; and (3) Transanal total mesorectal excision. In addition, there are several platforms to carry out transluminal local excisions (without lymphadenectomy). Evidence on the various modalities is of mixed to moderate quality. It is unreasonable to expect a randomized comparison of all options in a single trial. This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks, recovery and complications, oncological and functional outcomes.

Over-The-Scope Clip system as a first-line therapy for high-risk bleeding peptic ulcers: a retrospective study

BACKGROUND

Effective hemostasis is essential to prevent rebleeding. We evaluated the efficacy and feasibility of the Over-The-Scope Clip (OTSC) system compared to combined therapy (through-the-scope clips with epinephrine injection) as a first-line endoscopic treatment for high-risk bleeding peptic ulcers.

METHODS

We retrospectively analyzed data of 95 patients from a single, tertiary center and underwent either OTSC (n = 46) or combined therapy (n = 49). The primary outcome of the present study was the efficacy of the OTSC system as a first-line therapy in patients with high-risk bleeding peptic ulcers compared to combined therapy with TTS clips and epinephrine injection. The secondary outcomes included the rebleeding rate, perforation rate, mean procedure time, reintervention rate, mean procedure cost and days of hospitalization in the two study groups within 30 days of the index procedure.

RESULTS

All patients achieved hemostasis within the procedure; two patients in the OTSC group and four patients in the combined therapy group developed rebleeding (p = 0.444). No patients experienced gastrointestinal perforation. OTSC had a shorter median procedure time than combined therapy (11 min versus 20 min; p < 0.001). The procedure cost was superior for OTSC compared to combined therapy ($102,000 versus $101,000; p < 0.001). We found no significant difference in the rebleeding prevention rate (95.6% versus 91.8%, p = 0.678), hospitalization days (3 days versus 4 days; p = 0.215), and hospitalization costs ($108,000 versus $240,000, p = 0.215) of the OTSC group compared to the combined therapy group.

CONCLUSION

OTSC treatment is an effective and feasible first-line therapy for high-risk bleeding peptic ulcers. OTSC confers comparable costs and patient outcomes as combined treatments, with a shorter procedure time.