Long-term outcomes of robot-assisted laparoscopic surgery versus conventional laparoscopic surgery for rectal cancer: single-center, retrospective, propensity score analyses

Although the short-term outcomes of robot-assisted laparoscopic surgery (RALS) for rectal cancer are well known, the long-term oncologic outcomes of RALS compared with those of conventional laparoscopic surgery (CLS) are not clear. This study aimed to compare the long-term outcomes of RALS and CLS for rectal cancer using propensity score matching. This retrospective study included 185 patients with stage I-III rectal cancer who underwent radical surgery at our institute between 2010 and 2019. Propensity score analyses were performed with 3-year overall survival (OS) and relapse-free survival (RFS) as the primary endpoints. After case matching, the 3-year OS and 3-year RFS rates were 86.5% and 77.9% in the CLS group and 98.4% and 88.5% in the RALS group, respectively. Although there were no significant differences in OS (p = 0.195) or RFS (p = 0.518) between the groups, the RALS group had slightly better OS and RFS rates. 3-year cumulative (Cum) local recurrence (LR) and 3-year Cum distant metastasis (DM) were 9.7% and 8.7% in the CLS group and 4.5% and 10.8% in the RALS group, respectively. There were no significant differences in Cum-LR (p = 0.225) or Cum-DM (p = 0.318) between the groups. RALS is a reasonable surgical treatment option for patients with rectal cancer, with long-term outcomes similar to those of CLS in such patients.

[Significance of Colorectal Cancer Resection for the Elderly]

INTRODUCTION

Elderly patients requiring surgical treatment is increasing in Japan, and while surgical treatment is expected to be effective even in the very elderly, there is a lack of evidence for the safety and efficacy of surgical resection due to problems with perioperative management and operative tolerance. We therefore retrospectively examined the short-term and long-term outcomes of colorectal cancer surgery for the very elderly at our hospital.

SUBJECTS

The study included 14 cases of colorectal cancer in the very elderly who underwent radical resection at our hospital between January 2010 and March 2020.

RESULTS

The mean age was 92 years, PS; 1/2=8/6, ASA-PS; 2/3/4=8/4/2, primary site was C/A/T/S/R= 2/5/2/2/3, pStage; 1/2/3=1/9/4, and only 1 case of decompression with ileus tube due to obstructive symptoms was treated before surgery. All patients underwent radical surgery. Median blood loss was 61 mL, median operation time was 190.5 min, and median postoperative hospital stay was 16 days. 5 patients had CD≥2 complications. All patients did not receive adjuvant chemotherapy, and recurrence in was observed 3 patients.

CONCLUSION

Surgical treatment of very elderly patients seems to be acceptable under appropriate patient selection.

[A Case of Pathologically Complete Response after Preoperative Chemotherapy in a Locally Advanced Rectal Cancer]

The case is a 78-year-old male. The chief complaint was melena and weight loss. After careful examination, the patient was diagnosed with advanced rectal cancer, and 3 courses of capecitabine plus oxaliplatin therapy were performed as preoperative chemotherapy. He underwent robot-assisted laparoscopic rectal resection, D3 lymphadenectomy, lateral lymphadenectomy, and temporary colostomy, and was discharged on hospital day 15. Postoperative pathological diagnosis showed only ulcerative lesions in the rectum, and malignant cells could not be confirmed. After postoperative adjuvant chemotherapy, the patient is alive without recurrence on an outpatient basis. There are many reports that it is slightly lower than radiotherapy. Therefore, it is important to select a more appropriate preoperative treatment, and the concentration of future cases is recognized.

Continuous suture closure using a LapraTy® suture clips is an effective method for reconstruction of cystic duct stump after laparoscopic subtotal cholecystectomy

Objective

Recently, number of laparoscopic subtotal cholecystectomy (LSC) has been increasing.

Summary background data

LSC is suitable as a treatment as it can avoid intraoperative bile duct injury and bleeding for difficult laparoscopic cholecystectomy. On the other hand, improper handling of remnant of GB can lead to postoperative bile leakage.

Methods

Here, we report our positive experience utilizing new technique of continuous suture closure and omental covering using Lapra Ty® suture clips on the remnant of GB.

Results

From January 2016 to July 2021, we experienced 30 cases of LSC for LC patients who had difficulty securing critical view of safety (CVS). In six of the 30 cases, we repaired remnant of GB using continuous suture closure and omental covering with Lapra Ty® suture clips. The median operating time was 136 min (range 112-199 ml), and amount of bleeding was 1 ml (range 1-100). There were no cases of postoperative bile leakage (postope. BL), remnant cystic duct stone, and abscess formation in abdomen.

Conclusion

we recommend this new suturing technique for closure of remnant of GB as it was very effective in preventing postope. BL after LSC.

Laparoscopic bailout surgery effective procedure for patients with difficult laparoscopic cholecystectomy

TG18 recommends bailout surgery (BOS) for difficult laparoscopic cholecystectomy. However, there is not a clear criterion on the decision process on whether to continue laparoscopic BOS or open BOS, and optimal procedure for treatment for the remnant cystic bile duct also awaits discussion. We comparted with open BOS and laparoscopic BOS, and compared with suture close and clipping or ligating of remnant cystic duct. We have accrued 57 patients underwent BOS during study period. Seventeen cases underwent laparoscopic BOS, and 38 cases underwent open BOS. There were 22 patients were accrued in suture closing and 35 patients were accrued in clipping or ligating. Open BOS experienced high levels of CRP, WBC, NLR, and CAR, and was associated with significantly longer hospitalization, operating time, and amount of bleeding. Suture close was higher in patients with preoperative endoscopic lithotripsy (EL). BOS can be sufficiently performed under laparoscopy. Patients underwent preoperative EL tended to be higher necessity to suture close of cystic duct.

[A Case of Isolated Metachronous Splenic Metastasis after Rectal Cancer Surgery]

A 50-year-old woman underwent laparotomic anterior resection(D3)and total hysterectomy with bilateral adnexectomy (type 2, 3.0×4.5 cm, pT4a[SE], N1a, M1c2[ovary and peritoneum], H0, P1, PUL0, stage Ⅳc, tub2>por, Cur B)for ovarian metastasis from rectal cancer in June 20XX. During the outpatient visit in May, 2 years and 11 months after surgery, a splenic tumor was found on abdominal contrast-enhanced CT, without distant metastasis in other organs. In July 20XX, laparoscopic splenectomy was performed for suspected splenic metastasis of rectal cancer. The specimen of the resected tumor showed pathological findings consistent with metastasis of rectal cancer. Currently, the patient is being followed up without any sign of recurrence. Herein, we report a rare case of isolated metachronous splenic metastasis, whose associated prognosis might be improved by surgical treatment, in reference to the literature.

[A Case of Diffuse Large B-Cell Lymphoma of the Testis, Which Also Developed in the Rectum after Resection of a Large B-Cell Lymphoma]

A man aged 65 years had undergone high orchidectomy of the right testis for diffuse large B-cell lymphoma(DLBCL) occurring primarily in the testis 11 months before. Although he was referred to another hospital for postoperative chemotherapy, he refused the treatment by self-judgement. For 1 month, he had been experiencing melena and anal pain, so he visited our department in June. Rectal palpation revealed a sub-circumference tumor palpable from the anal margin, in which a part protruded outside the anus. CT revealed a sub-circumference hypertrophic wall from the rectal Ra to the anus and intramural enlarged lymph nodes, without metastases to the other organs. Systemic gallium scintigraphy detected a strong concentration in the rectum. The endoscopic examination of the inferior region revealed a circumference type 2 tumor at Rb, and biopsy revealed DLBCL. Clinically, this case was considered a testoid DLBCL with rectal metastasis. Therefore, we performed laparoscopic rectal amputation in July, XX. sT3N1b, cM0. The postoperative course was uneventful. After the patient was discharged from our department, he received chemotherapy at another hospital. At present, 4 years 0 month postoperatively, the patient condition is favorable without recurrence. When perforation occurs in gastrointestinal DLBCL, the start of chemotherapy is delayed and the primary lesion worsen. Therefore, we performed surgical therapy first. Such cases must be evaluated for metastases or new lesions carefully.

[A Case of Mesenteric Undifferentiated Pleomorphic Sarcoma]

Undifferentiated pleomorphic sarcoma develops in adult soft tissues and has a poor prognosis. It often recurs in the limbs and trunk, but is rare in the mesentery. Complete resection of the tumor is the first-line treatment, and there are previously reported cases of the usefulness of chemotherapy and radiation therapy; however, several factors remain to be clarified. We report a case of undifferentiated pleomorphic sarcoma originating in the ascending mesocolon.

[Resection of Synchronous Liver Metastasis from Ascending Colon Cancer with Aplastic Anemia-A Case Report]

The aplastic anemia(AA)syndrome is characterized by pancytopenia and bone marrow hypoplasia. Although anemia, bleeding tendency, and susceptibility to infection are issues of concern during surgery, few reports have been published on the perioperative management, and management methods have not been established. A 77-year-old woman visited our hospital with chief complaints of melena and fatigability. Marked pancytopenia was observed at the first visit. After a detailed examination, she was diagnosed with ascending colon cancer accompanied by AA and solitary liver metastasis. As AA responded poorly to treatment, without improvement in pancytopenia, we decided to perform colectomy. The perioperative management, including blood transfusion and administration of a G-CSF preparation, was performed in collaboration with a hematologist, followed by right hemicolectomy and hepatic lateral segmentectomy. She was transferred to the department of hematology on hospital day 8 without complications. In conclusion, a highly invasive surgery, as in the present case, can be performed safely with an appropriate perioperative management even in cases complicated by AA.

[Efficacy of Palliative Radiotherapy in Hemorrhage Control in Patients with Unresectable Gastric Cancer]

We report the case of an 80-year-old man with unresectable, advanced gastric cancer and pulmonary cancer because of multiple liver metastases. The serum hemoglobin level declined to 5.3 g/dL during fourth-line chemotherapy. Radiation therapy of 30 Gy was administered in 10 fractions. After radiation treatment was completed, the serum hemoglobin level increased to 8.5g/dL. No new adverse event was observed. Subsequently, the progression of anemia stopped, and oral intake became possible. Thus, palliative radiation therapy is useful for hemorrhage control in unresectable, advanced gastric cancer patients with a poor general condition and difficult surgical treatment.

[Usefulness of the CONUT Score for Predicting the Risk of Surgical Site Infections]

BACKGROUND

Surgical site infections(SSIs)occur at a high frequency in patients after rectal cancer surgery and are readily aggravated. Therefore, prophylactic measures for infections based on the evaluation of the patient's perioperative risk are very important. We investigated risk factors of SSI onset in patients after rectal cancer surgery.

METHODS

In total, 66 patients with rectal cancer who underwent resection in our department between January 2015 and December 2016 were retrospectively examined.

RESULTS

The patients in our study included 38 men and 28 women with a median age of 66 years and a median BMI of 21.3 kg/m2. Fifteen patients underwent laparotomy and 51 underwent laparoscopy. Among 66 patients, 24 had an artificial anus. The median operative time was 367 minutes, median bleeding loss was 100 mL, and median Controlling Nutritional Status(CONUT)score was 2. Twenty patients developed SSI after rectal cancer surgery. Univariate analysis demonstrated that operative time(p=0.004, OR: 1.005, 95%CI: 1.002-1.009)and CONUT score(p=0.035, OR: 1.386, 95%CI: 1.023-1.878) were significant risk factors for SSI development. Multivariate analysis also demonstrated that operative time(p=0.003, OR: 1.006, 95%CI: 1.002-1.010)and CONUT score(p=0.025, OR: 1.508, 95%CI: 1.053-2.161)were significant risk factors for SSI development.

CONCLUSIONS

The CONUT score was identified as a significant preoperative risk factor for SSI after rectal cancer surgery in both the univariate and multivariate analyses. Therefore, the preoperative evaluation using the CONUT score may be useful for predicting the risk of SSI in patients undergoing rectal cancer surgery.

Nasal lesions induced by intranasal administration of benzaikonium chloride in rats

We investigated the lesions of nasal cavity mucous membrane caused by administration of 0.01, 0.05 and 0.10 w/v% Benzalkonium chloride (BZC) solutions in the nasal cavity of rats. No BZC-induced symptoms or nasal lesions were seen in the 0.01 w/v% BZC-treated group. On the other hand, BZC-induced symptoms such as nasal sound and rubbing the nose with forelegs were observed in the 0.05 and 0.10 w/v% BZC-treated groups. Additionally, BZC-induced lesions, including epithelial desquamation, inflammation and edema, occurred in the anterior nasal cavity in the 0.05 and 0.10 w/v% BZC-treated groups, but these lesions were confined to the dorsal meatus and the adjacent nasal septum. These results indicate that 0.01 w/v% BZC solution has no effect on the nasal cavity mucous membrane. However, 0.05 and 0.10 w/v% BZC solutions induce lesions in the nasal cavity mucous membrane due to their irritating effect.

Changes in nasal cavity volume and target area of exposure to nasal drops with age in rats

The changes in the nasal cavity volume of rats with age and the area exposed to nasal drops administered into the nasal cavity were investigated. Results indicated that the nasal cavity volume lineally increased as rats grew older. In 7-week-old rats, the exposed area in the case of an administration volume of 25 microliters, based on practice, was naso-, maxillo-, and ethmoid turbinate and this volume was enough to expose the whole area of the nasal cavity including the ethmoid turbinate. On the other hand, in 27-week-old rats, administration volumes of 10 and 25 microliters were not enough to expose the ethmoid turbinate. This indicated that the exposed area tended to become narrower in 27-week-old rats than in 7-week-old rats, but the exposed area in the case of an administration volume of 50 microliters was naso-, maxillo-, and ethmoid turbinate in 27-week-old rats. In this case, the volume was enough to spread to the ethmoid turbinate. Differences in the exposed area might be caused by differences in the volume of the nasal cavity. It was also indicated that the main exposed area was the inferior meatus in the 30 min immediately after administration. At all administration volumes, however, notice should be taken of the outflow of nasal drops into the oral cavity through the nasopalatine.