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Sorrentino L, Bogani G, Sampietro GM. It is not the surgical approach, but the R0 margins to drive survival after rectal cancer surgery. Dig Liver Dis 2025; 57:906-907. [PMID: 39894728 DOI: 10.1016/j.dld.2025.01.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Revised: 01/12/2025] [Accepted: 01/13/2025] [Indexed: 02/04/2025]
Affiliation(s)
- Luca Sorrentino
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gianluca M Sampietro
- Division of General and HPB Surgery. Rho Memorial Hospital. ASST Rhodense, Rho, Milano, Italy.
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de'Angelis N, Schena CA, Azzolina D, Carra MC, Khan J, Gronnier C, Gaujoux S, Bianchi PP, Spinelli A, Rouanet P, Martínez-Pérez A, Pessaux P. Histopathological outcomes of transanal, robotic, open, and laparoscopic surgery for rectal cancer resection. A Bayesian network meta-analysis of randomized controlled trials. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:109481. [PMID: 39581810 DOI: 10.1016/j.ejso.2024.109481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 11/04/2024] [Accepted: 11/16/2024] [Indexed: 11/26/2024]
Abstract
BACKGROUND While total mesorectal excision is the gold standard for rectal cancer, the optimal surgical approach to achieve adequate oncological outcomes remains controversial. This network meta-analysis aims to compare the histopathological outcomes of robotic (R-RR), transanal (Ta-RR), laparoscopic (L-RR), and open (O-RR) resections for rectal cancer. MATERIALS AND METHODS MEDLINE, Embase, and the Cochrane Library were screened from inception to June 2024. Of the 4186 articles screened, 27 RCTs were selected. Pairwise comparisons and Bayesian network meta-analyses applying random effects models were performed. RESULTS The 27 RCTs included a total of 8696 patients. Bayesian pairwise meta-analysis revealed significantly lower odds of non-complete mesorectal excision with Ta-RR (Odds Ratio, OR, 0.60; 95%CI, 0.33, 0.92; P = .02; I2:11.7 %) and R-RR (OR, 0.68; 95%CI, 0.46, 0.94; P = .02; I2:41.7 %) compared with laparoscopy. Moreover, lower odds of positive CRMs were observed in the Ta-RR group than in the L-RR group (OR, 0.36; 95%CI, 0.13, 0.91; P = .02; I2:43.9 %). The R-RR was associated with more lymph nodes harvested compared with L-RR (Mean Difference, MD, 1.24; 95%CI, 0.10, 2.52; P = .03; I2:77.3 %). Conversely, Ta-RR was associated with a significantly lower number of lymph nodes harvested compared with all other approaches. SUCRA plots revealed that Ta-RR had the highest probability of being the best approach to achieve a complete mesorectal excision and negative CRM, followed by R-RR, which ranked the best in lymph nodes retrieved. CONCLUSION When comparing the effectiveness of the available surgical approaches for rectal cancer resection, Ta-RR and R-RR are associated with better histopathological outcomes than L-RR.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Robotic and Minimally Invasive Digestive Surgery, Department of Surgery, Ferrara University Hospital Arcispedale Sant'Anna, via Aldo Moro 8, 44124, Ferrara, Cona), Italy; Department of Translational Medicine and LTTA Centre, University of Ferrara, 44121, Ferrara, Italy.
| | - Carlo Alberto Schena
- Unit of Robotic and Minimally Invasive Digestive Surgery, Department of Surgery, Ferrara University Hospital Arcispedale Sant'Anna, via Aldo Moro 8, 44124, Ferrara, Cona), Italy.
| | - Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy.
| | - Maria Clotilde Carra
- Department of Translational Medicine and LTTA Centre, University of Ferrara, 44121, Ferrara, Italy; Université Paris Cité, INSERM-Sorbonne Paris Cité Epidemiology and Statistics Research Centre, Paris, France.
| | - Jim Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, University of Portsmouth, Portsmouth, United Kingdom.
| | - Caroline Gronnier
- Eso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Pessac, France.
| | - Sébastien Gaujoux
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France.
| | - Paolo Pietro Bianchi
- Department of Surgery, Asst Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, Milan, Italy.
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Philippe Rouanet
- Department of Surgery, Institut Régional du Cancer de Montpellier, Montpellier, France.
| | - Aleix Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain; Biosanitary Research Institute, Valencian International University (VIU), Valencia, Spain.
| | - Patrick Pessaux
- Visceral and Digestive Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France.
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Ma L, Yu H, Zhu Y, Li W, Xu K, Zhao A, Ding L, Gao H. Laparoscopy is non-inferior to open surgery for rectal cancer: A systematic review and meta-analysis. Cancer Med 2024; 13:e7363. [PMID: 38970275 PMCID: PMC11226727 DOI: 10.1002/cam4.7363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/19/2024] [Accepted: 05/27/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Laparoscopic surgery has been endorsed by clinical guidelines for colon cancer, but not for rectal cancer on account of unapproved oncologic equivalence with open surgery. AIMS We started this largest-to-date meta-analysis to comprehensively evaluate the safety and efficacy of laparoscopy in the treatment of rectal cancer compared with open surgery. MATERIALS & METHODS Both randomized and nonrandomized controlled trials comparing laparoscopic proctectomy and open surgery between January 1990 and March 2020 were searched in PubMed, Cochrane Library and Embase Databases (PROSPERO registration number CRD42020211718). The data of intraoperative, pathological, postoperative and survival outcomes were compared between two groups. RESULTS Twenty RCTs and 93 NRCTs including 216,615 patients fulfilled the inclusion criteria, with 48,888 patients received laparoscopic surgery and 167,727 patients underwent open surgery. Compared with open surgery, laparoscopic surgery group showed faster recovery, less complications and decreased mortality within 30 days. The positive rate of circumferential margin (RR = 0.79, 95% CI: 0.72 to 0.85, p < 0.0001) and distal margin (RR = 0.75, 95% CI: 0.66 to 0.85 p < 0.0001) was significantly reduced in the laparoscopic surgery group, but the completeness of total mesorectal excision showed no significant difference. The 3-year and 5-year local recurrence, disease-free survival and overall survival were all improved in the laparoscopic surgery group, while the distal recurrence did not differ significantly between the two approaches. CONCLUSION Laparoscopy is non-inferior to open surgery for rectal cancer with respect to oncological outcomes and long-term survival. Moreover, laparoscopic surgery provides short-term advantages, including faster recovery and less complications.
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Affiliation(s)
- Ling Ma
- Department of Gastrointestinal Tumor SurgeryBeijing Shijitan Hospital Affiliated to Capital Medical UniversityBeijingPeople's Republic of China
| | - Hai‐jiao Yu
- Department of Gastrointestinal Tumor SurgeryBeijing Shijitan Hospital Affiliated to Capital Medical UniversityBeijingPeople's Republic of China
| | - Yu‐bing Zhu
- Department of Gastrointestinal Tumor SurgeryBeijing Shijitan Hospital Affiliated to Capital Medical UniversityBeijingPeople's Republic of China
| | - Wen‐xia Li
- Department of Gastrointestinal Tumor SurgeryBeijing Shijitan Hospital Affiliated to Capital Medical UniversityBeijingPeople's Republic of China
| | - Kai‐yu Xu
- Department of Gastrointestinal Tumor SurgeryBeijing Shijitan Hospital Affiliated to Capital Medical UniversityBeijingPeople's Republic of China
| | - Ai‐min Zhao
- Department of Gastrointestinal Tumor SurgeryBeijing Shijitan Hospital Affiliated to Capital Medical UniversityBeijingPeople's Republic of China
| | - Lei Ding
- Department of Gastrointestinal Tumor SurgeryBeijing Shijitan Hospital Affiliated to Capital Medical UniversityBeijingPeople's Republic of China
| | - Hong Gao
- Department of Gastrointestinal Tumor SurgeryBeijing Shijitan Hospital Affiliated to Capital Medical UniversityBeijingPeople's Republic of China
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Walker RJB, Easson AM, Hosni A, Kim J, Weiss ES, Santiago AT, Chesney TR, Salit IE. Anal Cancers in Previously Screened Versus Unscreened Patients: Tumor Stage and Treatment Outcomes. Dis Colon Rectum 2024; 67:32-41. [PMID: 37787557 DOI: 10.1097/dcr.0000000000002922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND Targeted screening programs for patients at high risk for anal squamous-cell carcinoma have been proposed; however, the evidence in support of screening remains unclear. OBJECTIVE This study aimed to determine whether screening high-risk patients (predominantly those living with HIV) detected squamous-cell carcinoma at an earlier stage compared to the routine practice of not screening. DESIGN This is a cohort study. SETTINGS This study was conducted at a quaternary care center in Canada. PATIENTS Included patients were at least 18 years old with a pathologic diagnosis of invasive anal squamous-cell carcinoma between 2002 and 2022. INTERVENTIONS Patients diagnosed through a high-risk screening program were compared to those who did not undergo screening. MAIN OUTCOME MEASURES The primary outcome was clinical stage at presentation, categorized as T1N0M0 vs other. Secondary outcomes included treatments received, treatment failure, and overall survival. RESULTS A total of 612 patients with anal squamous-cell carcinoma were included, with 26 of those patients diagnosed through a screening program. Patients with screen-detected cancers had greater odds of presenting with T1N0M0 tumors compared to unscreened patients (18 [69.2%] vs 84 [14.3%]; adjusted OR 9.95; 95% CI, 3.95-25.08). A propensity score-matched sensitivity analysis found similar results (OR 11.13; 95% CI, 4.67-26.52). Screened patients had greater odds of treatment with wide local excision alone, as opposed to any combination of chemotherapy, radiation therapy, and surgery (3 [12.5%] vs 18 [3.2%]; OR 4.38; 95% CI, 1.20-16.04). There were no statistically significant differences in treatment failure or overall survival between groups. LIMITATIONS The small number of screened patients limits the power of the analysis. CONCLUSIONS Screening for anal squamous-cell carcinoma among high-risk populations detects cancers at an earlier stage. Patients with screen-detected cancers also had a greater likelihood of being candidates for wide local excision alone, which may have spared them the morbidity associated with chemoradiotherapy or abdominoperineal resection. See Video Abstract. CNCERES DE ANO EN PACIENTES PREVIAMENTE DETECTADOS POR CRIBADO VERSUS NO DETECTADOS ESTADIO DEL TUMOR Y RESULTADOS DEL TRATAMIENTO ANTECEDENTES:Se han propuesto programas de cribado dirigidos a pacientes con alto riesgo de carcinoma anal de células escamosas; sin embargo, la evidencia a favor de la detección sigue sin estar clara.OBJETIVO:Este estudio tuvo como objetivo determinar si el cribado de pacientes de alto riesgo (predominantemente aquellos que viven con el VIH) detectó el carcinoma de células escamosas en una etapa más temprana en comparación con la práctica habitual de no cribado.DISEÑO:Este es un estudio de cohortes.CONFIGURACIÓN:Este estudio se realizó en un centro de atención cuaternaria en Canadá.PACIENTES:Los pacientes incluidos tenían al menos 18 años con un diagnóstico patológico de carcinoma de células escamosas anal invasivo entre 2002 y 2022.INTERVENCIONES:Los pacientes diagnosticados mediante un programa de cribado de alto riesgo se compararon con aquellos que no se sometieron a cribado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el estadio clínico en la presentación, categorizado como T1N0M0 versus otro. Los resultados secundarios incluyeron los tratamientos recibidos, el fracaso del tratamiento y la supervivencia general.RESULTADOS:Se incluyeron un total de 612 pacientes con carcinoma anal de células escamosas, con 26 de esos pacientes diagnosticados a través de un programa de cribado. Los pacientes con cánceres detectados mediante cribado tenían mayores probabilidades de presentar tumores T1N0M0 en comparación con los pacientes no cribados (18 [69.2%] frente a 84 [14.3%]; razón de probabilidad ajustada 9.95; intervalo de confianza del 95 % 3.95 -25.08). Un análisis de sensibilidad emparejado por puntaje de propensión encontró resultados similares (odds ratio 11.13; intervalo de confianza del 95% 4.67 -26.52; p < 0.001). Los pacientes examinados tenían mayores probabilidades de recibir tratamiento con escisión local amplia sola, en comparación con cualquier combinación de quimioterapia, radiación y cirugía (3 [12.5%] frente a 18 [3.2%]; razón de probabilidad 4.38; intervalo de confianza del 95 % 1.20 -16.04). No hubo diferencias estadísticamente significativas en el fracaso del tratamiento o la supervivencia global entre los grupos.LIMITACIONES:El pequeño número de pacientes evaluados limita el poder del análisis.CONCLUSIONES:La detección del carcinoma anal de células escamosas entre las poblaciones de alto riesgo detecta los cánceres en una etapa más temprana. Los pacientes con cánceres detectados mediante cribado también tenían una mayor probabilidad de ser candidatos para una escisión local amplia sola, lo que puede haberles evitado la morbilidad asociada con la quimiorradioterapia o la resección abdominoperineal. (Traducción --Dr. Aurian Garcia Gonzalez ).
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Affiliation(s)
- Richard J B Walker
- Department of Surgery, University Health Network, Toronto, Ontario, Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra M Easson
- Department of Surgery, University Health Network, Toronto, Ontario, Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgical Oncology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ali Hosni
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - John Kim
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Edward S Weiss
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Anna T Santiago
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Tyler R Chesney
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Irving E Salit
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Seow W, Dudi-Venkata NN, Bedrikovetski S, Kroon HM, Sammour T. Outcomes of open vs laparoscopic vs robotic vs transanal total mesorectal excision (TME) for rectal cancer: a network meta-analysis. Tech Coloproctol 2023; 27:345-360. [PMID: 36508067 DOI: 10.1007/s10151-022-02739-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Total mesorectal excision (TME) for rectal cancer can be achieved using open (OpTME), laparoscopic (LapTME), robotic (RoTME), or transanal techniques (TaTME). However, the optimal approach for access remains controversial. The aim of this network meta-analysis was to assess operative and oncological outcomes of all four surgical techniques. METHODS Ovid MEDLINE, EMBASE, and PubMed databases were searched systematically from inception to September 2020, for randomised controlled trials (RCTs) comparing any two TME surgical techniques. A network meta-analysis using a Bayesian random-effects framework and mixed treatment comparison was performed. Primary outcomes were the rate of clear circumferential resection margin (CRM), defined as > 1 mm from the closest tumour to the cut edge of the tissue, and completeness of mesorectal excision. Secondary outcomes included radial and distal resection margin distance, postoperative complications, locoregional recurrence, disease-free survival, and overall survival. Surface under cumulative ranking (SUCRA) was used to rank the relative effectiveness of each intervention for each outcome. The higher the SUCRA value, the higher the likelihood that the intervention is in the top rank or one of the top ranks. RESULTS Thirty-two RCTs with a total of 6151 patients were included. Compared with OpTME, there was no difference in the rates of clear CRM: LapTME RR = 0.99 (95% (Credible interval) CrI 0.97-1.0); RoTME RR = 1.0 (95% CrI 0.96-1.1); TaTME RR = 1.0 (95% CrI 0.96-1.1). There was no difference in the rates of complete mesorectal excision: LapTME RR = 0.98 (95% CrI 0.98-1.1); RoTME RR = 1.1 (95% CrI 0.98-1.4); TaTME RR = 1.0 (95% CrI 0.91-1.2). RoTME was associated with improved distal resection margin distance compared to other techniques (SUCRA 99%). LapTME had a higher rate of conversion to open surgery when compared with RoTME: RoTME RR = 0.23 (95% CrI 0.034-0.70). Length of stay was shortest in RoTME compared to other surgical approaches: OpTME mean difference in days (MD) 3.3 (95% CrI 0.12-6.0); LapTME MD 1.7 (95% CrI - 1.1-4.4); TaTME MD 1.3 (95% CrI - 5.2-7.4). There were no differences in 5-year overall survival (LapTME HR 1.1, 95% CrI 0.74, 1.4; TaTME HR 1.7, 95% CrI 0.79, 3.4), disease-free survival rates (LapTME HR 1.1, 95% CrI 0.76, 1.4; TaTME HR 1.1, 95% CrI 0.52, 2.4), or anastomotic leakage (LapTME RR = 0.92 (95% CrI 0.63, 1.1); RoTME RR = 1.0 (95% CrI 0.48, 1.8); TaTME RR = 0.53 (95% CrI 0.19, 1.2). The overall quality of evidence as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessments across all outcomes including primary and secondary outcomes was deemed low. CONCLUSIONS In selected patients eligible for a RCT, RoTME achieved improved distal resection margin distance and a shorter length of hospital stay. No other differences were observed in oncological or recovery parameters between (OpTME), laparoscopic (LapTME), robotic (RoTME), or trans-anal TME (TaTME). However, the overall quality of evidence across all outcomes was deemed low.
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Affiliation(s)
- Warren Seow
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia
| | - Nagendra N Dudi-Venkata
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia.
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - Sergei Bedrikovetski
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia
| | - Hidde M Kroon
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Chok AY, Zhao Y, Tan IEH, Au MKH, Tan EJKW. Cost-effectiveness comparison of minimally invasive, robotic and open approaches in colorectal surgery: a systematic review and bayesian network meta-analysis of randomized clinical trials. Int J Colorectal Dis 2023; 38:86. [PMID: 36988723 DOI: 10.1007/s00384-023-04361-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE This study compares the cost-effectiveness of open, laparoscopic (LAP), laparoscopic-assisted (LAPA), hand-assisted laparoscopic (HAL), and robotic colorectal surgery using a network meta-analysis. METHODS Randomized clinical trials (RCTs) evaluating the cost-effectiveness of comparing the five different approaches in colorectal surgery were included in a literature search until September 2022. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, odds ratio (OR), and 95% credible intervals (CrIs) were reported for total costs, surgical costs, operating time, length of stay (LOS), and postoperative outcomes. Cluster analysis was performed to examine the similarity and classification of surgical approaches into homogeneous clusters. The cophenetic correlation coefficient (cc) was evaluated to identify the most cost-effective clustering method. The primary outcomes assessed were: costs-morbidity, costs-mortality, and costs-efficacy, measuring total costs against postoperative complications, mortality rate, and LOS, respectively. RESULTS 22 RCTs with 4239 patients were included. Open surgery had the lowest total costs, surgical costs, and operating time but the longest LOS and most postoperative complications. LOS was significantly decreased in LAP compared to open surgery (OR 0.67, 95% CrI 0.46-0.96). Robotic surgery resulted in the highest total costs, surgical costs, and most extended operative duration but the shortest LOS and lowest mortality. LAPA and robotic surgery were superior in the costs-morbidity analysis. HAL was associated with the worst costs-mortality profile. LAP, LAPA, and HAL were better in terms of costs-efficacy. CONCLUSION Overall, LAP and LAPA are the most cost-effective approaches for colorectal surgery in terms of overall postoperative complications, mortality, and LOS.
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Affiliation(s)
- Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Emile John Kwong Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore.
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Outcomes and Cost Analysis of Robotic Versus Laparoscopic Abdominoperineal Resection for Rectal Cancer: A Case-Matched Study. Dis Colon Rectum 2022; 65:1279-1286. [PMID: 35195554 DOI: 10.1097/dcr.0000000000002394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although laparoscopy for abdominoperineal resection has been well defined, the literature lacks comparative studies on robotic abdominoperineal resection. Because robotic abdominoperineal resections typically do not require splenic mobilization or an anastomosis for reconstruction, the mean console time is expected to be shorter than low anterior resection. We hypothesized that robotic and laparoscopic abdominoperineal resection would provide similar oncologic and financial outcomes. OBJECTIVE The study aimed to compare the perioperative, oncologic, and economic outcomes of the robotic and laparoscopic abdominoperineal resection. DESIGN This was a retrospective, case-matched patient cohort. SETTINGS This study was conducted at a tertiary referral center. PATIENTS This study included all patients who underwent either laparoscopic or robotic abdominoperineal resections between January 2008 and April 2017; they were case-matched in a 1:1 ratio based on age ±5 years, BMI ±3 kg/m 2 , and sex criteria. MAIN OUTCOME MEASURES Perioperative, oncologic, and economic (including survival) outcomes were compared. Because of institutional policy, actual cost values are presented as the lowest direct cost value as "100%," and other values are presented as proportional to the index value. RESULTS We examined 68 patients (34 in each group). Both groups had similar preoperative characteristics, including preoperative chemoradiation rates. Operative time (319 vs 309 min), length of stay (7.2 vs 7.4 d), postoperative complications (38.2% vs 41.2%), conversion to open (5 vs 4), complete mesorectal excision (76.4% vs 79.4%), radial margin involvement (2.9% vs 8.9%), and direct hospital cost parameters (mean difference 26%, median difference 43%) were comparable between robotic and laparoscopic abdominoperineal resection groups, respectively (all p > 0.05). Local recurrence, disease-free survival, and overall survival rates (85.3% vs 76.5%) were also similar after 22 months of follow-up between the groups. LIMITATIONS The main limitations of this study are its retrospective nature and the variety in concomitant procedures. CONCLUSIONS Robotic abdominoperineal resections provided in carefully matched patients with rectal cancer showed similar perioperative and short-term oncologic outcomes compared to laparoscopic abdominoperineal resections. Our study was not powered to detect a significant increase in cost with robotic abdominoperineal resections. See Video Abstract at http://links.lww.com/DCR/B920 . RESULTADOS Y ANLISIS DE COSTO DE LA RESECCIN ABDOMINOPERINEAL LAPAROSCPICA VS LA ROBTICA EN CASOS DE CNCER DE RECTO ESTUDIO DE CASOS EMPAREJADOS ANTECEDENTES:Si bien la resección abdominoperineal laparoscópica está bien definida, la literatura carece de estudios comparativos sobre la resección abdominoperineal robótica. Dado que las resecciones abdominoperineales robóticas generalmente no requieren movilización esplénica o una anastomosis en casos de reconstrucción, se supone que el tiempo medio en la consola sea más corto que durante una resección anterior baja. Hipotéticamente las resecciones abdominoperineales robóticas y laparoscópicas nos proporcionarían resultados oncológicos y económicos similares.OBJETIVO:Comparar los resultados perioperatorios, oncológicos y económicos de la resección abdominoperineal robótica y laparoscópica.DISEÑO:Esta fue una cohorte de pacientes retrospectiva, emparejada por casos.AJUSTE:Estudio realizado en un centro de referencia terciario.PACIENTES:Todos los pacientes que se sometieron a resecciones abdominoperineales LAParoscópicas o ROBóticas entre Enero de 2008 y Abril de 2017 fueron identificados y emparejados según la edad ±5, el IMC ±3 y los criterios de sexo en una proporción de 1:1.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados perioperatorios, oncológicos y económicos (incluida la sobrevida). Debido a la política institucional, los valores de costos reales se presentan como el valor de costo directo más bajo al 100% y los otros valores se presentan como proporcionales al valor índice.RESULTADOS:Se analizaron 68 pacientes (LAP-34 y ROB-34). Ambos grupos tenían características preoperatorias similares, incluidas las tasas de radio-quimioterapia pre-operatoria. Los tiempos operatorios fueron de 319 y 309 minutos, la estadía hospitalaria de 7 días en los dos grupos, las complicaciones post-operatorias fueron de 38,2% LAP frente a 41,2% ROB, la tasa de conversion fué de 5 a 4, la excisión total del mesorrecto de 76,4% frente a 79,4%, la resección radial con afectación de los márgenes de 2,9% frente a 8,9% y los parámetros de costes hospitalarios directos (diferencia de medias 26%, diferencia de medianas 43%) fueron comparables entre los grupos, de resección abdominoperineal robótica y laparoscópica, respectivamente (todos p > 0,05). Las tasas de recurrencia local, sobrevida libre de enfermedad y sobrevida general (85,3% frente a 76,5%) también fueron similares después de 22 meses de seguimiento entre los grupos.LIMITACIONES:La naturaleza retrospectiva y la variedad de procedimientos concomitantes fueron las principales limitaciones de este estudio.CONCLUSIONES:Las resecciones abdominoperineales robóticas proporcionaron resultados oncológicos perioperatorios y a corto plazo similares en pacientes con cáncer de recto cuidadosamente emparejados en comparación con las resecciones abdominoperineales laparoscópicas. Nuestro estudio no fue diseñado para detectar un aumento significativo en el costo relacionado con la resección abdominoperineal robótica. Consulte Video Resumen en http://links.lww.com/DCR/B920 . (Traducción-Dr. Xavier Delgadillo ).
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Mathew DAP, Wagh DMS. Abdominoperineal Excision in current era. Cancer Treat Res Commun 2022; 32:100580. [PMID: 35668011 DOI: 10.1016/j.ctarc.2022.100580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
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Segev L, Schtrechman G, Kalady MF, Liska D, Gorgun IE, Valente MA, Nissan A, Steele SR. Long-term Outcomes of Minimally Invasive Versus Open Abdominoperineal Resection for Rectal Cancer: A Single Specialized Center Experience. Dis Colon Rectum 2022; 65:361-372. [PMID: 34784318 DOI: 10.1097/dcr.0000000000002067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Randomized studies have validated laparoscopic proctectomy for the treatment of rectal cancer as noninferior to an open proctectomy, but most of those studies have included sphincter-preserving resections along with abdominoperineal resection. OBJECTIVE This study aimed to compare perioperative and long-term oncological outcomes between minimally invasive and open abdominoperineal resection. DESIGN This study is a retrospective analysis of a prospectively maintained database. SETTINGS The study was conducted in a single specialized colorectal surgery department. PATIENTS All patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2016 were included. MAIN OUTCOME MEASURES The primary outcomes measured were the perioperative and long-term oncological outcomes. RESULTS We included 452 patients, 372 in the open group and 80 in the minimally invasive group, with a median follow-up time of 74 months. There were significant differences between the groups in terms of neoadjuvant radiation treatment (67.5% of the open versus 81.3% of the minimally invasive group, p = 0.01), operative time (mean of 200 minutes versus 287 minutes, p < 0.0001), and mean length of stay (9.5 days versus 6.6 days, p < 0.0001). Overall complication rates were similar between the groups (34.5% versus 27.5%, p = 0.177). There were no significant differences in the mean number of lymph nodes harvested (21.7 versus 22.2 nodes, p = 0.7), circumferential radial margins (1.48 cm versus 1.37 cm, p = 0.4), or in the rate of involved radial margins (10.8% versus 6.3%, p = 0.37). Five-year overall survival was 70% in the open group versus 80% in the minimally invasive group (p = 0.344), whereas the 5-year disease-free survival rate in the open group was 63.2% versus 77.6% in the minimally invasive group (p = 0.09). LIMITATIONS This study was limited because it describes a single referral institution experience. CONCLUSIONS Although both approaches have similar perioperative outcomes, the minimally invasive approach benefits the patients with a shorter length of stay and a lower risk for surgical wound infections. Both approaches yield similar oncological technical quality in terms of the lymph nodes harvested and margins status, and they have comparable long-term oncological outcomes. See Video Abstract at http://links.lww.com/DCR/B754.RESULTADOS A LARGO PLAZO DE LA RESECCIÓN ABDOMINOPERINEAL MÍNIMAMENTE INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: EXPERIENCIA DE UN SOLO CENTRO ESPECIALIZADOANTECEDENTES:Estudios aleatorizados han validado la proctectomía laparoscópica para el tratamiento del cáncer de recto igual a la proctectomía abierta, pero la mayoría de esos estudios han incluido resecciones con preservación del esfínter junto con resección abdominoperineal.OBJETIVO:Comparar los resultados oncológicos perioperatorios y a largo plazo entre la resección abdominoperineal abierta y mínimamente invasiva.DISEÑO:Análisis retrospectivo de una base de datos mantenida de forma prospectiva.ENTORNO CLINICO:Servicio único especializado en cirugía colorrectal.PACIENTES:Todos los pacientes que se sometieron a resección abdominoperineal por cáncer de recto primario entre 2000 y 2016.PRINCIPALES MEDIDAS DE VALORACION:Resultados oncológicos perioperatorios y a largo plazo.RESULTADOS:Se incluyeron 452 pacientes, 372 en el grupo abierto y 80 en el grupo mínimamente invasivo, con una mediana de seguimiento de 74 meses. Hubo diferencias significativas entre los grupos en términos de tratamiento con radiación neoadyuvante (67,5% del grupo abierto versus 81,3% del grupo mínimamente invasivo, p = 0,01), tiempo operatorio (media de 200 minutos versus 287 minutos, p < 0,0001) y la duración media de la estancia (9,5 días frente a 6,6 días, p < 0,0001). Las tasas generales de complicaciones fueron similares entre los grupos (34,5% versus 27,5%, p = 0,177). No hubo diferencias significativas en el número medio de ganglios linfáticos extraídos (21,7 versus 22,2 ganglios, p = 0,7), márgenes radiales circunferenciales (1,48 cm y 1,37 cm, p = 0,4), ni en la tasa de márgenes radiales afectados (10,8 cm). % versus 6,3%, p = 0,37). La supervivencia general a 5 años fue del 70% en el grupo abierto frente al 80% en el grupo mínimamente invasivo (p = 0,344), mientras que la tasa de supervivencia libre de enfermedad a 5 años en el grupo abierto fue del 63,2% frente al 77,6% en el grupo mínimamente invasivo (p = 0,09).LIMITACIONES:Experiencia en una institución de referencia única.CONCLUSIONES:Si bien ambos tienen resultados perioperatorios similares, el enfoque mínimamente invasivo, beneficia a los pacientes con estadía más corta y menor riesgo de infecciones de la herida quirúrgica. Ambos enfoques, producen una calidad técnica oncológica similar en términos de ganglios linfáticos extraídos y estado de los márgenes, y tienen resultados oncológicos comparables a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B754. (Traducción - Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Lior Segev
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gal Schtrechman
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - I Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Aviram Nissan
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Spinelli A. Colorectal Cancer: Minimally Invasive Surgery. THE ASCRS TEXTBOOK OF COLON AND RECTAL SURGERY 2022:619-642. [DOI: 10.1007/978-3-030-66049-9_36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Schietroma M, Romano L, Apostol AI, Vada S, Necozione S, Carlei F, Giuliani A. Mid- and low-rectal cancer: laparoscopic vs open treatment-short- and long-term results. Meta-analysis of randomized controlled trials. Int J Colorectal Dis 2022; 37:71-99. [PMID: 34716474 DOI: 10.1007/s00384-021-04048-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The laparoscopic approach in the treatment of mid- or low-rectal cancer is still controversial. Compared with open surgery, laparoscopic resection of extraperitoneal cancer is associated with improved short-time non-oncological outcomes, although high-level evidence showing similar short- and long-term oncological outcomes is scarce. OBJECTIVE The aim of our paper is to study the oncological and non-oncological outcomes of laparoscopic versus open surgery for extraperitoneal rectal cancer. DATA SOURCES A systematic review of MedLine, EMBASE, and CENTRAL from January 1990 to October 2020 was performed by combining various key words. STUDY SELECTION Only randomized controlled trials (RCTs) comparing laparoscopic versus open surgery for extraperitoneal rectal cancer were included. The quality of RCTs was assessed using the Cochrane reviewer's handbook. This meta-analysis was based on the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. INTERVENTION(S) This study analyzes laparoscopic versus open surgery for extraperitoneal rectal cancer. MAIN OUTCOME MEASURES Primary outcomes were oncological parameters. RESULTS Fifteen RCTs comprising 4,411 patients matched the selection criteria. Meta-analysis showed a significant difference between laparoscopic and open surgery in short-time non-oncological outcomes. Although laparoscopic approach increased operation time, it decreases significantly the blood loss and length of hospital stay. No significant difference was noted regarding short- and long-term oncological outcomes, but 4 and 5 years disease-free survival were statistically higher in the open group. LIMITATIONS There are still questions about the long-term oncological outcomes of laparoscopic surgery for extraperitoneal rectal cancer being comparable to the open technique. CONCLUSIONS Considering that all surgical resections have been performed in high volume centers by expert surgeons, the minimally invasive surgery in patients with extraperitoneal cancer could still be not considered equivalent to open surgery in terms of oncological radicality.
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Affiliation(s)
- Mario Schietroma
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| | - Lucia Romano
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy.
| | - Adriana Ionelia Apostol
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| | - Silvia Vada
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| | - Stefano Necozione
- Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Carlei
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| | - Antonio Giuliani
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
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Lim WH, Tan DJH, Ng CH, Syn N, Tai BC, Gu T, Xiao J, Chin YH, Wing Ow ZG, Wong NW, Foo FJ, Lynch AC, Moran BJ, Chong CS. Laparoscopic versus open resection for rectal cancer: An individual patient data meta analysis of randomized controlled trials. Eur J Surg Oncol 2021; 48:1133-1143. [PMID: 34794842 DOI: 10.1016/j.ejso.2021.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/07/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND AND AIMS The role of laparoscopic rectal cancer resection remains controversial. Thus, we aimed to conduct a one-stage meta-analysis with reconstructed patient-level data using randomized trial data to compare long-term oncologic efficacy of laparoscopic and open surgical resection for rectal cancer. METHODS Medline, EMBASE and Scopus were searched for articles comparing laparoscopic with open surgery for rectal cancer. Primary outcome was disease free survival (DFS) while secondary outcome was overall survival (OS). One-stage meta-analysis was conducted using patient-level survival data reconstructed from Kaplan-Meier curves with Web Plot Digitizer. Shared-frailty and stratified Cox models were fitted to compare survival endpoints. RESULTS Seven randomized trials involving 1767 laparoscopic and 1293 open resections for rectal cancer were included. There were no significant differences between both groups for DFS and OS with respective hazard ratio estimates of 0.91 (95% CI: 0.78-1.06, p = 0.241) and 0.86 (95% CI:0.73-1.02, p = 0.090). Sensitivity analysis for non-metastatic patients and patients with mid and lower rectal cancer showed no significant differences in OS and DFS between both surgical approaches. In the laparoscopic arm, improved DFS was noted for stage II (HR: 0.73, 95% CI:0.54-0.98, p = 0.036) and stage III rectal cancers (HR: 0.74, 95% CI:0.55-0.99, p = 0.041). CONCLUSIONS This meta-analysis concludes that laparoscopic rectal cancer resection does not compromise long-term oncologic outcomes compared with open surgery with potential survival benefits for a minimal access approach in patients with stage II and III rectal cancer.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Biostatistics & Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Bee Choo Tai
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Biostatistics & Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Tianyuan Gu
- Biostatistics & Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | | | - Neng Wei Wong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore
| | - Fung Joon Foo
- Department of Colorectal Surgery, Sengkang General Hospital, Singapore
| | - Andrew C Lynch
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - Choon Seng Chong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore.
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Sasi S, Kammar P, Masillamany S, De' Souza A, Engineer R, Ostwal V, Saklani A. Laparoscopic versus open resection in locally advanced rectal cancers: a propensity matched analysis of oncological and short-term outcomes. Colorectal Dis 2021; 23:2894-2903. [PMID: 34379866 DOI: 10.1111/codi.15870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 07/28/2021] [Accepted: 08/01/2021] [Indexed: 02/08/2023]
Abstract
AIM The aim was to compare oncological and short-term outcomes between open and laparoscopic surgery in locally advanced rectal cancers. METHODS It is a retrospective analysis conducted in a high volume tertiary centre. Matching was carried out for nine variables, including preoperative factors, neoadjuvant treatment and sphincter preservation. RESULTS Both the open and laparoscopic surgery arms had 239 patients each. The distributions of pretreatment MRI T3, T4, circumferential resection margin (CRM) positive tumours, neoadjuvant long-course chemoradiation and sphincter preservation were 80.3%, 13.6%, 50%, 89% and 56.4% respectively. The mean number of nodes harvested (12.9 vs. 12.7, P = 0.716), pathological CRM positivity (6.3% in open vs. 5.4% in laparoscopic, P = 0.697) and distal resection margins were similar. The mean blood loss was higher in open surgeries (910 ml vs. 349 ml, P < 0.001). Anastomotic leaks and Clavien-Dindo Grade 3-4 complications were higher in the open arm than in the laparoscopy arm (5.9% vs. 1.7%, P = 0.024, and 12.5% vs. 6.7%, P = 0.015 respectively). The median postoperative hospital stay was significantly shorter in the laparoscopy arm (7 vs. 6, P = 0.015). In CRM positive and threatened cases, the measured outcomes were similar between the two groups except for blood loss which was significantly higher in the open surgery (872 vs. 379, P = 0.000). CONCLUSIONS In high volume centres, in the hands of experienced colorectal surgeons, laparoscopic rectal surgery is oncologically safe in locally advanced rectal cancers and has lesser morbidity and shorter hospital stay than open surgery. In CRM positive and threatened cases the laparoscopic surgery showed less blood loss compared to open surgery, while other outcome measures were similar to open surgery.
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Affiliation(s)
- Sajith Sasi
- Colorectal Division, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India
| | - Praveen Kammar
- Department of Surgical Oncology, Saifee Hospital, Mumbai, India
| | | | - Ashwin De' Souza
- Colorectal Division, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Colorectal Division, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India
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Peng J, Li W, Tang J, Li Y, Li X, Wu X, Lu Z, Lin J, Pan Z. Surgical Outcomes of Robotic Resection for Sigmoid and Rectal Cancer: Analysis of 109 Patients From a Single Center in China. Front Surg 2021; 8:696026. [PMID: 34504865 PMCID: PMC8422034 DOI: 10.3389/fsurg.2021.696026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/27/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Robotic colorectal surgery has been increasingly performed in recent years. The safety and feasibility of its application has also been demonstrated worldwide.However, limited studies have presented clinical data for patients with colorectal cancer (CRC) receiving robotic surgery in China. The aim of this study is to present short-term clinical outcomes of robotic surgery and further confirm its safety and feasibility in Chinese CRC patients. Methods: The clinical data of 109 consecutive CRC patients who received robotic surgery at Sun Yat-sen University Cancer Center between June 2016 and May 2019 were retrospectively reviewed. Patient characteristics,tumor traits, treatment details, complications, pathological details, and survival status were evaluated. Results: Among the 109 patients, 35 (32.1%) had sigmoid cancer, and 74 (67.9%) had rectal cancer. Thirty-seven (33.9%) patients underwent neoadjuvant chemoradiotherapy. Ten (9.2%) patients underwent sigmoidectomy, 38 (34.9%) underwent high anterior resection (HAR), 45 (41.3%) underwent low anterior resection (LAR), and 16 (14.7%) underwent abdominoperineal resection (APR). The median surgical procedure time was 270 min (range 120–465 min). Pathologically complete resection was achieved in all patients. There was no postoperative mortality. Complications occurred in 11 (10.1%) patients, including 3 (2.8%) anastomotic leakage, 1 (0.9%) anastomotic bleeding, 1 (0.9%) pelvic hemorrhage, 4 (3.7%) intestinal obstruction, 2 (1.8%) chylous leakage, and 1 (0.9%) delayed wound union. At a median follow-up of 17 months (range 1–37 months), 1 (0.9%) patient developed local recurrence and 5 (4.6%) developed distant metastasis, with one death due to disease progression. Conclusions: Our results suggest that robotic surgery is technically feasible and safe for Chinese CRC patients, especially for rectal cancer patients who received neoadjuvant treatment. A robotic laparoscope with large magnification showed a clear surgical space for pelvic autonomic nerve preservation in cases of mesorectal edema.
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Affiliation(s)
- Jianhong Peng
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Weihao Li
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jinghua Tang
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yuan Li
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xueying Li
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaojun Wu
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhenhai Lu
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Junzhong Lin
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhizhong Pan
- State Key Laboratory of Oncology in South China, Department of Colorectal Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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Zhang GQ, Sahyoun R, Stem M, Lo BD, Rajput A, Efron JE, Atallah C, Safar B. Operative Approach Does Not Impact Radial Margin Positivity in Distal Rectal Cancer. World J Surg 2021; 45:3686-3694. [PMID: 34495388 DOI: 10.1007/s00268-021-06278-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Robotic surgery is attractive for resection of low rectal cancer due to greater dexterity and visualization, but its benefit is poorly understood. We aimed to determine if operative approach impacts radial margin positivity (RMP) and postoperative outcomes among patients undergoing abdominoperineal resection (APR). METHODS This was a retrospective cohort study of patients from the National Surgical Quality Improvement Program who underwent APR for low rectal cancer from 2016 to 2019. Patients were stratified by operative approach: robotic, laparoscopic, and open APR (R-APR, L-APR, and O-APR). Emergent cases were excluded. The primary outcome was RMP. 30-day postoperative outcomes were also evaluated, using logistic regression analysis. RESULTS Among 1,807 patients, 452 (25.0%) underwent R-APR, 474 (26.2%) L-APR, and 881 (48.8%) O-APR. No differences regarding RMP (13.5% R-APR vs. 10.8% L-APR vs. 12.3% O-APR, p = 0.44), distal margin positivity, positive nodes, readmission, or operative time were observed between operative approaches. Adjusted analysis confirmed that operative approach did not predict RMP (p > 0.05 for all). Risk factors for RMP included American Society of Anesthesiologists (ASA) classification III (ASA I-II ref; OR 1.46, p = 0.039), pT3-4 stage (T0-2 ref, OR 4.02, p < 0.001), pN2 stage (OR 1.98, p = 0.004), disseminated cancer (OR 1.90, p = 0.002), and lack of preoperative radiation (OR 1.98, p < 0.01). CONCLUSIONS No difference in RMP was observed among R-APR, L-APR, and O-APR. Postoperatively, R-APR yielded greater benefit when compared to O-APR, but was comparable to that of L-APR. Minimally invasive surgery may be an appropriate option and worthy consideration for patients with distal rectal cancer requiring APR.
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Affiliation(s)
- George Q Zhang
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca Sahyoun
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian D Lo
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashwani Rajput
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Liu D, Zhou H, Liu L, Zhu Z, Liu S, Fang Y. A Diagnostic Nomogram for Predicting the Risk of Anastomotic Leakage in Elderly Patients With Rectal Cancer: A Single-center Retrospective Cohort Study. Surg Laparosc Endosc Percutan Tech 2021; 31:734-741. [PMID: 34292209 DOI: 10.1097/sle.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Laparoscopic resection for rectal cancer has been gaining popularity over the past 2 decades. Whether elderly patients had more benefits from laparoscopy-assisted anterior resection (LAR) need further investigation when comparing with open anterior resection (OAR). OBJECTIVES This study aimed to evaluate the clinical outcomes and prognosis of LAR in elderly patients (65 y and above) with rectal cancer and investigate the factors associated with the anastomotic leakage (AL). Besides, the study sought to create a nomogram for precise prediction of AL after anterior resection for rectal cancer. MATERIALS AND METHODS A total of 343 rectal cancer patients over 65 years old who underwent LAR or OAR at a single center between January 2013 to January 2021 were retrospectively reviewed. Univariate analysis was conducted to explore potential risk factors for AL, and a nomogram for AL was created based on the multivariate logistic regression model. RESULTS A total of 343 patients were included in this study, 271 patients in LAR group and 72 patients in OAR group. Most of the variables were comparable between the 2 groups. The mean operative time was longer in the LAR group than that in the OAR group (191.66±58.33 vs. 156.85±53.88 min, P<0.0001). The LAR group exhibited a significantly lower intraoperative blood loss than the OAR group (85.17±50.03 vs. 131.67±79.10 mL; P<0.0001). Moreover, laparoscopic surgery resulted in shorter postoperative hospital stay, lower rates of diverting stoma and receiving sphincter sparing surgery in comparison with open surgery. The overall rates of complications were 25.1% and 40.3% in the LAR and OAR groups (P=0.011), respectively. And the reoperation rates in the OAR group (0%) was lower than in the LAR group (1.5%), but the difference did not reach statistical significance (P=0.300). Sex, location of tumor, diverting stoma and combined organ resection were identified as independent risk factors for AL based on multivariate analysis. Such factors were selected to develop a nomogram. After a median follow-up of 37.0 months, our study showed no significant difference in overall survival or disease free survival between the 2 groups for treatment of rectal cancer. CONCLUSIONS This study suggests that LAR is an alternative minimally invasive surgical procedure in patients above 65 years with better short-term outcomes and acceptable long-term outcomes compared with OAR. In addition, our nomogram has satisfactory accuracy and clinical utility may benefit for clinical decision-making.
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Affiliation(s)
- Dongliang Liu
- Department of General Surgery, Anhui Provincial Hospital Affiliated to the Anhui Medical University
| | - Hong Zhou
- Department of General Surgery, The First Hospital Affiliated to the University of Science and Technology of China, Hefei, China
| | - Liu Liu
- Department of General Surgery, The First Hospital Affiliated to the University of Science and Technology of China, Hefei, China
| | - Zhiqiang Zhu
- Department of General Surgery, Anhui Provincial Hospital Affiliated to the Anhui Medical University
- Department of General Surgery, The First Hospital Affiliated to the University of Science and Technology of China, Hefei, China
| | - Shaojun Liu
- Department of General Surgery, The First Hospital Affiliated to the University of Science and Technology of China, Hefei, China
| | - Yu Fang
- Department of General Surgery, The First Hospital Affiliated to the University of Science and Technology of China, Hefei, China
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Zhong Y, Qiao T, Ma T, Hu H, Jin Y, Wang Y, Tang Q, Huang R, Wang G, Wang X. Long-Term Outcome Comparison Between Two Specimen Extraction Approaches for Middle Rectum Cancer: A Retrospective Study. Surg Innov 2021; 28:738-746. [PMID: 33787417 DOI: 10.1177/15533506211006970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective. There are few studies comparing the long-term results of natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic-assisted resection (LA) in the treatment of middle rectal cancer. This retrospective analysis aimed to evaluate the reliability of NOSES. Method. From January 2013 to December 2017, all patients diagnosed with median rectal cancer in our hospital who underwent NOSES and LA were enrolled. We used propensity-score matching (PSM) to balance baseline data between the NOSES group and the laparoscopic group. The primary endpoint was overall survival (OS) and disease-free survival (DFS). We used the Kaplan-Meier method to estimate OS and DFS. Student's t-test was used to analyze the difference of continuous data. Categorical data were compared using the Kruskal-Wallis test or Fisher's exact test. Results. After PSM, 38 patients were included in each group. We found that surgical bleeding volume in the NOSES group was considerably lower than that in the LA group (49.5 ± 47.5 mL vs. 86.3 ± 83.5 mL, P = .01). From the short-term results, the first flatus and regular diet time in the NOSES group were shorter than those in the LA group (41.3 ± 25.2 vs. 54.0 ± 19.2 hours, P < .01 and 63.9 ± 42.6 hours vs. 105.1 ± 66.8 hours, P < .01, respectively). Long-term OS and DFS were not different between the groups. Conclusion. Therefore, NOSES is a reliable technique for middle rectal cancer treatment. Short-term outcomes are pointedly better than LA, while the two surgical approaches did not differ in the long-term outcomes or complication rate.
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Affiliation(s)
- Yuchen Zhong
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Tianyu Qiao
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Tianyi Ma
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hanqing Hu
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yinghu Jin
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuliuming Wang
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qingchao Tang
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Rui Huang
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guiyu Wang
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xishan Wang
- Department of Colorectal Surgery, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, 12501Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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18
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Creavin B, Kelly ME, Ryan ÉJ, Ryan OK, Winter DC. Oncological outcomes of laparoscopic versus open rectal cancer resections: meta-analysis of randomized clinical trials. Br J Surg 2021; 108:469-476. [PMID: 33748848 DOI: 10.1093/bjs/znaa154] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The role of laparoscopic rectal cancer surgery has been questioned owing to conflicting reports on pathological outcomes from recent RCTs. However, it is unclear whether these pathological markers and the surgical approach have an impact on oncological outcomes. This study assessed oncological outcomes of laparoscopic and open rectal cancer resections. METHODS A meta-analysis of RCTs was performed. Primary endpoints included oncological outcomes (disease-free survival (DFS), overall survival (OS), local recurrence). Secondary endpoints included surrogate markers for the quality of surgical resection. RESULTS Twelve RCTs including 3744 patients (2133 laparoscopic, 1611 open) were included. There was no significant difference in OS (hazard ratio (HR) 0.87, 95 per cent c.i. 0.73 to 1.04; P = 0.12; I2 = 0 per cent) and DFS (HR 0.95, 0.81 to 1.11; P = 0.52; I2 = 0 per cent) between laparoscopic and open rectal resections. There was no significant difference in locoregional (odds ratio (OR) 1.03, 95 per cent c.i. 0.72 to 1.48; P = 0.86; I2 = 0 per cent) or distant (OR 0.87, 0.70 to 1.08; P = 0.20; I2 = 7 per cent) recurrence between the groups. Achieving a successful composite score (intact mesorectal excision, clear circumferential resection margin and distal margin) was significantly associated with improved DFS (OR 0.55, 0.33 to 0.74; P < 0.001; I2 = 0 per cent). An intact or acceptable mesorectal excision (intact mesorectal excision with or without superficial defects) had no impact on DFS. Finally, a positive CRM was associated with worse DFS. CONCLUSION Well performed surgery (laparoscopic or open) achieves excellent oncological outcomes with very little difference between the two modalities. The advantage and benefit of minimally invasive surgery should be assessed on an individual basis.
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Affiliation(s)
- B Creavin
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - M E Kelly
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - É J Ryan
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - O K Ryan
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - D C Winter
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
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Tang J, Chen H, Liu J, Gong A, Ding X, Wan Y, Wang X. Transanterior obturator nerve gateway: a novel approach to achieving intracorporeal distal rectal transection for ultralow rectal cancer. Surg Endosc 2021; 35:2362-2372. [PMID: 33625588 DOI: 10.1007/s00464-020-08208-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intracorporeal rectal transection at the anorectal junction for ultralow rectal cancer is technically difficult due to pelvic width and limited roticulation, which might require a transanal transection or an oblique transection with multiple firings. These procedures were reported to be associated with the increased risk of morbidity. To address these problems, we presented a novel technique Transanterior Obturator Nerve Gateway (TANG) to transect rectum for ultralow rectal cancer and evaluated its safety and feasibility in this study. METHODS A total of 210 consecutive patients who underwent laparoscopic coloanal anastomosis with or without partial intersphincteric resection (CAA/pISR) for rectal cancers between January 2017 and January 2020 were included. Eighty of these patients were analyzed using propensity score matching (PSM). The perioperative characteristics, TANG-related variables, and genitourinary and anal function outcomes were analyzed. RESULTS Among these enrolled patients, 170 patients underwent traditional transection, and 40 underwent TANG transection; the patients were matched to include 40 patients in each group by PSM. After PSM, there were no significant differences in the operating time (p = 0.351) or bleeding volume (p = 0.474) between the two groups. However, the TANG group had fewer cases of conversion to transanal transection (0 vs. 13, p < 0.001). Moreover, the patients in TANG group had a more desirable transection with longer distal resection margin (1.7 vs. 1.1 cm, p < 0.001), shorter stapling line (6.6 vs. 10.3 cm, p < 0.001) and fewer stapler firings (p < 0.001). The overall postoperative complication rates and genitourinary and anal function outcomes were not significantly different between the two groups. CONCLUSIONS The TANG approach appears to be a safe, feasible and effective approach for intracorporeal ultralow rectal transection with more distal resection, more vertical transection and fewer stapler firings.
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Affiliation(s)
- Jianqiang Tang
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China.
| | - Hekai Chen
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Junguang Liu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Aimin Gong
- Department of Colorectal and Anal Surgery, Dalian University Affiliated Xinhua Hospital, Dalian, 116000, China
| | - Xiping Ding
- Department of Colorectal and Anal Surgery, Shengli Oilfield Central Hospital, Dongying, 257034, China
| | - Yuanlian Wan
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Xin Wang
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China.
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20
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Total Laparoscopic Approach for Rectal Cancer Resection—a Novel Technique and Review of the Literature. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02299-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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21
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Effects of needlescopic surgery on postoperative pain in intersphincteric or abdominoperineal resection. Langenbecks Arch Surg 2020; 406:301-307. [PMID: 33221943 DOI: 10.1007/s00423-020-02035-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Laparoscopic surgery allows minimally invasive treatment of rectal cancer, and needlescopic surgery (NS) offers even more minimally invasive operations beyond the scope of conventional laparoscopic surgery (CS). The aim of this study was to compare short-term outcomes of NS for intersphincteric resection (ISR) or abdominoperineal resection (APR) to treat anal or rectal cancer without an abdominal incision for specimen extraction and to measure abdominal wound pain compared to CS. METHODS Between September 2014 and December 2016, a total of 134 patients underwent laparoscopic ISR or APR. Of these, 26 patients underwent NS, and 108 patients underwent CS. Postoperative abdominal wound pain was estimated using the numerical rating scale. Short-term outcomes were compared between NS and CS. RESULTS No conversion to CS or open surgery was required. Median operation time was significantly shorter with NS (295 min) than with CS (331.5 min; p = 0.020). Median estimated blood loss was significantly lower with NS (30 ml) than with CS (50 ml; p = 0.011). Postoperative pain score on postoperative day (POD)5 was significantly lower with NS than with CS (p = 0.025), and frequencies of analgesic use were significantly lower with NS than with CS on POD0, POD2, and POD3 (p = 0.032, p = 0.017, p = 0.045, respectively). The postoperative complications occurred at similar frequencies between groups (p = 0.655). CONCLUSION NS for ISR or APR offers comparable short-term outcomes to CS, with better pain outcomes.
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22
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Operative outcome of laparoscopic colorectal cancer surgery in a regional hospital in a developing country: A propensity score-matched comparative analysis. Asian J Surg 2020; 44:329-333. [PMID: 32873471 DOI: 10.1016/j.asjsur.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/13/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Laparoscopic surgery is an alternative procedure for colorectal cancers. However, high-level supporting evidence has been derived from high-volume centers in developed countries. During the early phase of applying the laparoscopic approach, we evaluated the procedure's short-term outcomes in our regional middle-volume hospital in a developing country. METHODS We retrospectively analyzed data for a cohort of 223 colorectal cancer patients who underwent elective surgery from October 2017 to September 2019. We compared 165 patients undergoing open surgery (OS group) with 58 undergoing laparoscopic surgery (LS group) using a propensity score-matched analysis. RESULTS After matching, each group contained 58 patients for evaluating outcomes. The LS group had more harvested mesenteric lymph nodes (5.0 nodes, 95% confidence interval (CI): 1.8-8.1; p-value: <0.01) with comparable blood loss (p-value: 0.54) and margin status (p-value: 0.66). However, LS was more time-consuming (68.8 min longer; 95% CI: 53.0-84.7; p-value: <0.01). Morbidity and mortality rates were equivalent (odds ratio (OR): 1.3, 95% CI: 0.25-2.73, p-value: 0.74, and OR: 2, 95% CI: 0.18-22.1, p-value: 0.57, respectively). The LS group experienced fewer days to begin normal eating (-0.5 days, 95% CI: -0.9 to -0.1, p-value: 0.04) and shorter hospital stay (-1.5 days, 95% CI: -2.7 to -0.4, p-value: <0.01). The conversion rate was 3.5%. CONCLUSION The laparoscopic approach was applicable even in a regional middle-volume hospital in a developing country. However, longer surgical time was a drawback.
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23
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Ryan OK, Ryan ÉJ, Creavin B, Rausa E, Kelly ME, Petrelli F, Bonitta G, Kennelly R, Hanly A, Martin ST, Winter DC. Surgical approach for rectal cancer: A network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches. Eur J Surg Oncol 2020; 47:285-295. [PMID: 33280950 DOI: 10.1016/j.ejso.2020.06.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal approach for total mesorectal excision (TME) of rectal cancer remains controversial. AIM To compare short- and long-term outcomes after open (OpTME), laparoscopic (LapTME), robotic (RoTME) and transanal TME (TaTME). METHODS A systematic search of electronic databases was performed up to January 1, 2020 for randomized controlled trials (RCTs) comparing at least 2 TME strategies. A Bayesian arm-based random effect network meta-analysis (NMA) was performed, specifically, a mixed treatment comparison (MTC). RESULTS 30 RCTs (and six updates) of 5586 patients with rectal cancer were included. No significant differences were identified in recurrence rates or survival rates. Operating time was shorter with OpTME (surface under the cumulative ranking curve [SUCRA] 0.96) compared to LapTME, RoTME and TaTME. Although OpTME was associated with the most blood loss (SUCRA 0.90) and had a slower recovery with increased length of stay (SUCRA 0.90) compared to the minimally invasive techniques, there was no difference in postoperative morbidity. OpTME was associated with a more complete TME specimen compared to LapTME (Risk Ratio [RR] 1.05, 95% Credible Interval [CrI] 1.01, 1.11), and TaTME had less involved CRMs (RR 0.173, 95% CrI 0.02, 0.76) versus LapTME. There were no differences between the modalities in terms of deep TME defects, DRM distance, or lymph node yield. CONCLUSIONS While OpTME was the most effective TME modality for short term histopathological resection quality, there was no difference in long-term oncologic outcomes. Minimally invasive approaches enhance postoperative recovery, at the cost of longer operating times. Technique selection should be based on individual tumour characteristics and patient expectations, as well as surgeon and institutional expertise.
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Affiliation(s)
- Odhrán K Ryan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
| | - Éanna J Ryan
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Emanuele Rausa
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Michael E Kelly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Fausto Petrelli
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Gianluca Bonitta
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Rory Kennelly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Ann Hanly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland; Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Allaix ME, Rebecchi F, Fichera A. The Landmark Series: Minimally Invasive (Laparoscopic and Robotic) Colorectal Cancer Surgery. Ann Surg Oncol 2020; 27:3704-3715. [PMID: 32648183 DOI: 10.1245/s10434-020-08833-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/19/2020] [Indexed: 12/31/2022]
Abstract
Current high-quality evidence supports the routine use of the laparoscopic approach for patients with colon cancer. Laparoscopic colectomy is associated with earlier resumption of gastrointestinal function and shorter hospital stay, with no increased morbidity or mortality. Pathology and long-term oncologic outcomes are similar to those achieved with open surgery. The absolute benefits of laparoscopic resection for rectal cancer are still under evaluation. While its safety in terms of early postoperative clinical outcomes has been confirmed, two recent randomized controlled trial (RCTs) have questioned its routine use even in expert hands, since its non-inferiority has not been demonstrated when compared with the gold standard of open surgery. Furthermore, the impact of robotic technology is still unclear, since the only RCT available so far failed to demonstrate any benefits compared with standard laparoscopic rectal resection.
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Affiliation(s)
- Marco E Allaix
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | | | - Alessandro Fichera
- Department of Surgery, Division of Colorectal Surgery, Baylor University Medical Center, 3409 Worth Street. Worth Tower, Suite 640, Dallas, TX, 75246, USA.
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25
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Black AJ, Karimuddin A, Raval M, Phang T, Brown CJ. The impact of laparoscopic technique on the rate of perineal hernia after abdominoperineal resection of the rectum. Surg Endosc 2020; 35:3014-3024. [DOI: 10.1007/s00464-020-07746-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/16/2020] [Indexed: 01/12/2023]
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Fukuoka H, Fukunaga Y, Minami H, Miyanari S, Suzuki S, Nagasaki T, Akiyoshi T, Konishi T, Fujimoto Y, Nagayama S, Ueno M. Needlescopic surgery for very low rectal cancer with no abdominal skin incision. Asian J Endosc Surg 2020; 13:180-185. [PMID: 31282070 DOI: 10.1111/ases.12730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/20/2019] [Accepted: 06/02/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Needlescopic surgery (NS) is a minimally invasive operation beyond traditional laparoscopic surgery. This study aimed to describe NS for intersphincteric resection (ISR) and abdominoperineal resection (APR) for low rectal cancer without a small abdominal skin incision for extracting the specimen and to evaluate the safety and feasibility of the operation. METHODS From January 2011 to April 2016, 36 patients underwent NS for either ISR or APR. By definition, NS for ISR or APR at our institution uses three 3-mm ports and two 5-mm ports at the umbilicus and in the right lower quadrant. The specimen was extracted through the anus or the perineal wound. The feasibility of this operation was determined based on short-term outcomes and pathological findings. RESULTS No patients required conversion to open surgery. The mean operation time was 299 minutes, and the mean estimated blood loss was 30 mL. Postoperative complications higher than Clavien-Dindo grade III occurred in 2.8% of patients (n = 1). The median number of harvested lymph nodes was 16 (range, 0-30), and in no case was there a positive circumferential resection margin. CONCLUSIONS Needlescopic surgery for ISR or APR is technically safe and feasible for low rectal cancer based on the short-term outcomes and the oncological quality, particularly when compared to conventional laparoscopic surgery as described in previous reports.
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Affiliation(s)
- Hironori Fukuoka
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Fukunaga
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hironori Minami
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shun Miyanari
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinsuke Suzuki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiya Nagasaki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Akiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshiya Fujimoto
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoshi Nagayama
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masashi Ueno
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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27
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Zheng B, Zhang X, Wang X, Ge L, Wei M, Bi L, Deng X, Wang Q, Li J, Wang Z. A comparison of open, laparoscopic and robotic total mesorectal excision: trial sequential analysis and network meta-analysis. Colorectal Dis 2020; 22:382-391. [PMID: 31600858 DOI: 10.1111/codi.14872] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 09/06/2019] [Indexed: 02/06/2023]
Abstract
AIM Total mesorectal excision (TME) for rectal cancer can be achieved by employing open (OpTME), laparoscopic (LaTME) and robotic (RoTME) approaches but which of these has the best outcome? The aim of present study is to identify the most effective technique for rectal cancer by comparing all outcomes. METHODS Randomized controlled trials (RCTs) which compared at least two TME strategies were identified by literature search of electronic databases of articles published to June 2018. Network meta-analysis with trial sequential analysis was performed using a frequentist approach with random-effects meta-analysis. Data collection and analysis We conducted a systematic search of PubMed, EmBase, the Cochrane Library, CNKI, and Web of Science. Titles and abstracts of the retrieved publications were independently and blindly assessed by two authors. RESULTS Twenty-two RCTs with 4882 rectal cancer patients were included in this analysis. The trial sequential analysis demonstrated that the cumulative Z-curve crossed either the traditional boundary or the trial sequential monitoring boundaries, suggesting that OpTME resulted in a more complete TME specimen than LaTME (relative risk 1.05, 95% confidence interval 1.01-1.08). Network meta-analysis showed there was no significant difference in the other comparisons. Based on the P score of completeness of the TME specimen and circumferential resection margin positivity, the best technique was OpTME, followed by RoTME and then LaTME. However, this order was reversed when complications and mortality were considered. RoTME led to better lymph node harvest. CONCLUSIONS Although OpTME may give better pathological specimens, minimally invasive techniques may have advantages when considering lymph node harvest, complications and mortality. More RCTs are needed to determine which technique actually gives the best chance of survival.
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Affiliation(s)
- B Zheng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X Wang
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - L Ge
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou, China
| | - M Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - L Bi
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Q Wang
- Digestive Disease Hospital, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - J Li
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Z Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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Becattini C, Pace U, Rondelli F, Delrio P, Ceccarelli G, Boncompagni M, Graziosi L, Visonà A, Chiari D, Avruscio G, Frasson S, Gussoni G, Biancafarina A, Camporese G, Donini A, Bucci AF, Agnelli G. Rivaroxaban for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer. Design of the PRO-LAPS II STUDY. Eur J Intern Med 2020; 72:53-59. [PMID: 31818628 DOI: 10.1016/j.ejim.2019.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND The clinical benefit of extending prophylaxis for venous thromboembolism (VTE) beyond hospital discharge after laparoscopic surgery for cancer is undefined. Extended prophylaxis with rivaroxaban is effective in reducing post-operative VTE after major orthopedic surgery without safety concern. METHODS PROLAPS II is an investigator-initiated, randomized, double-blind study aimed at assessing the efficacy and safety of extended antithrombotic prophylaxis with rivaroxaban compared with placebo after laparoscopic surgery for colorectal cancer in patients who had received antithrombotic prophylaxis with low molecular-weight heparin for 7 ± 2 days (NCT03055026). Patients are randomized to receive rivaroxaban (10 mg once daily) or placebo for 3 weeks (up to day 28 ± 2 from surgery). The primary study outcome is a composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT or VTE-related death at 28 ± 2 days from laparoscopic surgery. The primary safety outcome is major bleeding defined according to the International Society of Thrombosis and Haemostasis. Symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT, major bleeding or death by day 28 ± 2 and by day 90 from surgery are secondary outcomes. Assuming an 8% event rate with placebo and 60% reduction in the primary study outcome with rivaroxaban, 323 patients per group are necessary to show a statistically significant difference between the study groups. DISCUSSION The PROLAPS II is the first study with an oral anti-Xa agent in cancer surgery. The study has the potential to improve clinical practice by answering the question on the clinical benefit of extending prophylaxis after laparoscopic surgery for colorectal cancer.
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Affiliation(s)
- Cecilia Becattini
- Department of Internal and Cardiovascular Medicine and Stroke Unit, University of Perugia, Italy.
| | - Ugo Pace
- National Cancer Institute, "G. Pascale" Foundation, Napoli, Italy.
| | - Fabio Rondelli
- Department of General Surgery, S. Giovanni Battista Hospital, Foligno, Italy.
| | - Paolo Delrio
- National Cancer Institute, "G. Pascale" Foundation, Napoli, Italy.
| | | | - Michela Boncompagni
- Department of General Surgery, S. Maria della Misericordia Hospital, Perugia, Italy.
| | - Luigina Graziosi
- Department of Oncology Surgery, University of Perugia, Perugia, Italy.
| | - Adriana Visonà
- Department of Vascular Medicine, S.Giacomo Apostolo Hospital, Catelfranco Veneto, Treviso, Italy.
| | - Damiano Chiari
- Department of General Surgery, Istituto Clinico Humanitas Mater Domini, Castellanza, Varese, Italy.
| | - Giampiero Avruscio
- Department of Cardiac, Thoracic and Vascular Sciences, Unit of Angiology, University Hospital of Padua, Padua, Italy.
| | | | | | | | - Giuseppe Camporese
- Department of Cardiac, Thoracic and Vascular Sciences, Unit of Angiology, University Hospital of Padua, Padua, Italy.
| | - Annibale Donini
- Department of Oncology Surgery, University of Perugia, Perugia, Italy.
| | | | - Giancarlo Agnelli
- Department of Internal and Cardiovascular Medicine and Stroke Unit, University of Perugia, Italy.
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29
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Simillis C, Lal N, Thoukididou SN, Kontovounisios C, Smith JJ, Hompes R, Adamina M, Tekkis PP. Open Versus Laparoscopic Versus Robotic Versus Transanal Mesorectal Excision for Rectal Cancer: A Systematic Review and Network Meta-analysis. Ann Surg 2020; 270:59-68. [PMID: 30720507 DOI: 10.1097/sla.0000000000003227] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare techniques for rectal cancer resection. SUMMARY BACKGROUND DATA Different surgical approaches exist for mesorectal excision. METHODS Systematic literature review and Bayesian network meta-analysis performed. RESULTS Twenty-nine randomized controlled trials included, reporting on 6237 participants, comparing: open versus laparoscopic versus robotic versus transanal mesorectal excision. No significant differences identified between treatments in intraoperative morbidity, conversion rate, grade III/IV morbidity, reoperation, anastomotic leak, nodes retrieved, involved distal margin, 5-year overall survival, and locoregional recurrence. Operative blood loss was less with laparoscopic surgery compared with open, and with robotic surgery compared with open and laparoscopic. Robotic operative time was longer compared with open, laparoscopic, and transanal. Laparoscopic operative time was longer compared with open. Laparoscopic surgery resulted in lower overall postoperative morbidity and fewer wound infections compared with open. Robotic surgery had fewer wound infections compared with open. Time to defecation was longer with open surgery compared with laparoscopic and robotic. Hospital stay was longer after open surgery compared with laparoscopic and robotic, and after laparoscopic surgery compared with robotic. Laparoscopic surgery resulted in more incomplete or nearly complete mesorectal excisions compared with open, and in more involved circumferential resection margins compared with transanal. Robotic surgery resulted in longer distal resection margins compared with open, laparoscopic, and transanal. CONCLUSIONS The different techniques result in comparable perioperative morbidity and long-term survival. The laparoscopic and robotic approaches may improve postoperative recovery, and the open and transanal approaches may improve oncological resection. Technique selection should be based on expected benefits by individual patient.
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Affiliation(s)
- Constantinos Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Nikhil Lal
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah N Thoukididou
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Jason J Smith
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Roel Hompes
- Academic Medical Center, Amsterdam, The Netherlands
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Paris P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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Clinical, pathological, and oncologic outcomes of robotic-assisted versus laparoscopic proctectomy for rectal cancer: A meta-analysis of randomized controlled studies. Asian J Surg 2020; 43:880-890. [PMID: 31964585 DOI: 10.1016/j.asjsur.2019.11.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/07/2019] [Indexed: 12/27/2022] Open
Abstract
Although several meta-analyses regarding robot-assisted proctectomy (RP) and laparoscopic proctectomy (LP) in patients with rectal cancer are constantly being published, meta-analyses considering randomized controlled trials (RCTs) are still rare. It is therefore necessary to conduct an appropriate meta-analysis to provide reliable evidence for clinical decision-making. Databases such as PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CCTR) and Cochrane Database of Systematic Reviews (CDSR) were used to collect RCTs assessing the effectiveness and safety of RP and LP. Article search was performed until August 2019. Data were extracted and the quality was evaluated by two reviewers independently, according to the inclusion and exclusion criteria. Data were analyzed using R software. Eight RCTs were included involving 999 patients, 495 of them underwent RP and 504 underwent LP. The results showed that the RP group had a longer operative time (P < 0.01), a lower conversion rate (P = 0.03), a longer distance to the distal margin (DDM) (P = 0.001), and a lower incidence of erectile dysfunction (P = 0.02). No significant differences were found in perioperative mortality, complication rates, PRM, number of harvested lymph nodes, length of hospital stay and time to first bowel movement between the two groups. Current evidence suggests that RP is superior to LP in short-term clinical outcomes, which is similar to LP regarding pathological outcomes and has better DDM outcomes. However, the comparison between RP and LP regarding long-term oncology outcomes still require further multi-center and large RCT samples to confirm our evidences.
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Laparoscopic Versus Open Resection for Rectal Cancer: A Noninferiority Meta-analysis of Quality of Surgical Resection Outcomes. Ann Surg 2020; 269:849-855. [PMID: 30339624 DOI: 10.1097/sla.0000000000003072] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine whether laparoscopic surgery is noninferior to open surgery for rectal cancer in terms of quality of surgical resection outcomes. BACKGROUND Randomized clinical trials (RCTs) have evaluated the oncologic safety of laparoscopic versus open surgery for rectal cancer with conflicting results. Prior meta-analyses comparing these operative approaches in terms of quality of surgical resection aimed to demonstrate if one approach was superior. However, this method is not appropriate and potentially misleading when noninferiority RCTs are included. METHODS MEDLINE, EMBASE, and Cochrane were searched to identify RCTs comparing these operative approaches. Risk differences (RDs) were pooled using random-effects meta-analyses. One-sided Z tests were used to determine noninferiority. Noninferiority margins (ΔNI) for circumferential resection margin (CRM), plane of mesorectal excision (PME), distal resection margin (DRM), and a composite outcome ("successful resection") were based on the consensus of 58 worldwide experts. RESULTS Fourteen RCTs were included. Laparoscopic resection was noninferior compared with open resection for the rate of positive CRM [RD 0.79%, 90% confidence interval (CI) -0.46 to 2.04, ΔNI = 2.33%, PNI = 0.026], incomplete PME (RD 1.16%, 90% CI -0.27 to 2.59, ΔNI = 2.85%, PNI = 0.025), and positive DRM (RD 0.15%, 90% CI -0.58 to 0.87, ΔNI = 1.28%, PNI = 0.005). For the rate of "successful resection" (RD 6.16%, 90% CI 2.30-10.02), the comparison was inconclusive when using the ΔNI generated by experts (ΔNI = 2.71%, PNI = 0.07), although no consensus was achieved for this ΔNI. CONCLUSIONS Laparoscopy was noninferior to open surgery for rectal cancer in terms of individual quality of surgical resection outcomes. These findings are concordant with RCTs demonstrating noninferiority for long-term oncologic outcomes between the 2 approaches.
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Dai J, Yu Z. Comparison of Clinical Efficacy and Complications Between Laparoscopic Versus Open Surgery for Low Rectal Cancer. Comb Chem High Throughput Screen 2019; 22:179-186. [PMID: 30973104 DOI: 10.2174/1386207322666190411113252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/20/2018] [Accepted: 12/11/2018] [Indexed: 01/07/2023]
Abstract
Aim:
To compare the surgical outcomes of laparoscopic surgery for lower rectal cancer
with open surgery.
Methods:
The multiple databases including PubMed, Springer, EMBASE, EMBASE, OVID were
adopted to search for the relevant studies, and full-text articles involving the comparison of
unilateral and bilateral PVP surgery were reviewed. Review Manager 5.0 was adopted to estimate
the effects of the results among the selected articles. Forest plots, sensitivity analysis and bias
analysis for the articles included were also conducted.
Results:
Finally, 1186 patients were included in the 10 studies, which eventually satisfied the
eligibility criteria, and laparoscopic and open surgery group were 646 and 540, respectively. The
meta-analysis suggested that there was no significant difference of the operation time between
laparoscopic and open surgery group, while the time to solid intake, hospital stay time, blood loss
and complication rate of laparoscopic group are much less than those of open surgery.
Conclusion:
Although both these two punctures provide similar operation time, we encourage the
use of the laparoscopic surgery as the preferred surgical technique for treatment of lower rectal
cancer due to less time to solid intake, hospital stay time, blood loss and lower complication rate.
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Affiliation(s)
- Jian Dai
- Department of Colorectal and Anal Surgery, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua 321000, Zhejiang, China
| | - Zhou Yu
- Department of Colorectal and Anal Surgery, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua 321000, Zhejiang, China
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Huang YJ, Kang YN, Huang YM, Wu ATH, Wang W, Wei PL. Effects of laparoscopic vs robotic-assisted mesorectal excision for rectal cancer: An update systematic review and meta-analysis of randomized controlled trials. Asian J Surg 2019; 42:657-666. [DOI: 10.1016/j.asjsur.2018.11.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 02/08/2023] Open
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The prevalence of venous thromboembolism in rectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis 2019; 34:849-860. [PMID: 30824975 DOI: 10.1007/s00384-019-03244-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Venous thromboembolism (VTE) following rectal surgery is a significant and preventable cause of morbidity and mortality, yet the true prevalence is not well established. This systematic review and meta-analysis assessed the available literature and determined its prevalence following rectal surgery. METHODS A systematic review assessed the prevalence of VTE following rectal surgery. In addition, we evaluated whether subgroups (open vs. minimally invasive or benign vs. malignant resections) impacted on its prevalence or rate of deep venous thrombosis (DVT) or pulmonary embolism (PE). RESULT Thirty-eight studies met the predefined inclusion criteria. The aggregate prevalence of VTE following rectal surgery was 1.25% (95% CI 0.86-1.63), with DVT and PE occurring in 0.68% (95% CI 0.48-0.89) and 0.57% (95% CI 0.47-0.68) of patients. VTE following cancer and benign resection was 1.59% (95% CI 0.60-1.23 and 1.5% (95% CI 0.89-2.12) respectively. The prevalence of VTE in patients having minimally invasive resection was lower than those having open surgery [0.58% (16/2770) vs. 2.22% (250/11278); RR 0.54, 95% CI 0.33-0.86]. CONCLUSION This review observed that there is sparse evidence on prevalence of VTE following rectal surgery. It provides aggregated data and analysis of available literature, showing overall prevalence is low, especially in those having minimally invasive procedures.
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Song XJ, Liu ZL, Zeng R, Ye W, Liu CW. A meta-analysis of laparoscopic surgery versus conventional open surgery in the treatment of colorectal cancer. Medicine (Baltimore) 2019; 98:e15347. [PMID: 31027112 PMCID: PMC6831213 DOI: 10.1097/md.0000000000015347] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND This meta-analysis aimed to explore the overall effect and safety of anterior laparoscopic surgery versus conventional open surgery for patients with colorectal cancer based on eligible randomized controlled trials (RCTs), especially the difference in the postoperative incidence of deep venous thrombosis (DVT). METHODS PubMed, Cochrane, and Embase were searched based on keywords to identify eligible studies before February 2018. Only RCTs were eligible. We analyzed the main outcomes using the relative risk (RR) or mean difference (MD) along with 95% confidence interval (95% CI). RESULTS In this meta-analysis, we analyzed a total of 24 studies with 4592 patients in the laparoscopic surgery group and 3865 patients in the open surgery group. The results indicated that compared with the open surgery, laparoscopic surgery significantly decreased estimated blood loss (SMD: -1.14, 95%CI: -1.70 to -0.57), hospital stay (SMD: -1.12, 95%CI: -1.76 to -0.47), postoperative mortality (RR: 0.60, 95%CI: 0.41-0.86) and postoperative complication (RR: 0.83, 95%CI: 0.72-0.95). However, the operative time (WMD: 40.46, 95%CI: 35.94-44.9) was statistically higher in the laparoscopic surgery group than the open surgery group, and there was no significant difference in the incidence of DVT between the 2 groups (RR: 0.96, 95%CI: 0.46-2.02). CONCLUSION Laparoscopic surgery is superior to open surgery for patients with colorectal cancer. But the 2 surgeries showed no significant difference in the incidence of DVT.
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A Meta-Analysis and Systematic Review of Perioperative Outcomes of Laparoscopic-assisted Rectal Resection (LARR) Versus Open Rectal Resection (ORR) for Carcinoma. Surg Laparosc Endosc Percutan Tech 2019; 28:337-348. [PMID: 30358650 DOI: 10.1097/sle.0000000000000589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS AND OBJECTIVES The aim was to conduct a systematic review and meta-analysis of the randomized evidence to determine the relative merits of perioperative outcomes of laparoscopic-assisted (LARR) versus open rectal resection (ORR) for proven rectal cancer. MATERIALS AND METHODS A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English-language randomized clinical trials comparing LARR and ORR. The meta-analysis was prepared in accordance with the PRISMA statement. Thirteen outcome variables were analyzed. Random effects meta-analyses were performed due to heterogeneity. RESULTS A total of 14 randomized clinical trials that included 3843 rectal resections (LARR 2096, ORR 1747) were analyzed. The summary point estimates favored LARR for the intraoperative blood loss, commencement of oral intake, first bowel movement, and length of hospital stay. There was significantly longer duration of operating time of 38.29 minutes for the LARR group. Other outcome variables such as total complications, postoperative pain, postoperative ileus, abdominal abscesses, postoperative anastomotic leak, reintervention and postoperative mortality rates were found to have comparable outcomes for both cohorts. CONCLUSIONS LARR was associated with significantly reduced blood loss, quicker resumption of oral intake, earlier return of gastrointestinal function, and shorter length of hospital stay at the expense of significantly longer operating time. Postoperative morbidity and mortality and analgesia requirement for both these groups were comparable. LARR seems to be a safe and effective alternative to ORR; however, it needs to be performed in established colorectal units with experienced laparoscopic surgeons.
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Lin Z, Jiang ZL, Chen DY, Chen MF, Chen LH, Zhou P, Xia AX, Zhu YW, Jin H, Ge QQ. Short- and long-term outcomes of laparoscopic versus open surgery for rectal cancer: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e13704. [PMID: 30558085 PMCID: PMC6320083 DOI: 10.1097/md.0000000000013704] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/26/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The present meta-analysis aimed to evaluate the short- and long-term outcomes of laparoscopic surgery (LS) versus open surgery (OS) for rectal cancer. METHODS PubMed, Web of Science, and Cochrane Library, were searched for eligible randomized controlled trials (RCTs) published up to June 2017. Operation related index, postoperative complication, and long-term survival rate and disease-free survival rate were evaluated by meta-analytical techniques. RESULT Nine RCTs enrolling 4126 patients were included in the present meta-analysis. Compared to OS, LS had similar positive circumferential resection margin (CRM) and number of lymph nodes extracted (LNE) as well as long term 5 years survival rate and disease-free survival rate, but of which the risk tendency was higher in LS group. The short-term outcomes of major and total postoperative complication were lower in LS group. CONCLUSIONS LS for rectal cancer was as safe and effective as OS in terms of long-term outcomes, but with lower postoperative complication.
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Affiliation(s)
- Zhong Lin
- Department of Clinical Pharmacy, Taizhou Hospital of Zhejiang Province, Linhai
| | - Zheng-Li Jiang
- Department of Clinical Pharmacy, Taizhou Hospital of Zhejiang Province, Linhai
| | - Dan-Yang Chen
- Rehabilitation Department, Taizhou Hospital of Zhejiang Province
| | - Min-Fang Chen
- Department of Surgery, Wenlin Chinese Medicine Hospital, Wenlin, Zhejiang Province, China
| | | | - Peng Zhou
- Department of Clinical Pharmacy, Taizhou Hospital of Zhejiang Province, Linhai
| | - Ai-Xiao Xia
- Department of Clinical Pharmacy, Taizhou Hospital of Zhejiang Province, Linhai
| | - Yan-Wu Zhu
- Department of Clinical Pharmacy, Taizhou Hospital of Zhejiang Province, Linhai
| | - Hui Jin
- Department of Clinical Pharmacy, Taizhou Hospital of Zhejiang Province, Linhai
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Yang Z, Chunhua G, Huayan Y, Jianguo Y, Yong C. Anatomical basis for the choice of laparoscopic surgery for low rectal cancer through the pelvic imaging data-a cohort study. World J Surg Oncol 2018; 16:199. [PMID: 30290819 PMCID: PMC6173880 DOI: 10.1186/s12957-018-1498-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/21/2018] [Indexed: 01/21/2023] Open
Abstract
Background Low rectal cancer surgery without anus conservation needs permanent ileostomy or colostomy which seriously affects the quality of life of patients. Therefore, low rectal cancer surgery not only pays attention to the safety of surgical treatment but also to the anus conservation. Methods Sixty-seven patients suffering from low rectal cancer had undergone laparoscopic surgery which was analyzed through retrospective study. They were divided into the anus-conserving and non-anus-conserving groups. Thirty-five set of pelvic data was obtained from the preoperative CT and MRI images. After that, the discriminant function was obtained to predict the surgery methods for patients with low rectal carcinoma. Results Anal-conserving group discriminant function (F1) = − 33.698 + 6.045 × anal margin distance (cm) + 1.105 × T4; non-anus-conserving group discriminant function (F2) = − 14.125 + 3.138 × anal margin distance (cm) + 0.804 × T4. If F1 is greater than F2, then the case can be treated as the anus reservation while if F2 is greater than F1 the case cannot be treated anus reservation. The accuracy of the discriminant function was evaluated which was found to be 97%. Conclusion The discriminant function of pelvic data provides anatomical basis for the choice of surgical methods for low rectal cancer.
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Affiliation(s)
- Zhou Yang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Guo Chunhua
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yuan Huayan
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yang Jianguo
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Cheng Yong
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Liu Z, Zhou T, Yang G, Zhang G. Comparison of Clinical Outcomes Between Laparoscopic-Assisted and Minilaparotomy Approaches for Colon Cancer. J Gastrointest Cancer 2018; 49:158-166. [PMID: 28154967 DOI: 10.1007/s12029-017-9923-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS The minilaparotomy approach is feasible for the resection of colon cancer. This study aimed to compare the clinical and oncological outcomes of minilaparotomy and laparoscopic approaches in patients with colon cancer. METHODS We performed a retrospective analysis of consecutive patients undergoing minilaparotomy or laparoscopic resection for colon cancer from January 2009 to December 2014. RESULTS There were 376 patients with colon cancer. Seventy-one patients were excluded. The remaining 305 patients were allocated to the minilaparotomy (n = 146) group or laparoscopic group (n = 159). The demographic data of the two groups was similar except for body mass index. The time to first bowel movement (P = 0.000) and the hospital stay (P = 0.005) were less in the laparoscopic group. Compared with the minilaparotomy group, the mean operation time was longer and the costs higher for laparoscopic group (P = 0.000). The morbidity, mortality, and local recurrence were comparable between the two groups. The 5-year overall and disease-free survival rates were also similar (overall survival is 75.3 vs. 72.9%, P = 0.648; disease-free survival is 66.2 vs. 70.2%, P = 0.914). CONCLUSION The minilaparotomy approach was safe and equivalent to laparoscopic approach for patients with colon cancer. It is an alternative to the laparoscopic approach in selected patients.
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Affiliation(s)
- Zuoliang Liu
- The First Department of General Surgery, Institute of Hepatobiliary, Pancreas and Intestinal Disease, The Affiliated Hospital of North Sichuan Medical College, No. 63, Wenhua Road, Nanchong, Sichuan Province, 637000, China
| | - Tong Zhou
- The First Department of General Surgery, Institute of Hepatobiliary, Pancreas and Intestinal Disease, The Affiliated Hospital of North Sichuan Medical College, No. 63, Wenhua Road, Nanchong, Sichuan Province, 637000, China.
| | - Guodong Yang
- The First Department of General Surgery, Institute of Hepatobiliary, Pancreas and Intestinal Disease, The Affiliated Hospital of North Sichuan Medical College, No. 63, Wenhua Road, Nanchong, Sichuan Province, 637000, China
| | - Guangjun Zhang
- The First Department of General Surgery, Institute of Hepatobiliary, Pancreas and Intestinal Disease, The Affiliated Hospital of North Sichuan Medical College, No. 63, Wenhua Road, Nanchong, Sichuan Province, 637000, China
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Foster JD, Tou S, Curtis NJ, Smart NJ, Acheson A, Maxwell-Armstrong C, Watts A, Singh B, Francis NK. Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement. Colorectal Dis 2018; 20 Suppl 5:5-23. [PMID: 30182511 DOI: 10.1111/codi.14348] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/16/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE). METHODS A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations. RESULTS Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications. CONCLUSION This position statement updates clinicians on current evidence around perineal closure after APE surgery.
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Affiliation(s)
- J D Foster
- Department of General Surgery, Poole Hospital NHS Foundation Trust, Poole, Dorset, UK
| | - S Tou
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, Somerset, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - N J Smart
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - A Acheson
- Department of Colorectal Surgery, Nottingham University Hospital, Nottingham, UK
| | - C Maxwell-Armstrong
- Department of Colorectal Surgery, Nottingham University Hospital, Nottingham, UK
| | - A Watts
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - B Singh
- Department of General Surgery, Leicester General Hospital, Leicester, UK
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Sheng S, Zhao T, Wang X. Comparison of robot-assisted surgery, laparoscopic-assisted surgery, and open surgery for the treatment of colorectal cancer: A network meta-analysis. Medicine (Baltimore) 2018; 97:e11817. [PMID: 30142771 PMCID: PMC6112974 DOI: 10.1097/md.0000000000011817] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 07/13/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of this study was to find the better treatment for colorectal cancer (CRC) by comparing robot-assisted colorectal surgery (RACS), laparoscopic-assisted colorectal surgery (LACS), and open surgery using network meta-analysis. METHODS A literature search updated to August 15, 2017 was performed. All the included literatures were evaluated according to the quality evaluation criteria of bias risk recommended by the Cochrane Collaboration. All data were comprehensively analyzed by ADDIS. Odds ratio (OR), mean difference (MD), and 95% confidence interval (CI) were used to show the effect index of all data. The degree of convergence of the model was evaluated by the Brooks-Gelman-Rubin method with the potential scale reduction factor (PSRF) as the evaluation indicator. RESULTS The PSRF values of operation time, estimated blood loss, length of hospital stay, complication, mortality, and anastomotic leakage ranged from 1.00 to 1.01, and those of wound infection, bleeding, and ileus ranged from 1.00 to 1.02. Open surgery had the shortest operation time compared with LACS and RACS. Furthermore, compared with LACS, the amount of blood loss, complication, mortality, bleeding rate, and ileus rate for RACS were the least, and the length of hospital stay for RACS was the shortest. The anastomotic leakage rate for LACS was the least, but there was no significant difference compared with those of RACS and open surgery. The wound infection rate for LACS was the least, but there was no significant difference compared with that of RACS. CONCLUSION RACS might be a better treatment for patients with CRC.
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Affiliation(s)
| | - Tiancheng Zhao
- Department of Endoscopy Center, China-Japan Union Hospital of Jilin University
| | - Xu Wang
- Department of Colorectal and Anal Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, China
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Hawkins AT, Albutt K, Wise PE, Alavi K, Sudan R, Kaiser AM, Bordeianou L. Abdominoperineal Resection for Rectal Cancer in the Twenty-First Century: Indications, Techniques, and Outcomes. J Gastrointest Surg 2018; 22:1477-1487. [PMID: 29663303 DOI: 10.1007/s11605-018-3750-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 03/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made regarding need for modification of the surgical approach based on tumor anatomy and patient goals. DISCUSSION In this article, we address patient selection, preoperative planning, and intraoperative technique required to perform the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality of life.
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Affiliation(s)
- Alexander T Hawkins
- Department of Surgery, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA, USA.
- Division of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA.
| | - Katherine Albutt
- Department of Surgery, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Paul E Wise
- Section of Colon and Rectal Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Karim Alavi
- Department of Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Ranjan Sudan
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Andreas M Kaiser
- Department of Colorectal Surgery, University of Southern California, Los Angeles, CA, USA
| | - Liliana Bordeianou
- Department of Surgery, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA, USA
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Acuna SA, Chesney TR, Amarasekera ST, Baxter NN. Defining Non-inferiority Margins for Quality of Surgical Resection for Rectal Cancer: A Delphi Consensus Study. Ann Surg Oncol 2018; 25:3171-3178. [PMID: 30051366 DOI: 10.1245/s10434-018-6639-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Quality of surgical resection metrics (QSRMs) have been used as surrogates for long-term oncologic outcomes in non-inferiority randomized clinical trials (RCTs) comparing laparoscopic and open surgery for rectal cancer. However, non-inferiority margins (ΔNI) for QSRMs have not been previously defined. METHODS A two-round, web-based Delphi was used to define ΔNI for four QSRMs: positive circumferential resection margin (CRM), incomplete plane of mesorectal excision (PME), positive distal resection margin (DRM), and a composite of these outcomes. Overall, 130 international experts in rectal cancer (68 surgeons, 20 medical oncologists, 16 radiation oncologists, and 26 pathologists) were invited to participate. Experts were presented with evidence syntheses summarizing the association between QSRMs and long-term outcomes, and pooled quality of surgical resection outcomes for open surgery, and were asked to provide ΔNI for all outcomes balancing the risks and benefits of minimally invasive surgery. RESULTS Seventy-two experts participated: 57 completed the initial questionnaire and 58 completed the revised questionnaire, with 43 participating in both rounds. Consensus was reached for all individual QSRM ΔNI but not for the composite. The mean (standard deviation) ΔNI was an absolute difference of 2.33% (1.59%) for the proportion of positive CRMs when comparing surgical interventions for the treatment of rectal cancer: 2.85% (1.83%) for incomplete PME; 1.28% (1.13%) for positive DRMs; and 2.71% (2.28%) for the composite. However, opinions varied widely for the composite outcome. CONCLUSIONS Web-based Delphi processes are a feasible approach to generate ΔNI to evaluate novel surgical interventions. The generated ΔNI for QSRMs for rectal cancer can be used for future RCTs and non-inferiority meta-analyses.
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Affiliation(s)
- Sergio A Acuna
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tyler R Chesney
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sonali T Amarasekera
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Faculty of Science, McGill University, Montreal, QC, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. .,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. .,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Division of General Surgery, St. Michael's Hospital, Toronto, ON, Canada.
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Memon MA, Awaiz A, Yunus RM, Memon B, Khan S. Meta-analysis of histopathological outcomes of laparoscopic assisted rectal resection (LARR) vs open rectal resection (ORR) for carcinoma. Am J Surg 2018; 216:1004-1015. [PMID: 29958656 DOI: 10.1016/j.amjsurg.2018.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/01/2018] [Accepted: 06/14/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND We conducted a meta-analysis of the randomized evidence to determine the relative merits of histopathological outcomes of laparoscopic assisted (LARR) versus open rectal resection (ORR) for rectal cancer. DATA SOURCES A search of PubMed and other electronic databases comparing LARR and ORR between Jan 2000 and June 2016 was performed. Histopathological variables analyzed included; location of rectal tumors; complete and incomplete TME; positive and negative circumferential resection margins (+/-CRM); positive distal resected margins (+DRM); distance of tumor from DRM; number of lymph nodes harvested; resected specimen length; tumor size and perforated rectum. RESULTS Fourteen RCTs totaling 3843 patients (LARR = 2096, ORR = 1747) were analyzed. Comparable effects were noted for all these histopathological variables except for the variable perforated rectum which favored ORR. CONCLUSIONS LARR compares favorably to ORR for rectal cancer treatment. However, there is significantly higher risk of rectal perforation during LARR compared to ORR.
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Affiliation(s)
- Muhammed Ashraf Memon
- South East Queensland Surgery (SEQS), Sunnybank Obesity Centre, Sunnybank, Queensland, Australia; School of Agricultural, Computing and Environmental Sciences, International Centre for Applied Climate Science, University of Southern Queensland, Toowoomba, Queensland, Australia; Mayne Medical School, School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia; Faculty of Health and Social Science, Bolton University, Bolton, Lancashire, UK.
| | - Aiman Awaiz
- South East Queensland Surgery (SEQS), Sunnybank Obesity Centre, Sunnybank, Queensland, Australia.
| | | | - Breda Memon
- South East Queensland Surgery (SEQS), Sunnybank Obesity Centre, Sunnybank, Queensland, Australia.
| | - Shahjahan Khan
- School of Agricultural, Computing and Environmental Sciences, International Centre for Applied Climate Science, University of Southern Queensland, Toowoomba, Queensland, Australia.
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What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review. Int J Colorectal Dis 2018; 33:663-681. [PMID: 29623415 DOI: 10.1007/s00384-018-3036-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND "Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery. METHODS A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed. RESULTS Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact. CONCLUSIONS NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.
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Toda S, Kuroyanagi H, Matoba S, Hiramatsu K, Okazaki N, Tate T, Tomizawa K, Hanaoka Y, Moriyama J. Laparoscopic treatment of rectal cancer and lateral pelvic lymph node dissection: are they obsolete? MINERVA CHIR 2018; 73:558-573. [PMID: 29795062 DOI: 10.23736/s0026-4733.18.07704-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Laparoscopic surgery for rectal cancer offers favorable short-term results without compromising long term oncological outcomes so far, according to the data from major trials. For this reason, it is currently considered as a standard option for rectal cancer surgery. The learning curve of laparoscopic rectal cancer surgery is generally longer compared to colon cancer. Appropriate standardization and training of laparoscopic rectal cancer surgery is required. Several RCTs suggested the potential negative effect on quality of resected specimen, which can increase local recurrence. The long-term outcomes - especially local recurrence rate - of these RCTs are awaited. Lateral pelvic lymph node dissection (LPLND) has a certain effect of reducing local recurrence of rectal cancer even after neoadjuvant radiotherapy. Since LPLND is associated with postoperative morbidity, we should carefully select the candidate to maximize the effect of LPLND and minimize the morbidity caused by LPLND. Recent advancements in imaging study such as CT and MRI enable us to find the suitable candidates for LPLND. The morbidity caused by LPLND could be reduced by minimally invasive surgeries such as laparoscopic surgery and robotic surgery. We have to improve oncological outcomes and reduce morbidity by the multidisciplinary strategy for rectal cancer including total mesorectal excision, neoadjuvant chemoradiotherapy and LPLND together with laparoscopic surgery.
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Affiliation(s)
- Shigeo Toda
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan -
| | - Hiroya Kuroyanagi
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Shuichiro Matoba
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Kosuke Hiramatsu
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Naoto Okazaki
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Tomohiro Tate
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Kenji Tomizawa
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yutaka Hanaoka
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Jin Moriyama
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
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Is the laparoscopic approach for rectal cancer superior to open surgery? A systematic review and meta-analysis on short-term surgical outcomes. Wideochir Inne Tech Maloinwazyjne 2018; 13:129-140. [PMID: 30002744 PMCID: PMC6041579 DOI: 10.5114/wiitm.2018.75845] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 02/13/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction Over the past years the incidence of colorectal cancers has increased worldwide. Currently it is the most common gastrointestinal malignancy worldwide. The laparoscopic approach has become the gold standard for surgical treatment. However, a recently published meta-analysis showed no difference in short- and long-term oncological outcomes of laparoscopy for treating rectal cancer. Aim To assess current literature on short-term outcomes of rectal cancer treatment using laparoscopic surgery in comparison to the open approach. Material and methods We performed a systematic review and meta-analysis according to the PRISMA guidelines. The primary outcomes of interest were morbidity and short-term complications. Results We identified 4,328 potential references. In the end we included 13 randomized controlled trials (RCTs). We did not find any significant differences in terms of morbidity, haemorrhage, ureter injury, anastomotic leakage, mortality, intra-abdominal abscess or postoperative ileus. We found significant differences in the rate of surgical site infections, operative time, blood loss, length of hospital stay and time to first bowel movement. Conclusions This systematic review based on available RCTs confirms that laparoscopic rectal cancer surgery is associated with short-term outcomes comparable to the open approach. Moreover, in some aspects it provides better results (e.g. functional postoperative recovery, lower rate of surgical site infections (SSIs)). The quality of evidence is high; therefore in our opinion it is very unlikely that future trials will alter these results, and for this reason the laparoscopic approach can be considered the gold standard for the treatment of the majority of patients.
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Zhang X, Wu Q, Hu T, Gu C, Bi L, Wang Z. Laparoscopic Versus Conventional Open Abdominoperineal Resection for Rectal Cancer: An Updated Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2018; 28:526-539. [PMID: 29406806 DOI: 10.1089/lap.2017.0593] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Xubing Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qingbin Wu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Tao Hu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Chaoyang Gu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Bi
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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50
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Wu QB, Deng XB, Zhang XB, Kong LH, Zhou ZG, Wang ZQ. Short-Term and Long-Term Outcomes of Laparoscopic Versus Open Surgery for Low Rectal Cancer. J Laparoendosc Adv Surg Tech A 2018; 28:637-644. [PMID: 29323615 DOI: 10.1089/lap.2017.0630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the short-term and long-term outcomes of laparoscopic versus open surgery for low rectal cancer. METHODS Patients with low rectal cancer who underwent laparoscopic or open surgery at our department from January 2009 to December 2013 were enrolled in this retrospective study. The primary end points were 3-year local recurrence and overall and disease-free survival (DFS) rates. Secondary end points were intraoperative and postoperative outcomes. RESULTS Laparoscopic group had longer operative time (165.0 versus 140.0, P < .001), less blood loss (20.0 versus 40.0, P < .001), shorter length of incision (5.0 versus 18.0, P < .001), and more lymph node harvested (11.0 versus 9.0, P = .002). However, time to first flatus (P = .941), postoperative hospital stay (P = .095), postoperative complications (P = .155), and 30-day mortality (P = .683) was similar between two groups. With the median follow-up period of 65 months, the 3-year local recurrence rate was 4.3% in laparoscopic group and 7.5% in open group (P = .077); the 3-year overall and DFS rates were similar in two groups (85.9% versus 88.8%, P = .229 and 76.9% versus 79.2%, P = .448, respectively); and the overall and DFS curves were comparable between two groups (hazard ratio [HR] = 0.858, 95% confidence intervals [CI] 0.709-1.037, P = .112 and HR = 1.076, 95% CI 0.834-1.389, P = .275, respectively). CONCLUSIONS Laparoscopic surgery is safe and has equivalent long-term oncologic outcomes for low rectal cancer when compared to open surgery. Furthermore, large-scale, prospective randomized clinical trials are needed to confirm the present findings.
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Affiliation(s)
- Qing-Bin Wu
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China .,2 West China School of Medicine, Sichuan University , Chengdu, China
| | - Xiang-Bing Deng
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Xu-Bing Zhang
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China .,2 West China School of Medicine, Sichuan University , Chengdu, China
| | - Ling-Hong Kong
- 2 West China School of Medicine, Sichuan University , Chengdu, China
| | - Zong-Guang Zhou
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Zi-Qiang Wang
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China
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