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Tan WJ, Chew MH, Dharmawan AR, Singh M, Acharyya S, Loi CTT, Tang CL. Critical appraisal of laparoscopic vs open rectal cancer surgery. World J Gastrointest Surg 2016; 8:452-460. [PMID: 27358678 PMCID: PMC4919713 DOI: 10.4240/wjgs.v8.i6.452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/05/2016] [Accepted: 03/25/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Comparison between transverse mini-incision and longitudinal mini-incision for the resection of locally advanced colonic cancer. Int Surg 2015; 99:216-22. [PMID: 24833142 DOI: 10.9738/intsurg-d-13-00268.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
We performed a retrospective review of non-overweight (body mass index ≤ 25 kg/m(2)) patients scheduled to undergo a curative resection of locally advanced colon cancer via a transverse mini-incision (n = 62) or a longitudinal mini-incision (skin incision ≤7 cm, n = 62), with the latter group of patients randomly selected as historical controls matched with the former group according to tumor location. Extension of the transverse mini-incision wound was necessary in 3 patients (5%). Both groups were largely equivalent in terms of demographic, clinicopathological, and surgical factors and frequency of postoperative complications. Postoperative analgesic was significantly less (P = 0.04) and postoperative length of the hospital stay was significantly shorter (P < 0.01) in the transverse mini-incision group. Concerning a mini-incision approach for locally advanced colonic cancer, a transverse incision seems to be advantageous with regard to minimal invasiveness and early recovery compared with a longitudinal incision.
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Wang XD, Huang MJ, Yang CH, Li K, Li L. Minilaparotomy to rectal cancer has higher overall survival rate and earlier short-term recovery. World J Gastroenterol 2012; 18:5289-94. [PMID: 23066325 PMCID: PMC3468863 DOI: 10.3748/wjg.v18.i37.5289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 05/10/2012] [Accepted: 05/13/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To report our experience using mini-laparotomy for the resection of rectal cancer using the total mesorectal excision (TME) technique.
METHODS: Consecutive patients with rectal cancer who underwent anal-colorectal surgery at the authors’ hospital between March 2001 and June 2009 were included. In total, 1415 patients were included in the study. The cases were divided into two surgical procedure groups (traditional open laparotomy or mini-laparotomy). The mini-laparotomy group was defined as having an incision length ≤ 12 cm. Every patient underwent the TME technique with a standard operation performed by the same clinical team. The multimodal preoperative evaluation system and postoperative fast track were used. To assess the short-term outcomes, data on the postoperative complications and recovery functions of these cases were collected and analysed. The study included a plan for patient follow-up, to obtain the long-term outcomes related to 5-year survival and local recurrence.
RESULTS: The mini-laparotomy group had 410 patients, and 1015 cases underwent traditional laparotomy. There were no differences in baseline characteristics between the two surgical procedure groups. The overall 5-year survival rate was not different between the mini-laparotomy and traditional laparotomy groups (80.6% vs 79.4%, P = 0.333), nor was the 5-year local recurrence (1.4% vs 1.5%, P = 0.544). However, 1-year mortality was decreased in the mini-laparotomy group compared with the traditional laparotomy group (0% vs 4.2%, P < 0.0001). Overall 1-year survival rates were 100% for Stage I, 98.4% for Stage II, 97.1% for Stage III, and 86.6% for Stage IV. Local recurrence did not differ between the surgical groups at 1 or 5 years. Local recurrence at 1 year was 0.5% (2 cases) for mini-laparotomy and 0.5% (5 cases) for traditional laparotomy (P = 0.670). Local recurrence at 5 years was 1.5% (6 cases) for mini-laparotomy and 1.4% (14 cases) for traditional laparotomy (P = 0.544). Days to first ambulation (3.2 ± 0.8 d vs 3.9 ± 2.3 d, P = 0.000) and passing of gas (3.5 ± 1.1 d vs 4.3 ± 1.8 d, P = 0.000), length of hospital stay (6.4 ± 1.5 d vs 9.7 ± 2.2 d, P = 0.000), anastomotic leakage (0.5% vs 4.8%, P = 0.000), and intestinal obstruction (2.2% vs 7.3%, P = 0.000) were decreased in the mini-laparotomy group compared with the traditional laparotomy group. The results for other postoperative recovery function indicators, such as days to oral feeding and defecation, were similar, as were the results for immediate postoperative complications, including the physiologic and operative severity score for the enumeration of mortality and morbidity score.
CONCLUSION: Mini-laparotomy, as conducted in a single-centre series with experienced TME surgeons, is a safe and effective new approach for minimally invasive rectal cancer surgery. Further evaluation is required to evaluate the use of this approach in a larger patient sample and by other surgical teams.
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Ho KS, Quah HM, Lim JF, Tang CL, Eu KW. Endoscopic stenting and elective surgery versus emergency surgery for left-sided malignant colonic obstruction: a prospective randomized trial. Int J Colorectal Dis 2012; 27:355-62. [PMID: 22033810 DOI: 10.1007/s00384-011-1331-4] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2011] [Indexed: 02/08/2023]
Abstract
PURPOSE This study aims to evaluate the role of colonic stenting as a bridge to surgery in acutely obstructed left-sided colon cancer. METHODS Patients with acute left-sided malignant colonic obstruction with no evidence of peritonitis were recruited. After informed consent, patients were randomized to colonic stenting followed by elective surgery or immediate emergency surgery. Patients who had successful colonic stenting underwent elective surgery 1 to 2 weeks later, while the other group had emergency surgery. Patients in whom stenting was unsuccessful also underwent emergency surgery. RESULTS Twenty patients were randomized to stenting and 19 to emergency surgery. Fourteen patients (70%) had successful stenting and underwent elective surgery at a median of 10 days later; the rest underwent emergency surgery. Technical stent failure occurred in five patients (25%). One patient failed to decompress after successful stent deployment. All patients underwent definitive colonic resection with primary anastomosis. Two of 20 patients in the stenting group required defunctioning stomas compared to 6 of 19 in emergency surgery group, p = 0.127. Overall complication rate was 35% versus 58% (p = 0.152) and mortality was 0% versus 16% (p = 0.106) in the stenting group and emergency surgery group, respectively. Postoperatively, the stenting group was discharged from hospital earlier (median of 6 versus 8 days, p = 0.028) than the emergency surgery group. CONCLUSION Colonic stenting followed by interval elective surgery may be safer, with a trend towards lower morbidity and mortality when compared with the current practice of emergency surgery for left-sided malignant colonic obstruction.
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Affiliation(s)
- Kok-Sun Ho
- Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Republic of Singapore.
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Oncologic outcome of stages II/III colon cancer treated via minilaparotomy. Int Surg 2011; 96:127-34. [PMID: 22026303 DOI: 10.9738/1384.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We analyzed clinicopathologic, surgical, and survival data on consecutive series of patients with stages II/III colon cancer for whom curative resection via minilaparotomy (skin incision, < or = 7 cm) was attempted between September 2002 and March 2009 to clarify the oncologic safety of this type of surgery. There were 64 men and 55 women; the median age was 70 years (range, 25-91 years). The median body mass index was 21.7 kg/ m2 (range, 15.1-28.9 kg/m2). The minilaparotomy approach was successful in 115 cases (96.6%). The cumulative 5-year disease-free and overall survival rates were 89.7% and 82.4%, respectively, in patients with stage II disease (n = 62) and were 68.4% and 82.4%, respectively, in patients with stage III disease (n = 57), all of which were compatible with those of the historical control patients who underwent conventional open surgery. Minilaparotomy approach for stages II/III colon cancer seems to be oncologically equivalent to conventional open surgery.
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Abstract
AIM Standard laparoscopic splenic flexure mobilization is often hampered by redundant small bowel and usually necessitates additional ports. The retraction required runs the risk of inadvertent injury to the surrounding structures including the spleen. METHOD We present a new technique that permits a safe, rapid and complete mobilization of the splenic flexure even for the more difficult patients. RESULTS We have used it in 15 consecutive patients without mortality, re-operation or conversion to open surgery. CONCLUSION The right lateral position for splenic flexure mobilization gives better exposure of the left upper quadrant allowing complete dissection of the splenic flexure from the tail of the pancreas facilitating mobilization even in more difficult cases.
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Affiliation(s)
- R J Frame
- Department of Colorectal Surgery, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK
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Leroy J, Costantino F, Cahill RA, D'Agostino J, Morales A, Mutter D, Marescaux J. Laparoscopic resection with transanal specimen extraction for sigmoid diverticulitis. Br J Surg 2011; 98:1327-34. [PMID: 21560119 DOI: 10.1002/bjs.7517] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2011] [Indexed: 12/23/2022]
Abstract
BACKGROUND This prospective study evaluated the technical aspects and microbiological consequences of laparoscopic resection with transanal specimen extraction and per ano transcolonic stapler anvil insertion in patients requiring elective operation for previous diverticulitis. METHODS Laparoscopic sigmoid colectomy was performed with three ports, and specimen extraction carried out transanally through a complete opening of the rectal stump. A triple-stapled anastomosis restored colonic continuity. Systematic intraoperative bacteriological sampling was performed. Intraoperative data as well as microbiological and postoperative outcomes were evaluated prospectively. RESULTS Sixteen consecutive patients were studied over a 6-month period. All procedures were technically satisfactory, with a mean(s.d.) operating time of 120·9(41·9) min. No conversion or additional access was required. Four of the 16 patients developed complications, but none required intervention. Although polybacterial growth was present in all peritoneal culture samples, no infection-related complications were observed. Two patients had an extended course of perioperative antibiotic cover owing to overt peritoneal cavity contamination during surgery, and in two further patients antibiotics were instituted empirically following the development of postoperative fever alone. CONCLUSION Transanal specimen extraction in addition to per ano transcolonic stapler anvil insertion allows laparoscopic sigmoid resection to be performed with just three ports. Although intraperitoneal bacterial contamination occurs, this does not appear to translate into infectious morbidity.
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Affiliation(s)
- J Leroy
- Institute of Research Against Digestive Cancer-European Institute of TeleSurgery, 1 Place de l'Hôpital, 67091 Strasbourg Cedex, France.
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Laparoscopic versus open right hemicolectomy: a comparison of short-term outcomes. Int J Colorectal Dis 2009; 24:1333-9. [PMID: 19488767 DOI: 10.1007/s00384-009-0743-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND The laparoscopic approach is increasingly becoming the gold standard for colorectal resections. While laparoscopic surgery of the left colon and rectum has been evaluated in many studies, laparoscopic resection of the right colon has not been as widely examined. The aim of this study was to examine the short-term outcomes after laparoscopic right hemicolectomies and to determine if they were superior when compared with those after open resection. PATIENTS AND METHODS Consecutive cases of laparoscopic right hemicolectomies performed between May 2005 and December 2007, in the Department of Colorectal Surgery, Singapore General Hospital, were compared with a matched series of patients who underwent open surgery. RESULTS From a total of 37 laparoscopic cases, 36 patients successfully underwent laparoscopic right hemicolectomies. There was one conversion, giving a conversion rate of 2.7%. These 37 patients were compared with 40 patients who underwent open right hemicolectomies. The laparoscopic arm was characterised by shorter length of incisions (5.7 vs. 11.2 cm, p < 0.001) but longer operating times (110.8 vs. 71.6 min, p < 0.001). Mean number of lymph nodes harvested and length of proximal and distal margins were similar in both groups. There were also no significant differences between the groups in terms of narcotic use, recovery of bowel function, length of stay, post-operative morbidity and 30-day mortality. CONCLUSION Laparoscopic right hemicolectomies are as feasible and safe as the open technique. They confer improved cosmesis with smaller incisions but at the expense of longer operating time.
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Ooi BS, Quah HM, Fu CWP, Eu KW. Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer. Tech Coloproctol 2009; 13:61-4. [PMID: 19288243 DOI: 10.1007/s10151-009-0460-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 12/05/2008] [Indexed: 12/15/2022]
Abstract
Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. We describe a technique for laparoscopic resection of an early-stage upper rectal cancer in a 51-year-old man followed by transanal specimen delivery, hence avoiding the need for making any additional abdominal incisions for retrieval of the specimen. Pneumoperitoneum was created, followed by medial-tolateral mobilization of the sigmoid colon, and take down of the splenic flexure and division of the inferior mesenteric vessels laparoscopically. The upper rectum distal to the tumour and proximal colon was transected with a laparoscopic stapler. The specimen was retrieved transanally via an opening in the rectal stump. The proximal colon was then delivered transanally and the anvil of the circular stapler inserted before returning it to the pelvic cavity. The rectal stump was transected again just below the opening to close off the stump, and the colorectal anastomosis was then completed intracorporeally. The patient, a 51-year-old male (BMI 18.6 kg/m(2)) with a 2.5-cm, early-stage posterior rectal cancer 12 cm from the anal verge, underwent the above-described procedure. Postoperative recovery was uneventful. He resumed normal daily activities 1 week after surgery. Histology confirmed a T1N0 upper rectal cancer. In the effort to minimize surgical trauma and postoperative pain, natural orifice specimen extraction techniques have been attempted. This procedure may be applicable to benign tumours and early colorectal cancer, and serves as an intermediate step between laparoscopic and natural orifice surgery.
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Affiliation(s)
- B S Ooi
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Republic of Singapore.
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Seow-Choen F. Ultra-low anterior resection for low rectal cancer: five key tips to make it easy. Tech Coloproctol 2009; 13:89-93, discussion 93-4. [PMID: 19288241 DOI: 10.1007/s10151-009-0462-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Accepted: 10/20/2008] [Indexed: 02/07/2023]
Abstract
The primary treatment for rectal cancer is still surgery. Surgery however, may be either preceded or followed by chemotherapy and radiotherapy as and when needed. Good surgery on its own when applied appropriately is associated with a very low rate of local recurrence. Bad surgery however, is associated with a high risk of local and systemic recurrence. The well-performed ultra-low anterior resection with total mesorectal clearance has been shown to be the most important step in the treatment of a low rectal cancer. The author details five key tips to make the performance of an ultra-low anterior resection easy. These five key tips are: tip 1 Decide on the best approach for your particular patient before surgery; tip 2 The inferior mesenteric artery is crucial in obtaining the right dissection plane; tip 3 The sigmoid colon should be used for construction of the J-pouch whenever possible; tip 4 Use of a good light source is the key to obtaining a good idea of where to operate and to keeping to the right planes; tip 5 The last key to making surgery easier is to have a good head and good hands. Surgeons must know precisely the reasons why they do what they do in the way they do. Surgery which is difficult may be expected to carry with it more risks and therefore poorer results. Surgery which goes smoothly and is easy is usually rewarded with good results. Surgeons should try to make their surgery easier and the tips offered here are steps that will do this.
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Affiliation(s)
- F Seow-Choen
- Seow-Choen Colorectal Centre Pte Ltd, 3 Mt Elizabeth Medical Centre 09-10, Singapore.
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Katory M, Tang CL, Koh WL, Fook-Chong SMC, Loi TT, Ooi BS, Ho KS, Eu KW. A 6-year review of surgical morbidity and oncological outcome after high anterior resection for colorectal malignancy with and without splenic flexure mobilization. Colorectal Dis 2008; 10:165-9. [PMID: 17506796 DOI: 10.1111/j.1463-1318.2007.01265.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE High anterior resection (HAR) for colorectal cancer is traditionally performed with routine mobilization of the splenic flexure. This is a retrospective review of mortality and morbidity following HAR in which the splenic flexure has been preserved. METHOD From a prospective database, all patients who had undergone elective HAR for colorectal cancer between 1999 and 2005 were identified. Morbidity, mortality, pathology and survival data for patients having HAR with and without splenic flexure mobilization were analysed. RESULTS A total of 707 patients were identified. Five hundred and thirty-one had HAR with preservation of the splenic flexure. In these patients outcome was: anastomotic leak (0.4%), wound infection (3.6%), anastomotic stricture (0.4%) and 30-day mortality (0.9%). No statistical significant difference was found for postoperative morbidity (P = 0.1926), 30-day mortality (P =0.3285), lymph node harvest (P = 0.2127) or survival (P = 0.1457) compared with patients in whom the splenic flexure was mobilized. Longitudinal resection margins were greater following HAR with splenic flexure mobilization (P < 0.0001). CONCLUSION No morbidity, oncological or survival disadvantage in performing splenic flexure preserving HAR was found.
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Affiliation(s)
- M Katory
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Zargar-Shoshtari K, Hill AG. OPTIMIZATION OF PERIOPERATIVE CARE FOR COLONIC SURGERY: A REVIEW OF THE EVIDENCE. ANZ J Surg 2008; 78:13-23. [DOI: 10.1111/j.1445-2197.2007.04350.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Finan PJ, Campbell S, Verma R, MacFie J, Gatt M, Parker MC, Bhardwaj R, Hall NR. The management of malignant large bowel obstruction: ACPGBI position statement. Colorectal Dis 2007; 9 Suppl 4:1-17. [PMID: 17880381 DOI: 10.1111/j.1463-1318.2007.01371.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- P J Finan
- Department of Colorectal Surgery, General Infirmary at Leeds, Leeds, UK.
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Gatt M, Anderson ADG, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 2005; 92:1354-62. [PMID: 16237744 DOI: 10.1002/bjs.5187] [Citation(s) in RCA: 226] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing a wide range of colorectal procedures. METHODS Thirty-nine patients undergoing major elective colonic resection were recruited prospectively. Patients were randomized to receive a ten-point multimodal optimization package or conventional perioperative care. All patients were administered epidural analgesia and opiates were avoided. Outcome measures recorded related to length of hospital stay, physical and mental function, and gut function. RESULTS Optimization was associated with a significantly shorter median (interquartile range) hospital stay compared with conventional care (5 (4-9) versus 7.5 (6-10) days; P = 0.027). Duration of catheterization (P = 0.022) and duration of intravenous infusion (P = 0.007) were also less. Optimization was associated with a quicker recovery of gut function (P = 0.042). Grip strength was maintained in the postoperative period in the optimized group (P = 0.241) but not in the control group (P = 0.049). There were no differences in morbidity or mortality between the groups. CONCLUSION Optimization is safe and results in a significant reduction in postoperative stay along with other improved endpoints. This cannot be directly attributed to improvement in any single outcome measure or to the use of epidural analgesia. Improvements are more likely to be multifactorial and may relate to an earlier return of gut function.
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Affiliation(s)
- M Gatt
- Combined Gastroenterology Research Unit, Scarborough General Hospital, Scarborough, UK
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