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Negoi I. Guidance on the Surgical Management of Rectal Cancer: An Umbrella Review. Life (Basel) 2025; 15:955. [PMID: 40566606 DOI: 10.3390/life15060955] [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: 04/02/2025] [Revised: 06/07/2025] [Accepted: 06/10/2025] [Indexed: 06/28/2025] Open
Abstract
This umbrella review synthesizes international guidelines on the surgical management of rectal cancer to provide unified recommendations tailored to local healthcare organizations. This review emphasizes the importance of surgical centralization in high-volume centers, which maximizes outcomes, reduces morbidity, and increases survival rates. Minimally invasive approaches, such as laparoscopy and robotic surgery, are highlighted for their perioperative benefits, although careful patient selection and surgical expertise are required. Mechanical bowel preparation combined with oral antibiotics is recommended to effectively reduce complications, including surgical site infections and anastomotic leakage. Enhanced Recovery After Surgery protocols have been shown to significantly improve postoperative recovery and reduce hospital stay duration. Comprehensive perioperative care, including venous thromboembolism prophylaxis and infection control, is essential for optimal patient outcomes. This review underscores the need for structured training, certification, and regular audits for advanced techniques such as robotic surgery and transanal total mesorectal excision. Implementation of a national database is recommended to support ongoing improvements in rectal cancer surgery. This review centralizes evidence-based recommendations to guide surgical decision-making and harmonize the multidisciplinary care for patients with rectal cancer.
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Affiliation(s)
- Ionut Negoi
- Department of General Surgery, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 050474 Bucharest, Romania
- Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
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Ando M, Matsuda T, Yamashita K, Hasegawa H, Sawada R, Koterazawa Y, Urakawa N, Goto H, Kanaji S, Kakeji Y. Clinical significance of robot-assisted laparoscopic surgery for rectal cancer: a retrospective propensity score matching analysis. Langenbecks Arch Surg 2025; 410:165. [PMID: 40397199 PMCID: PMC12095325 DOI: 10.1007/s00423-025-03734-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2025] [Accepted: 05/06/2025] [Indexed: 05/22/2025]
Abstract
PURPOSE Conventional laparoscopic surgery (CLS) for rectal cancer may sometimes be difficult. Robot-assisted laparoscopic surgery (RALS) is expected to overcome these technical challenges of CLS and provide better short-term outcomes. However, previous randomized controlled trials indicated that the safety and feasibility of RALS compared to CLS remain controversial; therefore, we assessed the safety and feasibility of RALS for rectal cancer compared with CLS. METHODS This study retrospectively reviewed 702 patients who had undergone anterior resection by CLS or RALS for rectal malignancies from January 2009 to December 2023. Among the patients, 313 and 75 were included in the CLS and RALS groups, respectively. Short- and midterm outcomes of the two groups were compared after performing propensity score matching analysis (PSM) to adjust for patient and tumor characteristics. RESULTS A total of 140 and 70 patients in the CLS and RALS groups, respectively, were matched using PSM. The bleeding amount and C-reactive protein (CRP) levels on postoperative days 1 and 3 were significantly lower, the operation time was longer, and the postoperative hospital stay was significantly shorter in the RALS group than in the CLS group. The Kaplan-Meier curves for cause-specific survival, relapse-free survival, and the cumulative incidence of local recurrence demonstrated no difference between the two groups. CONCLUSION RALS for rectal cancer provided superior outcomes to CLS in terms of the bleeding amount, postoperative CRP levels, and postoperative hospital stay. The midterm oncological outcomes in RALS were comparable to those in CLS.
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Affiliation(s)
- Masayuki Ando
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeru Matsuda
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
- Division of Minimally Invasive Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Chuo-ku, Kobe, 650-0017, Japan.
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryuichiro Sawada
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasufumi Koterazawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Urakawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hironobu Goto
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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He G, Zhang Z, Yuan W, Li T, Tang B, Jia B, Zhou Y, Zhang W, Zhao R, Zhang C, Cheng L, Zhang X, Liang F, Wei Y, Feng Q, Xu J. Influence of surgical start time on the quality of surgery for middle and low rectal cancer: a post hoc analysis of the real trial. Int J Surg 2025; 111:3281-3288. [PMID: 40171564 PMCID: PMC12165524 DOI: 10.1097/js9.0000000000002345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 03/07/2025] [Indexed: 04/03/2025]
Abstract
BACKGROUND Surgical start time is considered to influence the quality of surgery due to surgeon fatigue. High-quality studies on middle and low rectal cancer are lacking. The analysis aims to find out the influence of surgical start time on the quality of surgery for middle and low rectal cancer, and whether robotic surgery could avoid the influence. MATERIALS AND METHODS This study was a post hoc analysis of the REAL (robotic vs. laparoscopic surgery for middle and low rectal cancer) study, a multicenter, randomized, controlled, unblinded, parallel group, superiority trial. This analysis included the modified intention-to-treat population of the REAL study, who were divided into Group I (the surgeon's first surgery of the day), Group II (the surgeon's second surgery of the day), and Group III (the surgeon's third and subsequent surgeries of the day) based on surgical information registered in the REAL study. The primary outcome was the percentage of patients with a positive circumferential resection margin. The second outcomes were the macroscopic completeness of resection the incidence of intraoperative complications and 30-day postoperative complications. RESULTS A total of 1171 patients from the REAL study were included and divided into three groups: 547 (46.7%) in Group I (the surgeon's first surgery), 420 (35.9%) in Group II (the surgeon's second surgery), and 204 (17.4%) in Group III (the surgeon's third and subsequent surgeries). There was a lower percentage of circumferential resection margin (CRM)-positive patients in Group I (3.9%) than in Group II (6.6%, unadjusted P = 0.069) and Group III (8.1%, unadjusted P = 0.027, adjusted P = 0.081). Group I also had fewer intraoperative complications (5.3%) than Group II (8.3%, unadjusted P = 0.060) and Group III (9.3%, unadjusted P = 0.046, adjusted P = 0.138). Macroscopic completeness of resection was not significantly different among the three groups (complete rate: Group I vs. Group II, 94.9% vs. 92.4%, unadjusted P = 0.254; Group I vs. Group III, 94.9% vs. 92.6%, unadjusted P = 0.334; Group II vs. Group III, 92.4% vs. 92.6%, unadjusted P = 0.488). The incidence of 30-day postoperative complications showed no significant difference among the three groups (Group I vs. Group II, 18.5% vs. 20.0%, unadjusted P = 0.547; Group I vs. Group III, 18.5% vs. 22.1%, unadjusted P = 0.268; Group II vs. Group III, 20.0% vs. 22.1%, unadjusted P = 0.551). The quality of robotic surgery was not significantly influenced by surgical start time. For laparoscopic surgery, Group I had a lower CRM positivity rate (4.3%) than Group II (9.4%, unadjusted P = 0.029, adjusted P = 0.087) and Group III (10.4%, unadjusted P = 0.031, adjusted P = 0.047). CONCLUSION According to this post hoc analysis of the REAL study, for middle and low rectal cancer surgery, surgical start time could influence surgical quality by affecting surgeon fatigue. Surgeries start later in a day bring worse quality compared to those early in a day. Robotic surgery could reduce this influence to some extent, while laparoscopic surgery is more susceptible.
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Affiliation(s)
- Guodong He
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive, Shanghai, China
| | - Zhuojian Zhang
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Weitang Yuan
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzho, Henan Province, China
| | - Taiyuan Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Bo Tang
- Department of General Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Baoqing Jia
- Department of General Surgery, The First Medical Center, PLA General Hospital, Beijing, China
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Ren Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cheng Zhang
- Department of General Surgery, Northern Theater Command General Hospital, Shenyang, Liaoning Province, China
| | - Longwei Cheng
- Second Department of Gastrointestinal Surgery, Jilin Cancer Hospital, Changchun, Jilin Province, China
| | - Xiaoqiao Zhang
- Department of General Surgery, Shandong Provincial Hospital affiliated to the Shandong First Medical University, Jinan, Shandong Province, China
| | - Fei Liang
- Department of Biostatistics, Zhongshan Hospital Fudan University, Shanghai, China
| | - Ye Wei
- Department of General Surgery, Huadong Hospital Fudan University, Shanghai, China
| | - Qingyang Feng
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive, Shanghai, China
| | - Jianmin Xu
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive, Shanghai, China
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Cirera de Tudela A, Marinello F, Espín Basany E. And after surgery, what's new for the rectal cancer survivor? Cir Esp 2025; 103:237-243. [PMID: 39855552 DOI: 10.1016/j.cireng.2025.01.001] [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: 09/09/2024] [Accepted: 11/21/2024] [Indexed: 01/27/2025]
Abstract
Low anterior resection syndrome is a common but underestimated complication after rectal cancer surgery that significantly impacts the quality of life of the surviving patient. It is characterised by symptoms such as faecal incontinence and voiding dysfunction and affects up to 90% of patients undergoing low anterior rectal resection. The aetiology of the syndrome is multifactorial with no clear determining factor. It includes the use of preoperative radiotherapy, the indication for a protective ileostomy, sphincteric lesions, nerve damage to the rectal autonomic plexuses, and changes in left colon motor function. Although various therapeutic modalities have been shown to be effective in the management of the symptoms of the syndrome, there is still no standard treatment or patient selection pattern. In this article, a critical review of the therapeutic possibilities for patients who have survived rectal surgery will be made.
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Affiliation(s)
- Arturo Cirera de Tudela
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Franco Marinello
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Eloy Espín Basany
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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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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Cardelli S, Stocchi L, Merchea A, Colibaseanu DT, DeLeon MF, Mishra N, Hancock KJ, Larson DW. Comparative Outcomes of Robotic Versus Open Proctectomy for Rectal Cancer at High Risk of Positive Circumferential Resection Margin. Dis Colon Rectum 2024; 67:1475-1484. [PMID: 39105515 DOI: 10.1097/dcr.0000000000003466] [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: 08/07/2024]
Abstract
BACKGROUND Concerns persist regarding the effectiveness of robotic proctectomy compared with open proctectomy for locally advanced rectal cancer with a high risk of circumferential resection margin involvement. OBJECTIVE Comparison of surrogate cancer outcomes after robotic versus open proctectomy in this subpopulation. DESIGN Retrospective cohort study. SETTING Three academic hospitals (Mayo Clinic Arizona, Florida, and Rochester) with data available through the Mayo Data Explorer platform. PATIENTS Patients at high risk of circumferential resection margin involvement were selected on the basis of the MRI-based definition from the MERCURY I and II trials. MAIN OUTCOME MEASURES Rate of pathologic circumferential resection margin involvement (≤1 mm), mesorectal grading, and rate of distal margin involvement. RESULTS Out of 413 patients, 125 (30%) underwent open and 288 (70%) underwent robotic proctectomy. Open proctectomy was significantly associated with a greater proportion of cT4 tumors (39.3% vs 24.8%, p = 0.021), multivisceral/concomitant resections (40.8% vs 18.4%, p < 0.001), and less frequent total neoadjuvant therapy use (17.1% vs 47.1%, p = 0.001). Robotic proctectomy was less commonly associated with pathologic circumferential resection margin involvement (7.3% vs 17.6%, p = 0.002), including after adjustment for cT stage, neoadjuvant therapy, and multivisceral resection (OR 0.326; 95% CI, 0.157-0.670, p = 0.002). Propensity score matching for 66 patients per group and related multivariable analysis no longer indicated any reduction of circumferential positive margin rate associated with robotic surgery ( p = 0.86 and p = 0.18). Mesorectal grading was comparable (incomplete mesorectum in 6% robotic proctectomy patients vs 11.8% open proctectomy patients, p = 0.327). All cases had negative distal resection margins. LIMITATION Retrospective design. CONCLUSIONS In patients with locally advanced rectal cancer at high risk of circumferential resection margin involvement, robotic proctectomy is an effective approach and could be pursued when technically possible as an alternative to open proctectomy. See Video Abstract . RESULTADOS COMPARATIVOS ENTRE LA PROCTECTOMA ROBTICA Y LA PROCTECTOMA ABIERTA EN CASOS DE CNCER DE RECTO CON ALTO RIESGO DE MRGEN DE RESECCIN CIRCUNFERENCIAL POSITIVO ANTECEDENTES:Persisten preocupaciones con respecto a la efectividad de la proctectomía robótica en comparación con la proctectomía abierta en casos de cáncer de recto localmente avanzado con un alto riesgo de margen de resección circunferencial positivo.OBJETIVO:Comparar los resultados en la subpoblación de portadores de cáncer luego de una proctectomía robótica versus una proctectomía abierta.DISEÑO:Estudio retrospectivo de cohortes.AJUSTE:Realizado en tres hospitales académicos (Mayo Clinic de Arizona, Florida y Rochester) a través de la plataforma Mayo Data Explorer.PACIENTES:Fueron seleccionados aquellos pacientes con alto riesgo de compromiso sobre el margen de resección circunferencial, según la definición de los Estudios Mercury I-II basada en la Imágen de Resonancia Magnética.MEDIDAS DE RESULTADO PRINCIPALES Y SECUNDARIAS:La tasa de compromiso patológico sobre el margen de resección circunferencial (≤1 mm), la clasificación mesorrectal y la tasa del compromiso del margen distal.RESULTADOS:De 413 pacientes, 125 (30%) fueron sometidos a una proctectomía abierta y 288 (70%) a proctectomía robótica. La proctectomía abierta se asoció significativamente con una mayor proporción de tumores cT4 (39,3% frente a 24,8%, p = 0,021), las resecciones multiviscerales/concomitantes fueron de 40,8% frente a 18,4%, p < 0,001 y una adminstración menos frecuente de terapia neoadyuvante total (17,1). % vs 47,1%, p = 0,001).La proctectomía robótica se asoció con menos frecuencia con la presencia de una lesión sobre el margen de resección circunferencial patológico (7,3% frente a 17,6%, p = 0,002), incluso después del ajuste por estadio cT, de la terapia neoadyuvante y de resección multivisceral (OR 0,326, IC 95% 0,157-0,670, p = 0,002). El apareado de propensión por puntuación en 66 pacientes por grupo y el análisis multivariable relacionado, no mostraron ninguna reducción en la tasa de margen positivo circunferencial asociado con la cirugía robótica ( p = 0,86 y p = 0,18). La clasificación mesorrectal fue igualmente comparable (mesorrecto incompleto en el 6% de los pacientes con RP frente al 11,8% de los pacientes con OP, p = 0,327). Todos los casos tuvieron márgenes de resección distal negativos.LIMITACIÓN:Diseño retrospectivo.CONCLUSIÓN:En pacientes con cáncer de recto localmente avanzado con alto riesgo de compromiso del margen de resección circunferencial, la proctectomía robótica es un enfoque eficaz y podría realizarse cuando sea técnicamente posible como alternativa a la proctectomía abierta. (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Stefano Cardelli
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida
| | - Luca Stocchi
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida
| | - Michelle F DeLeon
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida
| | - Nitin Mishra
- Division of Colon and Rectal Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Kevin J Hancock
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic Minnesota, Rochester, Minnesota
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Djinbachian R, Rex DK, Chiu HM, Fukami N, Aihara H, Bastiaansen BAJ, Bechara R, Bhandari P, Bhatt A, Bourke MJ, Byeon JS, Cardoso D, Chino A, Chiu PWY, Dekker E, Draganov PV, Elkholy S, Emura F, Goldblum J, Haji A, Ho SH, Jung Y, Kawachi H, Khashab M, Khomvilai S, Kim ER, Maselli R, Messmann H, Moons L, Mori Y, Nakanishi Y, Ngamruengphong S, Parra-Blanco A, Pellisé M, Pinto RC, Pioche M, Pohl H, Rastogi A, Repici A, Sethi A, Singh R, Suzuki N, Tanaka S, Vieth M, Yamamoto H, Yang DH, Yokoi C, Saito Y, von Renteln D. International consensus on the management of large (≥20 mm) colorectal laterally spreading tumors: World Endoscopy Organization Delphi study. Dig Endosc 2024; 36:1253-1268. [PMID: 38934243 DOI: 10.1111/den.14826] [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] [Received: 12/11/2023] [Accepted: 05/07/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES There have been significant advances in the management of large (≥20 mm) laterally spreading tumors (LSTs) or nonpedunculated colorectal polyps; however, there is a lack of clear consensus on the management of these lesions with significant geographic variability especially between Eastern and Western paradigms. We aimed to provide an international consensus to better guide management and attempt to homogenize practices. METHODS Two experts in interventional endoscopy spearheaded an evidence-based Delphi study on behalf of the World Endoscopy Organization Colorectal Cancer Screening Committee. A steering committee comprising six members devised 51 statements, and 43 experts from 18 countries on six continents participated in a three-round voting process. The Grading of Recommendations, Assessment, Development and Evaluations tool was used to assess evidence quality and recommendation strength. Consensus was defined as ≥80% agreement (strongly agree or agree) on a 5-point Likert scale. RESULTS Forty-two statements reached consensus after three rounds of voting. Recommendations included: three statements on training and competency; 10 statements on preresection evaluation, including optical diagnosis, classification, and staging of LSTs; 14 statements on endoscopic resection indications and technique, including statements on en bloc and piecemeal resection decision-making; seven statements on postresection evaluation; and eight statements on postresection care. CONCLUSIONS An international expert consensus based on the current available evidence has been developed to guide the evaluation, resection, and follow-up of LSTs. This may provide guiding principles for the global management of these lesions and standardize current practices.
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Affiliation(s)
- Roupen Djinbachian
- Montreal University Hospital Research Center, Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, USA
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, USA
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert Bechara
- Division of Gastroenterology, Kingston Health Sciences Centre, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | | | - Amit Bhatt
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, USA
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniela Cardoso
- Institute of Digestive Apparatus, Oncological Surgery, Goiâsnia, Brazil
| | - Akiko Chino
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Philip W Y Chiu
- Division of Upper GI Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, USA
| | - Shaimaa Elkholy
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Fabian Emura
- Gastroenterology Division, de La Sabana University, Chia, Colombia
- Advanced GI Endoscopy, EmuraCenter LatinoAmerica, Bogotá, Colombia
| | - John Goldblum
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, USA
| | - Amyn Haji
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Shiaw-Hooi Ho
- Department of Medicine, Malaya University, Kuala Lumpur, Malaysia
| | - Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hiroshi Kawachi
- Department of Pathology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, USA
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of Surgery Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Leon Moons
- Departments of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | | | - Adolfo Parra-Blanco
- NHR Nottingham Biomedical Research Centre, Department of Gastroenterology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Gastroenterology, University of Nottingham, Nottingham, UK
| | - María Pellisé
- Department of Gastroenterology, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Hospital Clinic of Barcelona, Biomedical Research Center in Hepatic and Digestive Diseases (CIBERehd), University of Barcelona, Barcelona, Spain
| | | | - Mathieu Pioche
- Endoscopic Division, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Heiko Pohl
- Department of Gastroenterology, VA Medical Center, White River Junction, USA
- Dartmouth-Hitchcock Medical Center, White River Junction, USA
| | - Amit Rastogi
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, USA
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York City, USA
| | - Rajvinder Singh
- Gastroenterology Unit, Division of Surgery, Northern Adelaide Local Health Area Network, Adelaide, Australia
- Department of Gastroenterology, University of Adelaide, Adelaide, Australia
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St. Mark's Hospital, London, UK
| | - Shinji Tanaka
- Gastroenterology Division, JA Onomichi General Hospital, Hiroshima, Japan
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chizu Yokoi
- Department of Gastroenterology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Daniel von Renteln
- Montreal University Hospital Research Center, Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
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Kuroyanagi H, Hida K, Ishii Y, Yamamoto S, Hasegawa S, Takahashi K, Saida Y, Inomata M, Nakamura M, Sakai Y. Practice guidelines on endoscopic surgery for qualified surgeons by the endoscopic surgical skill qualification system: Large intestine. Asian J Endosc Surg 2024; 17:e13364. [PMID: 39079698 DOI: 10.1111/ases.13364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/08/2024] [Indexed: 09/15/2024]
Affiliation(s)
| | - Koya Hida
- Department of Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Yoshiyuki Ishii
- Department of General and Gastrointestinal Surgery, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Seiichiro Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka, Japan
| | - Kenichi Takahashi
- Department of Colorectal Surgery, Tohoku Rosai Hospital, Sendai, Japan
| | - Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, OITA University Faculty of Medicine, Oita, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshiharu Sakai
- Department of Gastrointestinal Surgery, Red Cross Hospital Osaka, Osaka, Japan
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9
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de’Angelis N, Marchegiani F, Martínez-Pérez A, Biondi A, Pucciarelli S, Schena CA, Pellino G, Kraft M, van Lieshout AS, Morelli L, Valverde A, Lupinacci RM, Gómez-Abril SA, Persiani R, Tuynman JB, Espin-Basany E, Ris F. Robotic, transanal, and laparoscopic total mesorectal excision for locally advanced mid/low rectal cancer: European multicentre, propensity score-matched study. BJS Open 2024; 8:zrae044. [PMID: 38805357 PMCID: PMC11132137 DOI: 10.1093/bjsopen/zrae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 03/11/2024] [Accepted: 04/01/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Total mesorectal excision (TME) is the standard surgery for low/mid locally advanced rectal cancer. The aim of this study was to compare three minimally invasive surgical approaches for TME with primary anastomosis (laparoscopic TME, robotic TME, and transanal TME). METHODS Records of patients undergoing laparoscopic TME, robotic TME, or transanal TME between 2013 and 2022 according to standardized techniques in expert centres contributing to the European MRI and Rectal Cancer Surgery III (EuMaRCS-III) database were analysed. Propensity score matching was applied to compare the three groups with respect to the complication rate (primary outcome), conversion rate, postoperative recovery, and survival. RESULTS A total of 468 patients (mean(s.d.) age of 64.1(11) years) were included; 190 (40.6%) patients underwent laparoscopic TME, 141 (30.1%) patients underwent robotic TME, and 137 (29.3%) patients underwent transanal TME. Comparative analyses after propensity score matching demonstrated a higher rate of postoperative complications for laparoscopic TME compared with both robotic TME (OR 1.80, 95% c.i. 1.11-2.91) and transanal TME (OR 2.87, 95% c.i. 1.72-4.80). Robotic TME was associated with a lower rate of grade A anastomotic leakage (2%) compared with both laparoscopic TME (8.8%) and transanal TME (8.1%) (P = 0.031). Robotic TME (1.4%) and transanal TME (0.7%) were both associated with a lower conversion rate to open surgery compared with laparoscopic TME (8.8%) (P < 0.001). Time to flatus and duration of hospital stay were shorter for patients treated with transanal TME (P = 0.003 and 0.001 respectively). There were no differences in operating time, intraoperative complications, blood loss, mortality, readmission, R0 resection, or survival. CONCLUSION In this multicentre, retrospective, propensity score-matched, cohort study of patients with locally advanced rectal cancer, newer minimally invasive approaches (robotic TME and transanal TME) demonstrated improved outcomes compared with laparoscopic TME.
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Affiliation(s)
- Nicola de’Angelis
- Unit of Robotic and Minimally Invasive Digestive Surgery, Department of Surgery, Ferrara University Hospital, Ferrara (Cona), Italy
| | - Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital (AP-HP), Clichy, France
- University Paris Cité, Paris, 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
| | - Alberto Biondi
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Salvatore Pucciarelli
- General Surgery 3, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Carlo Alberto Schena
- Unit of Robotic and Minimally Invasive Digestive Surgery, Department of Surgery, Ferrara University Hospital, Ferrara (Cona), Italy
| | - Gianluca Pellino
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Miquel Kraft
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Annabel S van Lieshout
- Department of Surgery, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alain Valverde
- Department of Digestive Surgery, Groupe Hospitalier Diaconesses, Croix Saint-Simon, Paris, France
| | - Renato Micelli Lupinacci
- Department of Digestive Surgery, Groupe Hospitalier Diaconesses, Croix Saint-Simon, Paris, France
| | - Segundo A Gómez-Abril
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Roberto Persiani
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Eloy Espin-Basany
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Frederic Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
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10
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Guo Y, He L, Tong W, Ren S, Chi Z, Tan K, Wang B, Lie C, Wang Q. Intersphincteric resection following robotic-assisted versus laparoscopy-assisted total mesorectal excision for middle and low rectal cancer: a multicentre propensity score analysis of 1571 patients. Int J Surg 2024; 110:1904-1912. [PMID: 38241345 PMCID: PMC11020017 DOI: 10.1097/js9.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/21/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Robotic-assisted total mesorectal excision (RaTME) may be associated with reduced conversion to an open approach and a higher rate of complete total mesorectal excision (TME); however, studies on its advantages in intersphincteric resection (ISR) are inadequate. MATERIALS AND METHODS This retrospective multicenter cohort study enroled consecutive patients who underwent RaTME and laparoscopy-assisted total mesorectal excision (LaTME) at four medical centres between January 2020 and March 2023. Propensity score matching (PSM), inverse probability of treatment weight (IPTW), and multivariate logistic regression analyses were performed. The primary outcome was the ISR rate. Secondary outcomes were coloanal anastomosis (CAA), conversion to open surgery, conversion to transanal TME, abdominoperineal resection, postoperative morbidity and mortality within 30 days, and pathological outcomes. RESULTS Among the 1571 patients, 1211 and 450 underwent LaTME and RaTME, respectively, with corresponding ISR incidences of 5.3% and 8.4% ( P =0.024). After PSM and IPTW, RaTME remained associated with higher ISR rates (4.5% versus 9.4%, P =0.022 after PSM; 4.9% versus 9.2, P =0.005 after IPTW). This association remained in multivariate analysis after adjusting for other confounding factors. RaTME was further associated with a higher CAA rate, longer operating time, and higher hospitalization expenses. CONCLUSIONS RaTME may facilitate ISR in middle and low rectal cancers, showing an independent association with a higher ISR incidence, with pathological outcomes and complications comparable to those of LaTME. However, it may also require a longer operating time and incur higher hospitalization expenses.
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Affiliation(s)
- Yuchen Guo
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University
| | - Liang He
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University
| | | | - Shuangyi Ren
- Daping Hospital and the Research Institute of Surgery of the Third Military Medical University, Chongqing Municipality
| | - Zhaocheng Chi
- Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ke Tan
- Jilin Provincial Tumour Hospital, Changchun
| | - Bo Wang
- Daping Hospital and the Research Institute of Surgery of the Third Military Medical University, Chongqing Municipality
| | - Chunxiao Lie
- Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Quan Wang
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University
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11
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Reyes R, Kindler C, Smedh K, Tiselius C. A comparative study of the pathological outcomes of robot-assisted versus open surgery for rectal cancer. Ann Coloproctol 2024; 40:154-160. [PMID: 36575856 PMCID: PMC11082550 DOI: 10.3393/ac.2022.00332.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/12/2022] [Accepted: 10/09/2022] [Indexed: 12/29/2022] Open
Abstract
PURPOSE The use of robot-assisted surgery for rectal cancer is increasing, but the pathological outcomes have not been fully clarified. We compared the surgical and pathological outcomes between robot-assisted and open surgery in specimens from patients operated on for rectal cancer. METHODS All patients who underwent resection for rectal cancer from 2016 to 2018 were included (n=137). Specimens were divided into 3 sections to analyze the pathology of the lymph nodes. RESULTS The total specimen lengths were shorter in the robot-assisted group than in the open surgery group (mean±standard deviation: 29.1±8.6 cm vs. 33.8±9.9 cm, P=0.004) because of a shorter proximal resection margin (21.7±8.7 cm vs. 26.4±10.6 cm, P=0.006). The number of recruited lymph nodes (35.8±21.8 vs. 39.6±16.5, P=0.604) and arterial vessel length (8.84±2.6 cm vs. 8.78±2.4 cm, P=0.891) did not differ significantly between the 2 surgical approaches. Lymph node metastases were found in 33 of 137 samples (24.1%), but the numbers did not differ significantly between the procedures. Among these 33 cases, metastatic lymph nodes were located in the mesorectum (75.8%), in the sigmoid colon mesentery (33.3%), and at the arterial ligation site of the inferior mesenteric artery (12.1%). The circumferential resection margin and the proportion of complete mesorectal fascia were comparable between the groups. CONCLUSION There were no significant differences between the 2 surgical approaches regarding arterial vessel length, recruitment of lymph node metastases, and resection margins.
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Affiliation(s)
- René Reyes
- Department of Surgery, Västmanland Hospital Västerås, Västerås, Sweden
| | - Csaba Kindler
- Department of Pathology, Västmanland Hospital Västerås, Västerås, Sweden
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | - Kenneth Smedh
- Department of Surgery, Västmanland Hospital Västerås, Västerås, Sweden
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | - Catarina Tiselius
- Department of Surgery, Västmanland Hospital Västerås, Västerås, Sweden
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
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12
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Zeng K, Zhang F, Yang H, Zha X, Fang S. Laparoscopic versus open surgery in obstructive colorectal cancer patients following stents placement: a comprehensive meta-analysis of cohort studies. Surg Endosc 2024; 38:1740-1757. [PMID: 38443501 PMCID: PMC10978680 DOI: 10.1007/s00464-024-10710-4] [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: 11/12/2023] [Accepted: 01/21/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Over the past decade, the use of stent placement as a bridge to surgery (BTS) has emerged as an alternative to emergency surgery for patients with (OCRC). However, the optimal surgical approach remains indeterminate. This study seeks to evaluate the safety and feasibility of a combined treatment modality involving stent placement and laparoscopic surgery for OCRC presenting with malignant obstruction. METHODS A comprehensive search of PubMed, Cochrane Library, EMBASE, Web of Science, and ClinicalTrials.gov was conducted until June 2023 to identify studies that compared laparoscopic to open surgery in patients with OCBC following stent insertion. RESULTS The meta-analysis incorporated 12 cohort studies, encompassing 933 patients. There was no statistically significant difference in the 30-day mortality rates between the two groups (relative risk [RR], 1.09; 95% confidence interval [CI] 0.26 to 4.48; P = 0.95). Compared to the laparoscopic approach group, the open approach group had a higher rate of overall postoperative complications (POCs) (RR 0.52; 95% CI 0.37 to 0.72, P < 0.0001). There was no significant variance in lymph node (LN) dissection number between the groups (mean differences [MD], 1.64; 95% CI - 1.51 to 4.78; P = 0.31). Notably, laparoscopic surgery resulted in less intraoperative blood loss (MD, - 25.84 ml; 95% CI - 52.16 to 0.49; P = 0.05) and a longer operation time (MD, 20.99 mins; 95% CI 2.31 to 39.44; P = 0.03). The laparoscopic approach was associated with a shorter length of hospital stay (LOS) (MD - 3.29 days; 95% CI - 5.27 to 1.31; P = 0.001). Conversely, the open approach group had a higher rate of postoperative surgical site infection (SSI) (RR 0.47; 95% CI 0.23 to 0.96, P = 0.04). Although the number of included studies was insufficient to conduct a meta-analysis, several of them imply that laparoscopic surgery may yield more favorable outcomes in terms of the 3-year overall survival rate (OS), 3-year disease-free survival rate (DFS), 5-year OS, and 5-year DFS when compared to open surgery. It is worth noting that these differences lack statistical significance. CONCLUSION In patients with OCRC subjected to stent insertion, laparoscopic surgery arguably presents a modest superiority over open surgery by diminishing the overall postoperative risk and potentially reducing the LOS.
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Affiliation(s)
- Kerui Zeng
- Department of Colorectal Anal Surgery, Zigong Fourth People's Hospital, Zigong, Sichuan, China.
- Department of General Surgery, Zigong Fourth People's Hospital, No.282, Dangui Street, Ziliujing District, Zigong, 643000, Sichuan, People's Republic of China.
| | - Faqiang Zhang
- Department of Colorectal Anal Surgery, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Hua Yang
- Department of Colorectal Anal Surgery, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Xiaoying Zha
- Department of Wound Care Center, Department of Colorectal Anal Surgery, Zigong Fourth Hospital, Zigong, Sichuan, China
| | - Shixu Fang
- Department of Colorectal Anal Surgery, Zigong First People's Hospital, Zigong, Sichuan, China
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13
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Mokhtari L, Hosseinzadeh F, Nourazarian A. Biochemical implications of robotic surgery: a new frontier in the operating room. J Robot Surg 2024; 18:91. [PMID: 38401027 DOI: 10.1007/s11701-024-01861-6] [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: 11/23/2023] [Accepted: 02/01/2024] [Indexed: 02/26/2024]
Abstract
Robotic surgery represents a milestone in surgical procedures, offering advantages such as less invasive methods, elimination of tremors, scaled motion, and 3D visualization. This in-depth analysis explores the complex biochemical effects of robotic methods. The use of pneumoperitoneum and steep Trendelenburg positioning can decrease pulmonary compliance and splanchnic perfusion while increasing hypercarbia. However, robotic surgery reduces surgical stress and inflammation by minimizing tissue trauma. This contributes to faster recovery but may limit immune function. Robotic procedures also limit ischemia-reperfusion injury and oxidative damage compared to open surgery. They also help preserve native antioxidant defenses and coagulation. In a clinical setting, robotic procedures reduce blood loss, pain, complications, and length of stay compared to traditional procedures. However, risks remain, including device failure, the need for conversion to open surgery and increased costs. On the oncology side, there is still debate about margins, recurrence, and long-term survival. The advent of advanced technologies, such as intraoperative biosensors, localized drug delivery systems, and the incorporation of artificial intelligence, may further improve the efficiency of robotic surgery. However, ethical dilemmas regarding patient consent, privacy, access, and regulation of this disruptive innovation need to be addressed. Overall, this review sheds light on the complex biochemical implications of robotic surgery and highlights areas that require additional mechanistic investigation. It presents a comprehensive approach to responsibly maximize the potential of robotic surgery to improve patient outcomes, integrating technical skill with careful consideration of physiological and ethical issues.
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Affiliation(s)
- Leila Mokhtari
- Department of Nursing, Khoy University of Medical Sciences, Khoy, Iran
| | | | - Alireza Nourazarian
- Department of Basic Medical Sciences, Khoy University of Medical Sciences, Khoy, Iran.
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14
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Petersson J, Matthiessen P, Jadid KD, Bock D, Angenete E. Short-term results in a population based study indicate advantage for minimally invasive rectal cancer surgery versus open. BMC Surg 2024; 24:52. [PMID: 38341534 PMCID: PMC10858513 DOI: 10.1186/s12893-024-02336-z] [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: 08/30/2023] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The aim of this study was to determine if minimally invasive surgery (MIS) for rectal cancer is non-inferior to open surgery (OPEN) regarding adequacy of cancer resection in a population based setting. METHODS All 9,464 patients diagnosed with rectal cancer 2012-2018 who underwent curative surgery were included from the Swedish Colorectal Cancer Registry. PRIMARY OUTCOMES Positive circumferential resection margin (CRM < 1 mm) and positive resection margin (R1). Non-inferiority margins used were 2.4% and 4%. SECONDARY OUTCOMES 30- and 90-day mortality, clinical anastomotic leak, re-operation < 30 days, 30- and 90-day re-admission, length of stay (LOS), distal resection margin < 1 mm and < 12 resected lymph nodes. Analyses were performed by intention-to-treat using unweighted and weighted multiple regression analyses. RESULTS The CRM was positive in 3.8% of the MIS group and 5.4% of the OPEN group, risk difference -1.6% (95% CI -1.623, -1.622). R1 was recorded in 2.8% of patients in the MIS group and in 4.4% of patients in the OPEN group, risk difference -1.6% (95% CI -1.649, -1.633). There were no differences between the groups in adjusted unweighted and weighted analyses. All analyses demonstrated decreased mortality and re-admissions at 30 and 90 days as well as shorter LOS following MIS. CONCLUSIONS In this population based setting MIS for rectal cancer was non-inferior to OPEN regarding adequacy of cancer resection with favorable short-term outcomes.
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Affiliation(s)
- Josefin Petersson
- Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden.
- Sunshine Coast University Hospital, Britinya, QLD, Australia.
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health Sciences, Örebro University, Örebro, Sweden
| | - Kaveh Dehlaghi Jadid
- Department of Surgery, Faculty of Medicine and Health Sciences, Örebro University, Örebro, Sweden
| | - David Bock
- Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden
| | - Eva Angenete
- Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Göteborg, Sweden
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15
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Zhao S, Li R, Zhou J, Sun L, Sun Q, Wang W, Wang D. Comparative analysis of robotic and laparoscopic surgery for mid and low rectal cancer in patients with varied body mass indexes: evaluating of short-term outcomes. J Robot Surg 2024; 18:67. [PMID: 38329619 DOI: 10.1007/s11701-023-01803-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/17/2023] [Indexed: 02/09/2024]
Abstract
The main aim of this study was to evaluate and contrast the efficacy of robotic and laparoscopic surgical procedures in the treatment of low and mid rectal cancer in different BMI (body mass index) groups. The clinical records of patients who had laparoscopic or robotic proctectomy at a single center between December 2019 and August 2023 were analyzed. Then we utilized a classification framework to categorize individuals based on their BMI into three unique groups: non-obese, overweight, and obese. The short-term efficacy was evaluated. A consecutive sample of 1413 patients was included in this retrospective investigation. 1158 people out of the total sample chose laparoscopic surgery, whereas 255 people chose robotic surgery. In the group of obese people, robotic surgery showed a statistically significant decrease in blood loss compared to laparoscopic surgery (P = 0.026). People who were overweight or obese were in the hospital for a shorter amount of time after robotic surgery than after laparoscopic surgery (P = 0.033 and P = 0.031, respectively). People with different BMIs in the robotic surgery group took less time to have a flatus passage and oral intake those in the laparoscopic surgery group. Oncological outcomes and the frequency of complications were comparable between the two treatments with different BMIs. Surgical resection of patients undergoing low-anterior surgery may benefit from a robotic approach, particularly in overweight and obese patients.
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Affiliation(s)
- Shuai Zhao
- Department of General Surgery, Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
| | - Ruiqi Li
- Department of General Surgery, Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
| | - Jiajie Zhou
- Department of General Surgery, Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
| | - Longhe Sun
- Department of General Surgery, Taizhou Fourth People's Hospital, Taizhou, China
| | - Qiannan Sun
- Department of General Surgery, Northern Jiangsu People's Hospital, Yangzhou, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Wei Wang
- Department of General Surgery, Northern Jiangsu People's Hospital, Yangzhou, China
- Graduate School, Dalian Medical University, Dalian, China
| | - Daorong Wang
- Department of General Surgery, Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China.
- Department of General Surgery, Northern Jiangsu People's Hospital, Yangzhou, China.
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China.
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16
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Marchegiani F, Martinez-Pérez A, Pucciarelli S, de'Angelis N. Locoregional Recurrence in the RAPIDO Trial and the Importance of the Quality of the Resected Specimen: Does Surgical Resection Matter? Dis Colon Rectum 2024; 67:e124. [PMID: 37889996 DOI: 10.1097/dcr.0000000000003140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Affiliation(s)
- Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Aleix Martinez-Pérez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Salvatore Pucciarelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova 2, Padova, Italy
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
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You K, Hwang JA, Sohn DK, Lee DW, Park SS, Han KS, Hong CW, Kim B, Kim BC, Park SC, Oh JH. Exfoliate cancer cell analysis in rectal cancer surgery: comparison of laparoscopic and transanal total mesorectal excision, a pilot study. Ann Coloproctol 2023; 39:502-512. [PMID: 38145898 PMCID: PMC10781597 DOI: 10.3393/ac.2023.00479.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/26/2023] [Accepted: 11/05/2023] [Indexed: 12/27/2023] Open
Abstract
PURPOSE Minimally invasive surgery (MIS) is currently the standard treatment for rectal cancer. However, its limitations include complications and incomplete total mesorectal resection (TME) due to anatomical features and technical difficulties. Transanal TME (TaTME) has been practiced since 2010 to improve this, but there is a risk of local recurrence and intra-abdominal contamination. We aimed to analyze samples obtained through lavage to compare laparoscopic TME (LapTME) and TaTME. METHODS From June 2020 to January 2021, 20 patients with rectal cancer undergoing MIS were consecutively and prospectively recruited. Samples were collected at the start of surgery, immediately after TME, and after irrigation. The samples were analyzed for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) through a quantitative real-time polymerase chain reaction. The primary outcome was to compare the detected amounts of CEA and CK20 immediately after TME between the surgical methods. RESULTS Among the 20 patients, 13 underwent LapTME and 7 underwent TaTME. Tumor location was lower in TaTME (7.3 cm vs. 4.6 cm, P=0.012), and negative mesorectal fascia (MRF) was more in LapTME (76.9% vs. 28.6%, P=0.044). CEA and CK20 levels were high in 3 patients (42.9%) only in TaTME. There was 1 case of T4 with incomplete purse-string suture and 1 case of positive MRF with dissection failure. All patients were followed up for an average of 32.5 months without local recurrence. CONCLUSION CEA and CK20 levels were high only in TaTME and were related to tumor factors or intraoperative events. However, whether the detection amount is clinically related to local recurrence remains unclear.
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Affiliation(s)
- Kiho You
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Jung-Ah Hwang
- Genomics Core Facility, Research Core Center, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Sung Sil Park
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Bun Kim
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
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18
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Barzola E, Cornejo L, Gómez N, Pigem A, Julià D, Ortega N, Delisau O, Bobb KA, Farrés R, Planellas P. Comparative analysis of short-term outcomes and oncological results between robotic-assisted and laparoscopic surgery for rectal cancer by multiple surgeon implementation: a propensity score-matched analysis. J Robot Surg 2023; 17:3013-3023. [PMID: 37924415 DOI: 10.1007/s11701-023-01736-2] [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: 07/27/2023] [Accepted: 09/26/2023] [Indexed: 11/06/2023]
Abstract
Robotic-assisted surgery (RAS) is becoming increasingly common for the surgical treatment of rectal cancer. However, the use and implementation of robotic surgery remains controversial. This study aimed to compare the short-term outcomes of robotic surgery, focusing on pathological results and disease-free survival (DFS), in our cohort with initial robotic experience by multiple surgeon implementation. This retrospective study enrolled 571 patients diagnosed with rectal cancer, who were treated with chemoradiotherapy and surgery between January 2015 and December 2021. Surgical outcomes after RAS and laparoscopic surgery (LS) were compared using a propensity score-matching (PSM) analysis. After matching, 200 patients (100 in each group) were included. The median operative time was significantly longer in the RAS group than in the LS group (p < 0.001). The conversion and morbidity rates were similar between the groups. A significantly higher rate of complete mesorectal excision (92% vs. 72%; p = 0.001) and number of lymph nodes harvested (p = 0.009) was observed in the RAS group. There were no statistically significant differences between the groups regarding circumferential and distal resection margin involvement. The 3-year overall and disease-free survival rate was similar between the two groups (p = 0.849 and p = 0.582, respectively). Two patients in the LS group developed local recurrence and 27 patients (15.4%) developed metastatic disease. Multivariate analysis showed that tumor stage III was the only factor associated with disease-free survival (HR, 9.34; (95% CI 1.13-77.1), p = 0.038). RAS and LS showed similar outcomes in terms of perioperative, anatomopathological, and disease-free survival, after multiple surgeon implementations.
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Affiliation(s)
- E Barzola
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - L Cornejo
- Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Gómez
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - A Pigem
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - D Julià
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Ortega
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - O Delisau
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - K A Bobb
- Department of Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies-St. Augustine, Eric Williams Medical Sciences Complex, Mount Hope, Trinidad, West Indies, Trinidad and Tobago
| | - R Farrés
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - P Planellas
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain.
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19
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Al-Dhaheri M, Al-Ishaq F, Toffaha A, Nada MA, Parvaiz A, Kurer M. Transanal minimally invasive surgery for benign and malignant rectal lesions: midterm outcomes from a tertiary center. Ann Saudi Med 2023; 43:348-351. [PMID: 38071443 PMCID: PMC11182431 DOI: 10.5144/0256-4947.2023.348] [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] [Received: 08/05/2023] [Accepted: 10/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Although transanal minimally invasive surgery (TAMIS) for rectal neoplasia has gained wide acceptance, the mid-term and long-term outcomes are not widely reported in the literature. OBJECTIVE Describe the mid-term outcomes of patients who underwent TAMIS for benign and malignant rectal lesions in a single center. DESIGN Retrospective cohort study. SETTINGS Tertiary referral center. PATIENTS AND METHODS Demographic, clinical, and oncological outcomes of patients who underwent TAMIS between January 2015 and December 2022 were prospectively collected. The indication for TAMIS was based on the National Comprehensive Cancer Network guidelines. The follow up for the cancer patients included clinical examination, tumor markers every 6 months and MRI rectum at the end of one year. In addition, colonoscopy and CT scan at years one and three and a final CT scan and colonoscopy at year five. MAIN OUTCOME MEASURES Mid-term oncological and clinical outcome. RESULTS Thirty elective TAMIS procedures included adenocarcinoma for 33.3% (n=10) of the patients, 20% (n=6) neuroendocrine tumor and the 40% (n=12) were adenomatous lesions. Negative resection margins were achieved in all malignant lesions. Perioperative complications occurred in 2 patients (6.6%), one patient had breaching into the peritoneal cavity, and postoperative hypotension occurred in another patient. The median follow-up time was 23 months (range: 5-72 months). Two patients with adenoma and positive margins developed recurrent adenoma (6.6%) and one patient with initial polypectomy biopsy of adenocarcinoma, had TAMIS with histopathology of adenoma and distant metastasis had developed. CONCLUSIONS TAMIS for local excision of rectal neoplasia is a valid option with favorable mid-term outcomes provided there is adherence to careful selection criteria. LIMITATIONS Retrospective nature and small number of the patients.
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Affiliation(s)
| | - Fajer Al-Ishaq
- From the Colorectal Unit, Hamad Medical Corporation, Doha, Qatar
| | - Ali Toffaha
- From the Colorectal Unit, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Abu Nada
- From the Colorectal Unit, Hamad Medical Corporation, Doha, Qatar
| | - Amjad Parvaiz
- From the Colorectal Unit, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Kurer
- From the Colorectal Unit, Hamad Medical Corporation, Doha, Qatar
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20
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Emile SH, Horesh N, Garoufalia Z, Gefen R, Zhou P, Wexner SD. Predictors and survival outcomes of having less than 12 harvested lymph nodes in proctectomy for rectal cancer. Int J Colorectal Dis 2023; 38:225. [PMID: 37688758 DOI: 10.1007/s00384-023-04518-2] [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: 09/04/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Current recommendations suggest that a minimum of 12 lymph nodes (LNs) should be harvested during curative rectal cancer resection. We aimed to assess predictors and survival outcomes of harvesting < 12 lymph nodes in rectal cancer surgery. METHODS A retrospective case-control analysis of factors associated with harvesting < 12 LNs in rectal cancer surgery was conducted. Data were derived from the National Cancer Database 2010-2019. Univariate and multivariate binary logistic regression analyses were performed to determine predictors of harvesting < 12 LNs. Association between harvesting < 12 LNs and 5-year overall survival (OS) was assessed using Cox regression and Kaplan Meier statistics. RESULTS 67,529 patients (60.8% male; mean age: 61.2 ± 12.5 years) were included. Median number of harvested LNs was 15 (IQR: 11-20); 27.1% of patients had < 12 harvested LNs. Independent predictors of harvesting < 12 LNs were older age (OR: 1.016;p < 0.001), neoadjuvant systemic treatment (OR: 1.522;p < 0.001), neoadjuvant radiation treatment (OR: 1.367;p < 0.001), longer duration of radiation therapy (OR: 1.003;p < 0.001) and abdominoperineal resection (OR: 1.071;p = 0.017). Higher clinical TNM stage and tumor grade, pull-through coloanal anastomosis, and minimally invasive surgery were independently associated with ≥ 12 harvested LNs. < 12 harvested LNs was independently associated with lower 5-year OS (HR: 1.24;p < 0.001) and shorter mean OS (96.7 vs 102.8 months;p < 0.001) than ≥ 12 harvested LNs. CONCLUSIONS Older age, open resection, and neoadjuvant therapy were independent predictors of < 12 harvested LNs. Conversely, higher clinical TNM stage and tumor grade, coloanal anastomosis, and minimally invasive surgery were predictive of ≥ 12 harvested LNs. < 12 LNs harvested was associated with lower OS.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Tel Aviv University, Tel Aviv, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peige Zhou
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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21
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Widmann KM, Dawoud C, Harpain F, Aigner F, Presl J, Rosen H, Zitt M, Schoppmann SF, Emmanuel K, Riss S. Standardization of rectal cancer surgery and bowel preparation in Austria : A multicenter nationwide survey by the Austrian Society of Surgical Oncology. Wien Klin Wochenschr 2023; 135:457-462. [PMID: 37358643 PMCID: PMC10497700 DOI: 10.1007/s00508-023-02227-y] [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: 02/19/2023] [Accepted: 05/14/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Standardized management of colorectal cancer is crucial for achieving an optimal clinical and oncological outcome. The present nationwide survey was designed to provide data about the surgical management of rectal cancer patients. In addition, we evaluated the standard approach for bowel preparation in all centers in Austria performing elective colorectal surgery. METHODS The Austrian Society of Surgical Oncology (ACO["Arbeitsgemeinschaft für chirurgische Onkonlogie"]-ASSO) conducted a multicenter questionnaire-based study comprising 64 hospitals between October 2020 and March 2021. RESULTS The median number of low anterior resections performed annually per department was 20 (range 0-73). The highest number was found in Vienna, with a median of 27 operations, whereas Vorarlberg was the state with the lowest median number of 13 resections per year. The laparoscopic approach was the standard technique in 46 (72%) departments, followed by the open approach in 30 (47%), transanal total mesorectal excision (TaTME) in 10 (16%) and robotic surgery in 6 hospitals (9%). Out of 64 hospitals 51 (80%) named a standard for bowel preparation before colorectal resections. No preparation was commonly used for the right colon (33%). CONCLUSION Considering the low number of low anterior resections performed in each hospital per year in Austria, defined centers for rectal cancer surgery are still scarce. Many hospitals did not transfer recommended bowel preparation guidelines into clinical practice.
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Affiliation(s)
- Kerstin M Widmann
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christopher Dawoud
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Felix Harpain
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Felix Aigner
- Department of Surgery, Krankenhaus der Barmherzigen Brüder Graz, Graz, Austria
| | - Jaroslav Presl
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Harald Rosen
- Department of Surgical Oncology, Sigmund Freud Private University (SFU), Vienna, Austria
| | - Matthias Zitt
- Department of General Surgery, Krankenhaus der Stadt Dornbirn, Dornbirn, Austria
| | - Sebastian F Schoppmann
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Stefan Riss
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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22
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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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23
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Zhang Q, Wei J, Chen H. Advances in pelvic imaging parameters predicting surgical difficulty in rectal cancer. World J Surg Oncol 2023; 21:64. [PMID: 36843078 PMCID: PMC9969644 DOI: 10.1186/s12957-023-02933-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/11/2023] [Indexed: 02/28/2023] Open
Abstract
Due to the fixed bony structure of the pelvis, the pelvic operation space is limited, complicating the surgical operation of rectal cancer, especially middle and low rectal cancer. The closer the tumor is to the anal verge, the smaller the operative field and operating space, the longer the operative time, and the greater the incidence of intraoperative side injuries and postoperative complications. To date, there is still no clear definition of a difficult pelvis that affects the surgical operation of rectal cancer. Few related research reports exist in the literature, and views on this aspect are not the same between countries. Therefore, it is particularly important to predict the difficulty of rectal cancer surgery in a certain way before surgery and to select the surgical method most suitable for each case during the treatment of rectal cancer.
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Affiliation(s)
- Qingbai Zhang
- grid.411491.8Department of General Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiufeng Wei
- grid.411491.8Department of General Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongsheng Chen
- Department of General Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China.
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24
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Khajeh E, Aminizadeh E, Dooghaie Moghadam A, Nikbakhsh R, Goncalves G, Carvalho C, Parvaiz A, Kulu Y, Mehrabi A. Outcomes of Robot-Assisted Surgery in Rectal Cancer Compared with Open and Laparoscopic Surgery. Cancers (Basel) 2023; 15:cancers15030839. [PMID: 36765797 PMCID: PMC9913667 DOI: 10.3390/cancers15030839] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
With increasing trends for the adoption of robotic surgery, many centers are considering changing their practices from open or laparoscopic to robot-assisted surgery for rectal cancer. We compared the outcomes of robot-assisted rectal resection with those of open and laparoscopic surgery. We searched Medline, Web of Science, and CENTRAL databases until October 2022. All randomized controlled trials (RCTs) and prospective studies comparing robotic surgery with open or laparoscopic rectal resection were included. Fifteen RCTs and 11 prospective studies involving 6922 patients were included. The meta-analysis revealed that robotic surgery has lower blood loss, less surgical site infection, shorter hospital stays, and higher negative resection margins than open resection. Robotic surgery also has lower conversion rates, lower blood loss, lower rates of reoperation, and higher negative circumferential margins than laparoscopic surgery. Robotic surgery had longer operation times and higher costs than open and laparoscopic surgery. There were no differences in other complications, mortality, and survival between robotic surgery and the open or laparoscopic approach. However, heterogeneity between studies was moderate to high in some analyses. The robotic approach can be the method of choice for centers planning to change from open to minimally invasive rectal surgery. The higher costs of robotic surgery should be considered as a substitute for laparoscopic surgery (PROSPERO: CRD42022381468).
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Affiliation(s)
- Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69121 Heidelberg, Germany
- Digestive Unit, Department of Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal
| | - Ehsan Aminizadeh
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69121 Heidelberg, Germany
| | - Arash Dooghaie Moghadam
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69121 Heidelberg, Germany
| | - Rajan Nikbakhsh
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69121 Heidelberg, Germany
| | - Gil Goncalves
- Digestive Unit, Department of Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal
| | - Carlos Carvalho
- Digestive Unit, Department of Oncology, Champalimaud Foundation, 1400-038 Lisbon, Portugal
| | - Amjad Parvaiz
- Digestive Unit, Department of Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal
| | - Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69121 Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69121 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-5636223
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25
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Miyakawa T, Michihata N, Kumazawa R, Matsui H, Honda M, Yasunaga H. Short-term surgical outcomes of laparoscopic and open surgery for rectal cancer: A nationwide retrospective analysis. Asian J Endosc Surg 2023. [PMID: 36693819 DOI: 10.1111/ases.13166] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/26/2022] [Accepted: 01/11/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Laparoscopy for treatment of rectal cancer is widely used in clinical practice. However, the safety and advantages of laparoscopy over open surgery at the national level remain unclear. We compared the short-term outcomes of laparoscopy and open surgery for rectal cancer. METHODS Using a Japanese nationwide inpatient database, this study analyzed data on patients who underwent rectal resection between July 2010 and March 2018. We performed propensity score matching analyses to compare in-hospital mortality, morbidities, blood transfusion, diverting stomas, anastomotic leakages, duration of anesthesia, postoperative length of stay, and readmission within 30 days between the laparoscopy and open surgery groups. RESULTS Among 99 137 eligible patients, propensity score matching generated 29 717 pairs. Laparoscopy was associated with lower in-hospital mortality (0.4% vs 0.6%, P = .006), overall morbidities (28.7% vs 33.2%, P < .001), and blood transfusion rate (11.5% vs 22.9%, P < .001); shorter postoperative duration of stay (16 days vs 18 days, P < .001); and longer duration of anesthesia (390 vs 310 minutes, P < .001). Grade C anastomotic leakage was not different between the groups. CONCLUSION With respect to in-hospital mortality, morbidities, blood transfusion, postoperative length of hospitalization, and readmission within 30 days, laparoscopy is advantageous over open surgery in the treatment of rectal cancer.
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Affiliation(s)
- Teppei Miyakawa
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.,Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryosuke Kumazawa
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Michitaka Honda
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Giesen LJX, Dekker JWT, Verseveld M, Crolla RMPH, van der Schelling GP, Verhoef C, Olthof PB. Implementation of robotic rectal cancer surgery: a cross-sectional nationwide study. Surg Endosc 2023; 37:912-920. [PMID: 36042043 PMCID: PMC9945537 DOI: 10.1007/s00464-022-09568-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022]
Abstract
AIM An increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches. METHODS Patients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach. RESULTS Between 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13-16%) in 2018 to 22% (95% CI 20-24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3-5%) versus 7% (95% CI 6-8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38-46%) versus 29% (95% CI 26-31%)]. CONCLUSION Rectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.
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Affiliation(s)
- L J X Giesen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.
| | - J W T Dekker
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - M Verseveld
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - C Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - P B Olthof
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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27
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Bartos A, Mărgărit S, Bocse H, Krisboi I, Iancu I, Breazu C, Plesa-Furda P, Brînzilă S, Leucuta D, Iancu C, Puia C, Al Hajjar N, Ciobanu L. Laparoscopic Pancreatoduodenectomy in Elderly Patients: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12111810. [PMID: 36362961 PMCID: PMC9695297 DOI: 10.3390/life12111810] [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: 08/25/2022] [Revised: 10/31/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background and Aims: Recent single-center retrospective studies have focused on laparoscopic pancreatoduodenectomy (LPD) in elderly patients, and compared the outcomes between the laparoscopic and open approaches. Our study aimed to determine the outcomes of LPD in the elderly patients, by performing a systematic review and a meta-analysis of relevant studies. Methods: A comprehensive literature review was conducted utilizing the Embase, Medline, PubMed, Scopus and Cochrane databases to identify all studies that compared laparoscopic vs. open approach for pancreatoduodenectomy (PD). Results: Five retrospective studies were included in the final analysis. Overall, 90-day mortality rates were significantly decreased after LPD in elderly patients compared with open approaches (RR = 0.56; 95%CI: 0.32−0.96; p = 0.037, I2 = 0%). The laparoscopic approach had similar mortality rate at 30-day, readmission rate in hospital, Clavien−Dindo complications, pancreatic fistula grade B/C, complete resection rate, reoperation for complications and blood loss as the open approach. Additionally, comparing with younger patients (<70 years old), no significant differences were seen in elderly cohort patients regarding mortality rate at 90 days, readmission rate to hospital, and complication rate. Conclusions: Based on our meta-analysis, we identify that LPD in elderly is a safe procedure, with significantly lower 90-day mortality rates when compared with the open approach. Our results should be considered with caution, considering the retrospective analyses of the included studies; larger prospective studies are required.
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Affiliation(s)
- Adrian Bartos
- Medicine Faculty, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
- Correspondence: (A.B.); (S.M.)
| | - Simona Mărgărit
- Medicine Faculty, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
- Correspondence: (A.B.); (S.M.)
| | - Horea Bocse
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Iulia Krisboi
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Ioana Iancu
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Caius Breazu
- Medicine Faculty, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Patricia Plesa-Furda
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Sandu Brînzilă
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Daniel Leucuta
- Medicine Faculty, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Cornel Iancu
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Cosmin Puia
- Medicine Faculty, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Nadim Al Hajjar
- Medicine Faculty, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
| | - Lidia Ciobanu
- Medicine Faculty, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Prof. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400012 Cluj-Napoca, Romania
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Feng Q, Yuan W, Li T, Tang B, Jia B, Zhou Y, Zhang W, Zhao R, Zhang C, Cheng L, Zhang X, Liang F, He G, Wei Y, Xu J, Feng Q, Wei Y, He G, Liang F, Yuan W, Sun Z, Li T, Tang B, Tang B, Gao L, Jia B, Li P, Zhou Y, Liu X, Zhang W, Lou Z, Zhao R, Zhang T, Zhang C, Li D, Cheng L, Chi Z, Zhang X, Yang G. Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7:991-1004. [PMID: 36087608 DOI: 10.1016/s2468-1253(22)00248-5] [Citation(s) in RCA: 212] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/15/2022] [Accepted: 07/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Robotic surgery for rectal cancer is gaining popularity, but evidence on long-term oncological outcomes is scarce. We aimed to compare surgical quality and long-term oncological outcomes of robotic and conventional laparoscopic surgery in patients with middle and low rectal cancer. Here we report the short-term outcomes of this trial. METHODS This multicentre, randomised, controlled, superiority trial was done at 11 hospitals in eight provinces of China. Eligible patients were aged 18-80 years with middle (>5 to 10 cm from the anal verge) or low (≤5 cm from the anal verge) rectal adenocarcinoma, cT1-T3 N0-N1 or ycT1-T3 Nx, and no evidence of distant metastasis. Central randomisation was done by use of an online system and was stratified according to participating centre, sex, BMI, tumour location, and preoperative chemoradiotherapy. Patients were randomly assigned at a 1:1 ratio to receive robotic or conventional laparoscopic surgery. All surgical procedures complied with the principles of total mesorectal excision or partial mesorectal excision (for tumours located higher in the rectum). Lymph nodes at the origin of the inferior mesenteric artery were dissected. In the robotic group, the excision procedures and dissection of lymph nodes were done by use of robotic techniques. Neither investigators nor patients were masked to the treatment allocation but the assessment of pathological outcomes was masked to the treatment allocation. The primary endpoint was 3-year locoregional recurrence rate, but the data for this endpoint are not yet mature. Secondary short-term endpoints are reported in this article, including two key secondary endpoints: circumferential resection margin positivity and 30-day postoperative complications (Clavien-Dindo classification grade II or higher). The outcomes were analysed according in a modified intention-to-treat population (according to the original assigned groups and excluding patients who did not undergo surgery or no longer met inclusion criteria after randomisation). This trial was registered with ClinicalTrials.gov, number NCT02817126. Study recruitment has completed, and the follow-up is ongoing. FINDINGS Between July 17, 2016, and Dec 21, 2020, 1742 patients were assessed for eligibility. 502 patients were excluded, and 1240 patients were enrolled and randomly assigned to receive either robotic surgery (620 patients) or laparoscopic surgery (620 patients). 69 patients were excluded (34 in the robotic surgery group and 35 in the laparoscopic surgery group). 1171 patients were included in the modified intention-to-treat analysis (586 in the robotic group and 585 in the laparoscopic group). Six patients in the robotic surgery group received laparoscopic surgery and seven patients in the laparoscopic surgery group received robotic surgery. 22 (4·0%) of 547 patients in the robotic group had a positive circumferential resection margin as did 39 (7·2%) of 543 patients in the laparoscopic group (difference -3·2 percentage points [95% CI -6·0 to -0·4]; p=0·023). 95 (16·2%) of patients in the robotic group had at least one postoperative complication (Clavien-Dindo grade II or higher) within 30 days after surgery, as did 135 (23·1%) of 585 patients in the laparoscopic group (difference -6·9 percentage points [-11·4 to -2·3]; p=0·003). More patients in the robotic group had a macroscopic complete resection than in the laparoscopic group (559 [95·4%] of 586 patients vs 537 [91·8%] of 585 patients, difference 3·6 percentage points [0·8 to 6·5]). Patients in the robotic group had better postoperative gastrointestinal recovery, shorter postoperative hospital stay (median 7·0 days [IQR 7·0 to 11·0] vs 8·0 days [7·0 to 12·0], difference -1·0 [95% CI -1·0 to 0·0]; p=0·0001), fewer abdominoperineal resections (99 [16·9%] of 586 patients vs 133 [22·7%] of 585 patients, difference -5·8 percentage points [-10·4 to -1·3]), fewer conversions to open surgery (10 [1·7%] of 586 patients vs 23 [3·9%] of 585 patients, difference -2·2 percentage points [-4·3 to -0·4]; p=0·021), less estimated blood loss (median 40·0 mL [IQR 30·0 to 100·0] vs 50·0 mL [40·0 to 100·0], difference -10·0 [-20·0 to -10·0]; p<0·0001), and fewer intraoperative complications (32 [5·5%] of 586 patients vs 51 [8·7%] of 585 patients; difference -3·3 percentage points [-6·3 to -0·3]; p=0·030) than patients in the laparoscopic group. INTERPRETATION Secondary short-term outcomes suggest that for middle and low rectal cancer, robotic surgery resulted in better oncological quality of resection than conventional laparoscopic surgery, with less surgical trauma, and better postoperative recovery. FUNDING Shenkang Hospital Development Center, Shanghai Municipal Health Commission (Shanghai, China), and Zhongshan Hospital Fudan University (Shanghai, China).
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Affiliation(s)
- Qingyang Feng
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Weitang Yuan
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Taiyuan Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Bo Tang
- Department of General Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Baoqing Jia
- Department of General Surgery, The First Medical Center, PLA General Hospital, Beijing, China
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Ren Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cheng Zhang
- Department of General Surgery, Northern Theater Command General Hospital, Shenyang, Liaoning Province, China
| | - Longwei Cheng
- Second Department of Gastrointestinal Surgery, Jilin Cancer Hospital, Changchun, Jilin Province, China
| | - Xiaoqiao Zhang
- Department of General Surgery, The 960th Hospital of the PLA Joint Logistic Support Force, Jinan, Shandong Province, China; Department of General Surgery, Shandong Provincial Hospital affiliated to the Shandong First Medical University, Jinan, Shandong Province, China
| | - Fei Liang
- Department of Biostatistics, Zhongshan Hospital Fudan University, Shanghai, China
| | - Guodong He
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Ye Wei
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Jianmin Xu
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China.
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Quero G, Mascagni P, Kolbinger FR, Fiorillo C, De Sio D, Longo F, Schena CA, Laterza V, Rosa F, Menghi R, Papa V, Tondolo V, Cina C, Distler M, Weitz J, Speidel S, Padoy N, Alfieri S. Artificial Intelligence in Colorectal Cancer Surgery: Present and Future Perspectives. Cancers (Basel) 2022; 14:3803. [PMID: 35954466 PMCID: PMC9367568 DOI: 10.3390/cancers14153803] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 02/05/2023] Open
Abstract
Artificial intelligence (AI) and computer vision (CV) are beginning to impact medicine. While evidence on the clinical value of AI-based solutions for the screening and staging of colorectal cancer (CRC) is mounting, CV and AI applications to enhance the surgical treatment of CRC are still in their early stage. This manuscript introduces key AI concepts to a surgical audience, illustrates fundamental steps to develop CV for surgical applications, and provides a comprehensive overview on the state-of-the-art of AI applications for the treatment of CRC. Notably, studies show that AI can be trained to automatically recognize surgical phases and actions with high accuracy even in complex colorectal procedures such as transanal total mesorectal excision (TaTME). In addition, AI models were trained to interpret fluorescent signals and recognize correct dissection planes during total mesorectal excision (TME), suggesting CV as a potentially valuable tool for intraoperative decision-making and guidance. Finally, AI could have a role in surgical training, providing automatic surgical skills assessment in the operating room. While promising, these proofs of concept require further development, validation in multi-institutional data, and clinical studies to confirm AI as a valuable tool to enhance CRC treatment.
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Affiliation(s)
- Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Pietro Mascagni
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
- Institute of Image-Guided Surgery, IHU-Strasbourg, 67000 Strasbourg, France
| | - Fiona R. Kolbinger
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Davide De Sio
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Fabio Longo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Carlo Alberto Schena
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Roberta Menghi
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Valerio Papa
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Vincenzo Tondolo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Caterina Cina
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Marius Distler
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Juergen Weitz
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Stefanie Speidel
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
| | - Nicolas Padoy
- Institute of Image-Guided Surgery, IHU-Strasbourg, 67000 Strasbourg, France
- ICube, Centre National de la Recherche Scientifique (CNRS), University of Strasbourg, 67000 Strasbourg, France
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
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Wu D, Bian L, Chen Y, Zhang L, Qu H, Li Z, Chen X. A pilot study on preoperative vascular anatomy and clinical application in rectal cancer resection. Clin Radiol 2022; 77:701-707. [PMID: 35680447 DOI: 10.1016/j.crad.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/06/2022] [Indexed: 11/03/2022]
Abstract
AIM To assess the utility of preoperatively evaluating the vascular anatomy using multisection spiral computed tomography angiography (CTA) and image fusion technology in the treatment of obese patients undergoing laparoscopic radical resection for rectal cancer. MATERIALS AND METHODS This randomised prospective study included 56 patients who underwent laparoscopic surgery for rectal cancer. Patients were randomly divided into two groups: the fusion imaging group (preoperative CTA and image fusion reconstruction [n=28]) and the control group (not performed CTA and image fusion reconstruction before the operation [n=28]). Duration of surgery was defined as the primary endpoint, and the volume of bleeding, the number of lymph node dissections, conversion to laparotomy, time to recovery of postoperative flatus, length of hospitalisation as well as perioperative complications were defined as secondary endpoints. RESULTS Compared with the control group, the duration of surgery in the image fusion group was shorter, bleeding volume was reduced, and the number of lymph node dissections was greater (p<0.05); however, there was no significant differences between the two groups regarding time to postoperative flatus recovery, conversion to laparotomy, length of hospitalisation, and perioperative complications (p>0.05). CONCLUSIONS Preoperative assessment of the vascular anatomy was an effective method and avoided some invisible risks during surgery, and resulted in a better therapeutic effect.
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Affiliation(s)
- D Wu
- Department of Radiology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - L Bian
- Department of Radiology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Y Chen
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China.
| | - L Zhang
- Department of Radiology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China.
| | - H Qu
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Z Li
- Information Section, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - X Chen
- Department of Pathology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
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Coco D, Leanza S. Robotic Transanal Total Mesorectal Excision Compared to Laparoscopic Transanal Total Mesorectal Excision: Oncologic Results of the Past 5 Years. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Colorectal cancer is one of the deadliest diseases on the planet. Rectal cancer (RC) is the 8
th
most common type of cancer disease worldwide, accounting for over 300,000 fatalities in 2018. Total mesorectal excision (TME) is considered as the gold standard approach for surgical RC management. To alleviate technical problems associated with dissection of distal rectal, transanal procedure to mesorectum was developed. The robotic operating platforms’ development has brought about the most significant change. The robotic method, which was described first in the year 2001, is gaining popularity in colorectal surgery. A stable camera platform with three-dimensional imaging and tremor filtering, motion scaling, instruments with numerous degrees of freedom, 3
rd
arm for fixed retraction, ambidextrous capability, superior ergonomics, and less fatigue, all these advantages have all influenced robotics implementation. However, there are certain disadvantages to robotic surgery, such as high expenses, lengthy time of operation, a bulky cart, and absence of haptic sense. Robotic transanal TME (R-TA TME) is unique method that integrates potential advantages of perineal dissection with precise control of distal margins, along with all robotic technology advantages with respect to dexterity and greater precision. This review goal is to evaluate the available literature critically regarding R-TA TME in comparison to laparoscopic TA TME (L-TA TME) using the most prevalent histopathological metrics, which are the circumferential resection margin, the distal rectal margin, recurrence rate, specimen quality, advantages, and disadvantages. Oncological results for the past 5 years were used. The resources were obtained from electronic sources such as Google Scholar and PubMed. The conclusion of this review revealed that R-TA TME is as safe as well as feasible as L-TA TME, is technically possible, and has comparable oncological results and short-term post-operative outcomes. However, further investigation is required to evaluate long-term oncological or functional results.
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Kong M, Chen H, Shan K, Sheng H, Li L. Comparison of Survival Among Adults With Rectal Cancer Who Have Undergone Laparoscopic vs Open Surgery: A Meta-analysis. JAMA Netw Open 2022; 5:e2210861. [PMID: 35532937 PMCID: PMC9086842 DOI: 10.1001/jamanetworkopen.2022.10861] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Two large randomized clinical trials (RCTs) found that laparoscopic surgery failed to yield noninferior pathologic outcomes compared with open surgery for patients with rectal cancer. The results raised concerns regarding the effectiveness of the laparoscopic approach for patients with rectal cancer. OBJECTIVE To compare the long-term oncologic outcomes of laparoscopic and open surgery for patients with rectal cancer. DATA SOURCES PubMed, Web of Science, Embase, and Cochrane Central Register of Controlled Trials were searched from database inception to August 13, 2021. Studies published in English were retrieved. STUDY SELECTION The meta-analysis included RCTs that compared laparoscopic surgery with open surgery for patients with rectal cancer and reported the outcome of disease-free survival (DFS) or overall survival (OS). The following exclusion criteria were used: (1) non-RCTs, (2) studies without long-term survival outcomes of interest, and (3) studies that did not report Kaplan-Meier survival curves. DATA EXTRACTION AND SYNTHESIS This meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline for individual participant data development groups. Individual participant data on DFS and OS were extracted from the published Kaplan-Meier survival curves. One-stage and 2-stage meta-analyses were performed. MAIN OUTCOMES AND MEASURES Meta-analyses were conducted for DFS and OS. Hazard ratios (HRs) were used as effective measures. RESULTS Of 8471 records screened, 10 articles with 12 RCTs and 3709 participants were selected. The reconstructed survival curves for the combined population showed that the 5-year estimated DFS rates were 72.2% (95% CI, 69.4%-74.8%) for the laparoscopic group and 70.1% (95% CI, 67.0%-73.0%) for the open surgery group, and the 5-year estimated OS rates were 76.2% (95% CI, 73.8%-78.5%) for the laparoscopic group and 72.7% (95% CI, 69.8%-75.3%) for open surgery group. In 1-stage meta-analyses, DFS had a nonsignificant HR of 0.92 (95% CI, 0.80-1.06; P = .26), which suggested that DFS in the laparoscopic and open surgery groups was comparable; however, OS was significantly better in the laparoscopic group (HR, 0.85; 95% CI, 0.74-0.97; P = .02). The results were confirmed by 2-stage meta-analyses and were validated by sensitivity analysis with large RCTs. CONCLUSIONS AND RELEVANCE A similar DFS but significantly better OS were found for patients who have undergone laparoscopic surgery compared with open surgery for rectal cancer. These findings address concerns regarding the effectiveness of laparoscopic surgery and support the routine use of laparoscopic surgery for patients with rectal cancer.
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Affiliation(s)
- Meng Kong
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hongyuan Chen
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Keshu Shan
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hongguang Sheng
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Leping Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
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Effects of surgical approach on short- and long-term outcomes in early-stage rectal cancer: a multicenter, propensity score-weighted cohort study. Surg Endosc 2022; 36:5833-5839. [PMID: 35122149 DOI: 10.1007/s00464-022-09033-z] [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: 06/03/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Randomized controlled trials have been unable to demonstrate noninferiority of minimally invasive surgery for rectal cancer. The aim of this study was to assess oncologic resection success, short- and long-term morbidity, and overall survival by operative approach in a homogenous early-stage rectal cancer cohort. METHODS This is a multicenter, propensity score-weighted cohort study utilizing deidentified data from the National Cancer Database. Individuals who underwent a formal proctectomy for early-stage rectal cancer (T1-2, N0, M0) from 2010 to 2015 were included. The primary outcome was a composite variable indicating successful oncologic resection stratified by operative approach, defined as negative margins with at least 12 lymph nodes evaluated. RESULTS Among 3649 proctectomies for rectal adenocarcinoma, 1660 (45%) were approached open, 1461 (40%) laparoscopically, and 528 (15%) robotically. After propensity score weighting, compared to open approach, there were no differences in odds of successful oncologic resection (ORadj = 1.07, 95% CI 0.9, 1.28 and ORadj = 1.28, 95% CI 0.97, 1.7). Open approach was associated with longer mean (± SD) length of stay compared to laparoscopic (7.7 ± 0.18 vs. 6.5 ± 0.25 days, p < 0.001) and robotic (7.7 ± 0.18 vs. 6.3 ± 0.35 days, p < 0.001) approaches. In regard to 90-day mortality, compared to open approach, laparoscopic (ORadj = 0.56, 95% CI 0.36, 0.88) and robotic (ORadj = 0.45, 95% CI 0.22, 0.94) approaches were associated with a reduced odd of 90-day mortality. This mortality benefit persists in the long-term for laparoscopic approach (p = 0.003). CONCLUSION For individuals with early-stage rectal cancer treated with proctectomy, successful oncologic resection can be achieved irrespective of technical approach. Minimally invasive approaches provide short-term reduction in morbidity. Surgical approach must be tailored to each patient based on surgeon experience and judgement in collaboration with a multi-disciplinary team.
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Pla-Martí V, Martín-Arévalo J, Moro-Valdezate D, García-Botello S, Pérez-Santiago L, Lapeña-Rodríguez M, Bauzá-Collado M, Huerta M, Roselló-Keränen S, Espí-Macías A. Prognostic implications of surgical specimen quality on the oncological outcomes of open and laparoscopic surgery in mid and low rectal cancer. Langenbecks Arch Surg 2021; 406:2759-2767. [PMID: 34716825 PMCID: PMC8803799 DOI: 10.1007/s00423-021-02351-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/06/2021] [Indexed: 11/03/2022]
Abstract
Purpose Determine differences in pathologic outcomes between laparoscopic (LAP) and open surgery (OPEN) for mid and low rectal cancer and its influence in long-term oncological outcomes. Methods Retrospective case matched study at a tertiary institution. Adults with rectal cancer below 12 cm from the anal verge operated between January 2005 and September 2018 were included. Primary outcomes were quality of specimen, overall survival (OS), disease-free survival (DFS), and local recurrence (LR). Results The study included 311 patients, LAP = 108 (34.7%), OPEN = 203 (65,3%). A successful resection was accomplished in 81% of the LAP group and in 84.5% of the OPEN (p = 0.505). No differences in free distal margin (LAP = 100%, OPEN = 97.5%; p = 0.156) or circumferential resection margin (LAP = 95.2%, OPEN = 93.2%; p = 0.603) were observed. However, mesorectum quality was incomplete in 16.2% for LAP and in 8.1% for OPEN (p = 0.048). OS was 91.1% for LAP and 81.1% for OPEN (p = 0.360). DFS was 81.4% for LAP and 77.5% for OPEN (p = 0.923). Overall, LR was 2.3% without differences between groups. Conclusions Laparoscopic approach could affect the quality of surgical specimen due to technical aspects. However, if principles of surgical oncology are respected, minor pathologic differences in the quality of the mesorectum may not influence on the long-term oncologic outcomes.
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Affiliation(s)
- Vicente Pla-Martí
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Av. Blasco Ibáñez, 17. 46010, Valencia, Spain.,Department of Surgery, Universidad de Valencia, Valencia, Spain
| | - José Martín-Arévalo
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Av. Blasco Ibáñez, 17. 46010, Valencia, Spain
| | - David Moro-Valdezate
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Av. Blasco Ibáñez, 17. 46010, Valencia, Spain. .,Department of Surgery, Universidad de Valencia, Valencia, Spain.
| | - Stephanie García-Botello
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Av. Blasco Ibáñez, 17. 46010, Valencia, Spain.,Department of Surgery, Universidad de Valencia, Valencia, Spain
| | - Leticia Pérez-Santiago
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Av. Blasco Ibáñez, 17. 46010, Valencia, Spain
| | - María Lapeña-Rodríguez
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Av. Blasco Ibáñez, 17. 46010, Valencia, Spain
| | - Mireia Bauzá-Collado
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Av. Blasco Ibáñez, 17. 46010, Valencia, Spain
| | - Marisol Huerta
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Susana Roselló-Keränen
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain.,Instituto de Salud Carlos III, CIBERONC, Valencia, Spain
| | - Alejandro Espí-Macías
- Colorectal Surgery Unit, Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico Universitario, Av. Blasco Ibáñez, 17. 46010, Valencia, Spain.,Department of Surgery, Universidad de Valencia, Valencia, Spain
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Valadão M, Cesar D, Véo CAR, Araújo RO, do Espirito Santo GF, Oliveira de Souza R, Aguiar S, Ribeiro R, de Castro Ribeiro HS, de Souza Fernandes PH, Oliveira AF. Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer. J Surg Oncol 2021; 125:194-216. [PMID: 34585390 DOI: 10.1002/jso.26676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice. OBJECTIVES The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence. METHODS Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts. RESULTS The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients. CONCLUSION These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.
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Affiliation(s)
- Marcus Valadão
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Daniel Cesar
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | - Rodrigo Otávio Araújo
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | | | - Samuel Aguiar
- Department of Surgical Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Reitan Ribeiro
- Department of Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
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Sebastián-Tomás JC, Martínez-Pérez A, Martínez-López E, de'Angelis N, Gómez Ruiz M, García-Granero E. Robotic transanal total mesorectal excision: Is the future now? World J Gastrointest Surg 2021; 13:834-847. [PMID: 34512907 PMCID: PMC8394387 DOI: 10.4240/wjgs.v13.i8.834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/22/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023] Open
Abstract
Total mesorectal excision (TME) is the standard surgical treatment for the curative radical resection of rectal cancers. Minimally invasive TME has been gaining ground favored by the continuous technological advancements. New procedures, such as transanal TME (TaTME), have been introduced to overcome some technical limitations, especially in low rectal tumors, obese patients, and/or narrow pelvis. The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME. However, recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series. Robotic TaTME (R-TaTME) has been proposed as a novel technique incorporating the potential benefits of a perineal dissection together with precise control of the distal margins, and also offers all those advantages provided by the robotic technology in terms of improved precision and dexterity. Encouraging short-term results have been reported for R-TaTME, but further studies are needed to assess the real role of the new technique in the long-term oncological or functional outcomes. The present review aims to provide a general overview of R-TaTME by analyzing the body of the available literature, with a special focus on the potential benefits, harms, and future perspectives for this novel approach.
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Affiliation(s)
- Juan Carlos Sebastián-Tomás
- Department of Surgery, Universidad de Valencia, Valencia 46010, Spain
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia 46017, Spain
| | - Aleix Martínez-Pérez
- Faculty of Health Sciences, Valencian International University, Valencia 46002, Spain
- Minimally Invasive and Robotic Digestive Surgery Unit, Miulli Hospital, Acquaviva delle Fonti 70021, Italy
| | - Elías Martínez-López
- Department of Surgery, Universidad de Valencia, Valencia 46010, Spain
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia 46017, Spain
| | - Nicola de'Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Miulli Hospital, Acquaviva delle Fonti 70021, Italy
| | - Marcos Gómez Ruiz
- Department of General and Digestive Surgery, Hospital Universitario Marqués de Valdecilla, Santander 39008, Spain
- Grupo de Investigación en Innovación Quirúrgica, Instituto de Investigación Biomédica Valdecilla (IDIVAL), Santander 39008, Spain
| | - Eduardo García-Granero
- Department of Surgery, Universidad de Valencia, Valencia 46010, Spain
- Department of General and Digestive Surgery, Hospital Universitario y Politécnico la Fe, Valencia 46026, Spain
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Nasir IUI, Shah MF, Panteleimonitis S, Figueiredo N, Parvaiz A. Spotlight on Laparoscopy in the Surgical Resection of Locally Advanced Rectal Cancer: Multicenter Propensity Score Match Study. Ann Coloproctol 2021; 38:307-313. [PMID: 34399445 PMCID: PMC9441543 DOI: 10.3393/ac.2020.01060.0151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 04/26/2021] [Indexed: 11/27/2022] Open
Abstract
Purpose This study was aimed to assess the feasibility of laparoscopic rectal surgery, comparing quality of surgical specimen, morbidity, and mortality. Methods Prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer, at 2 minimally invasive colorectal units, operated by the same team was included. Locally advanced rectal tumors were identified as T3B or T4 with preoperative magnetic resonance imaging scans. All the patients were operated on by the same team. The 1:1 propensity score matching was performed to create a perfect match in terms of tumor height. Results Total of 418 laparoscopic resections were performed, out of which 109 patients had locally advanced rectal cancer (LARC) and were propensity score matched with non-LARC (NLARC) patients. Median operation time was higher for the LARC group (270 minutes vs. 250 minutes, P=0.011). However, conversion to open surgery was done in 5 vs. 2 patients (P=0.445), reoperation in 8 vs. 7 (P=0.789), clinical anastomotic leak was found in 3 vs. 2 (P=0.670), and 30-day mortality rates was 2 vs. 1 (P>0.999) between LARC and NLARC, respectively. Readmission rate was higher in the NLARC group (33 patients vs. 19 patients, P=0.026), due to stoma-related issues. There was no statistically significant difference in the R0 resection between the 2 groups (99 patients in LARC vs. 104 patients in NLARC, P=0.284). Conclusion This study demonstrates that standardized approach to laparoscopy is safe and feasible in LARC. Comparable postoperative short-term clinical and pathological outcomes were seen between LARC and NLARC groups.
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Affiliation(s)
| | - Muhammad Fahd Shah
- Colorectal Surgery, Poole Hospital NHS Foundation Trust, Poole, United Kingdom
| | | | - Nuno Figueiredo
- Colorectal Surgery, Champalimaud Foundation, Lisbon, Portugal
| | - Amjad Parvaiz
- Colorectal Surgery, Champalimaud Foundation, Lisbon, Portugal.,Colorectal Surgery, Poole Hospital NHS Foundation Trust, Poole, United Kingdom.,Colorectal Surgery, University of Portsmouth, Portsmouth, United Kingdom
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Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
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Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Boualila L, Souadka A, Benslimane Z, Amrani L, Benkabbou A, Raouf M, Majbar MA. Comparison of Short-Term and Long-Term outcomes of Laparoscopy Versus Laparotomy in Rectal Cancer: Systematic Review and Meta-analysis of Randomized Controlled Trials. JOURNAL OF MEDICAL AND SURGICAL RESEARCH 2021. [DOI: 10.46327/msrjg.1.000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and objective: The last randomized controlled trials ,the ACOSOG Z6051 1,2 and the ALaCaRT trial3, 4 could not show the non-inferiority of the laparoscopy in comparison to laparotomy for rectal cancer. In fact, the ten first years of practicing laparoscopy were years when surgeons developed their learning curve. Therefore, by excluding this learning bias, it is possible to end up with a more fair and correct comparison between the two techniques. It is henceforth relevant to pursue a new meta-analysis that compares the two techniques and excludes studies done during the earlier periods of laparoscopic rectal surgery. Results: Six randomized controlled trials met the eligibility criteria, involving a total of 1556 patients in the laparoscopy group and 1188 patients in the laparotomy group. Our meta-analysis was in favor of laparoscopy in a significant way for blood loss, first bowel movement and the number of harvested lymph nodes. It was non-significantly in favour of laparoscopy for 30-days mortality after surgery and length of hospital stay. It was significantly in favor of laparotomy for operative duration. No significant difference was found in anastomotic leakage) , reoperation within 30 days, number of positive CRMs and completeness of mesorectal excision between the two groups. No difference was found in recurrence, disease-free survival and overall survival between laparoscopy group and laparotomy group. Conclusion: The comparison of the randomized controlled trials published before and after 2010, showed no significant difference in outcomes between the learning period and after.
Keywords: Laparoscopy, laparotomy, long-term outcomes, meta-analysis, short-term outcomes, rectal cancer
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Yellinek S, Krizzuk D, Gilshtein H, Moreno-Djadou T, de Sousa CAB, Qureshi S, Wexner SD. Early postoperative outcomes of diverting loop ileostomy closure surgery following laparoscopic versus open colorectal surgery. Surg Endosc 2021; 35:2509-2514. [PMID: 32458288 DOI: 10.1007/s00464-020-07662-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although diverting loop ileostomy (DLI) formation reduces the consequences of anastomotic leak and may also decrease the incidence of this severe complication, DLI closure can result in significant complications. The laparoscopic approach in colorectal surgery has numerous benefits, including reduced length of stay (LOS), less wound infection, and better cosmesis. The aim of this study was to determine whether a laparoscopic approach at the time of the ileostomy creation has a beneficial effect on the outcomes of ileostomy closure. METHODS A retrospective analysis of an IRB-approved prospective database was performed for all patients who underwent DLI closure between 2010 and 2017. Patients' demographics, operative reports, and postoperative course were reviewed. Statistical analyses were performed using SPSS software and included descriptive statistics, Chi-square for categorical variables, and Student's t tests for continuous variables. Skewed variables were compared using the non-parametric Mann-Whitney U test. Regression analysis for overall complications and LOS were preformed to further assess the impact of laparoscopy. RESULTS We identified 795 patients (363 females) who underwent DLI reversal surgery. The surgical approach in the index operation was laparoscopy in 65% of patients. Conversion to laparotomy at the ileostomy closure occurred in 6.1% of patients. The overall complication rate was lower and the LOS was shorter for patients who underwent DLI closure following laparoscopic surgery. Laparoscopy at the index operation was also associated with a lower incidence of postoperative ileus and a lower estimated blood loss (EBL) at the time of DLI reversal. Multivariate regression analysis found laparoscopy to have significant benefits compared to laparotomy for overall complications and for LOS. CONCLUSION Ileostomy closure following laparoscopic colorectal surgery offers benefits including reductions in LOS and overall complications.
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Affiliation(s)
- Shlomo Yellinek
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Dimitri Krizzuk
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Hayim Gilshtein
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Teresa Moreno-Djadou
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | | | - Sana Qureshi
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Park JW, Kang SB, Hao J, Lim SB, Choi HS, Kim DW, Chang HJ, Kim DY, Jung KH, Kim TY, Kang GH, Chie EK, Kim SY, Sohn DK, Kim JS, Lee HS, Kim JH, Jeong SY, Oh JH. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): 10-year follow-up of an open-label, non-inferiority, randomised controlled trial. Lancet Gastroenterol Hepatol 2021; 6:569-577. [PMID: 33894918 DOI: 10.1016/s2468-1253(21)00094-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic surgery has been widely used for rectal cancer; however, its long-term outcomes remain controversial. This study aimed to assess the long-term oncological safety of laparoscopic surgery for rectal cancer using 10-year follow-up data of the Comparison of Open versus laparoscopic surgery for mid or low REctal cancer After Neoadjuvant chemoradiotherapy (COREAN) trial. METHODS The COREAN trial is a, open-label, non-inferiority, randomised controlled trial. Eligible participants were aged 18-80 years, had cT3N0-2M0 middle or low rectal cancer with lesions located within 9 cm of the anal verge, and had been treated with preoperative chemoradiotherapy. Patients were randomly assigned (1:1) to open or laparoscopic surgery with a computer-generated random allocation sequence with a random permuted block design. Neither patients nor clinicians were masked to treatment assignment. Open or laparoscopic total mesorectal excision was done 6-8 weeks after the administration of preoperative concurrent chemoradiotherapy (fluoropyrimidines alone, doublet therapy, or triplet therapy) at a dose of 50·5 Gy over 5·5 weeks. Postoperative adjuvant chemotherapy was administered for 4 months. The primary endpoint of 3-year disease-free survival was published previously. Here, we report 10-year overall survival, disease-free survival, and local recurrence. Analyses were done in the modified intention-to-treat population of all participants who were randomly assigned and provided follow-up data. This study is registered with ClinicalTrials.gov, NCT00470951. FINDINGS Of the 340 patients enrolled in the COREAN trial between April 4, 2006, and Aug 26, 2009 (170 patients in each group), two patients in the laparoscopic surgery group moved abroad and were lost to follow-up, so were not included in this 10-year analysis. The median duration of follow-up was 143 months (IQR 122-156). No differences were observed in 10-year overall survival (74·1% [95% CI 66·8-80·0] in the open surgery group vs 76·8% [69·6-82·5] in the laparoscopic surgery group; p=0·44), 10-year disease-free survival (59·3% [51·1-66·5] vs 64·3% [56·0-71·5]; p=0·20), or 10-year local recurrence (8·9% [5·2-15·0] vs 3·4% [1·4-7·9]; p=0·050) between the open surgery and laparoscopic surgery groups at 10 years after surgery. The stratified hazard ratios, adjusted for ypT and ypN classification and tumour regression grade, for open surgery versus laparoscopic surgery were 0·94 (95% CI 0·63-1·43) for overall survival, 1·05 (0·74-1·49) for disease-free survival, and 2·22 (0·78-6·34) for local recurrence. INTERPRETATION The 10-year follow-up of the COREAN trial confirms the long-term oncological safety of laparoscopic surgery in patients with rectal cancer treated with preoperative chemoradiotherapy. Similar to open surgery, laparoscopic surgery does not compromise long-term survival outcomes in rectal cancer when performed by well trained surgeons. FUNDING National Cancer Center, Goyang, South Korea.
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Affiliation(s)
- Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jie Hao
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyo Seong Choi
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Tae-You Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Gyeong Hoon Kang
- Department of Pathology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Sun Young Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hye Seung Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea.
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
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Kastner C, Reibetanz J, Germer CT, Wiegering A. [Evidence in minimally invasive oncological surgery of the colon and rectum]. Chirurg 2021; 92:334-343. [PMID: 33263772 DOI: 10.1007/s00104-020-01320-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An essential component of the treatment of colorectal cancer is a resection of the tumor-bearing segment of the bowels. After the development of minimally invasive procedures the feasibility and safety in oncological, colorectal surgery was questioned. The broad study situation for colon cancer over the last years showed predominantly consistent benefits during the perioperative phase and non-inferiority concerning long-term oncological outcomes. The implementation of laparoscopic rectal resection was more hesitant due to the complexity of the procedure and insufficient study data; however, overall the short-term benefits seem to be maintained and laparoscopic rectal resection is thought to be noninferior to open resection in the long run even though findings on the quality of the resected specimen are heterogeneous. Accordingly, most guidelines now include a recommendation of laparoscopic resection for colorectal cancer. The limitation with respect to an achievable oncological equivalency of resection takes account of the complexity and the requirements of the intervention only in the setting of rational selection of patients and sufficient experience of the surgeon.
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Affiliation(s)
- Carolin Kastner
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
- Institut für Biochemie und molekulare Biologie I, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland
| | - Joachim Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland.
- Institut für Biochemie und molekulare Biologie I, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland.
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland.
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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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Horsey ML, Parascandola SA, Sparks AD, Hota S, Ng M, Obias V. The impact of surgical approach on short- and long-term outcomes after rectal cancer resection in elderly patients: a national cancer database propensity score matched comparison of robotic, laparoscopic, and open approaches. Surg Endosc 2021; 36:1269-1277. [PMID: 33638109 DOI: 10.1007/s00464-021-08401-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/15/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Elderly patients are underrepresented in studies demonstrating the advantages of laparoscopy for the management of colorectal diseases. Moreover, few studies have examined the robotic approach in this population. In this retrospective analysis, we compare outcomes for open, laparoscopic, and robotic approaches in elderly patients with nonmetastatic rectal cancer. METHODS The U.S. National Cancer Database was queried for patients aged ≥ 65 with nonmetastatic adenocarcinoma of the rectum who underwent surgical resection from 2010 to 2016. Groups were separated based on approach (open, laparoscopic, robotic). One-to-one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze the primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression. RESULTS Inclusion criteria and PSM identified 1891 patients per approach (n = 5673). PSM provided adequate discrimination between cohorts (0.6 < AUC < 0.8), and potential confounding covariates did not significantly differ (respective P > 0.05). After PSM, robotic and laparoscopic approaches were associated with decreased odds of 90 day mortality compared to the open approach (P < 0.05). Compared to laparoscopy, a robotic approach was associated with increased odds of ≥ 12 regional lymph nodes examined and negative circumferential resection margin (P < 0.05). No differences were seen in 30 day or 90 day mortality between robotic and laparoscopic approaches. Cox proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open. CONCLUSION Our study demonstrates that in elderly patients, minimally invasive surgery for rectal adenocarcinoma was associated with equivalent or improved short- and long-term mortality over open surgery. Compared to laparoscopy, the robotic approach showed no survival disadvantage and greater odds of an appropriate oncological resection. Our study adds evidence to the conclusion that robotic rectal surgery can be safely performed in patients regardless of age.
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Affiliation(s)
- Michael L Horsey
- Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | | | - Andrew D Sparks
- Department of Surgery, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Salini Hota
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Matthew Ng
- Department of Colorectal Surgery, George Washington University Hospital, Washington, DC, USA
| | - Vincent Obias
- Department of Colorectal Surgery, George Washington University Hospital, Washington, DC, USA
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Curtis NJ, Foster JD, Miskovic D, Brown CSB, Hewett PJ, Abbott S, Hanna GB, Stevenson ARL, Francis NK. Association of Surgical Skill Assessment With Clinical Outcomes in Cancer Surgery. JAMA Surg 2021; 155:590-598. [PMID: 32374371 DOI: 10.1001/jamasurg.2020.1004] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are unclear. Objective To quantify surgical skill within advanced laparoscopic procedures and its association with histopathological and clinical outcomes. Design, Setting, and Participants This analysis of data and video from the Australasian Laparoscopic Cancer of Rectum (ALaCaRT) and 2-dimensional/3-dimensional (2D3D) multicenter randomized laparoscopic total mesorectal excision trials, which were conducted at 28 centers in Australia, the United Kingdom, and New Zealand, was performed from 2018 to 2019 and included 176 patients with clinical T1 to T3 rectal adenocarcinoma 15 cm or less from the anal verge. Case videos underwent blinded objective analysis using a bespoke performance assessment tool developed with a 62-international expert Delphi exercise and workshop, interview, and pilot phases. Interventions Laparoscopic total mesorectal excision undertaken with curative intent by 34 credentialed surgeons. Main Outcomes and Measures Histopathological (plane of mesorectal dissection, ALaCaRT composite end point success [mesorectal fascial plane, circumferential margin, ≥1 mm; distal margin, ≥1 mm]) and 30-day morbidity. End points were analyzed using surgeon quartiles defined by tool scores. Results The laparoscopic total mesorectal excision performance tool was produced and shown to be reliable and valid for the specialist level (intraclass correlation coefficient, 0.889; 95% CI, 0.832-0.926; P < .001). A substantial variation in tool scores was recorded (range, 25-48). Scores were associated with the number of intraoperative errors, plane of mesorectal dissection, and short-term patient morbidity, including the number and severity of complications. Upper quartile-scoring surgeons obtained excellent results compared with the lower quartile (mesorectal fascial plane: 93% vs 59%; number needed to treat [NNT], 2.9, P = .002; ALaCaRT end point success, 83% vs 58%; NNT, 4; P = .03; 30-day morbidity, 23% vs 50%; NNT, 3.7; P = .03). Conclusions and Relevance Intraoperative surgical skill can be objectively and reliably measured in complex cancer interventions. Substantial variation in technical performance among credentialed surgeons is seen and significantly associated with clinical and pathological outcomes.
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Affiliation(s)
- Nathan J Curtis
- Department of Surgery and Cancer, Imperial College London, London, England.,Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England
| | - Jake D Foster
- Department of Surgery and Cancer, Imperial College London, London, England.,Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England
| | | | - Chris S B Brown
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Peter J Hewett
- Department of Surgery, University of Adelaide, Adelaide, Australia
| | - Sarah Abbott
- Canterbury District Health Board, Christchurch, New Zealand
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, London, England
| | - Andrew R L Stevenson
- Faculty of Medical and Biomedical Sciences, University of Queensland, Brisbane, Australia.,Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England.,University College London, London, England
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The safety and efficacy of laparoscopic surgery versus laparoscopic NOSE for sigmoid and rectal cancer. Surg Endosc 2021; 36:222-235. [PMID: 33475847 DOI: 10.1007/s00464-020-08260-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Laparoscopic surgery with natural orifice specimen extraction (La-NOSE) is being performed more frequently for the minimally invasive management of sigmoid and rectal cancer. The objective of this meta-analysis was to compare the clinical and oncological safety and efficacy of La-NOSE versus conventional laparoscopy (CL). METHODS A search of the PubMed, Web of Science, and Cochrane databases was performed for studies that compared clinical or oncological outcomes of conventional laparoscopic resection using NOSE with conventional laparoscopic resection for sigmoid and rectal cancer. RESULTS Compared with CL group, the length of hospital stay and the pain score on the first day were shorter in the La-Nose group. The La-NOSE group had a lower incidence of total perioperative complications (OR 0.46; 95% CI [0.32 to 0.66]; I2 = 0%; P < 0.0001) and a lower incidence of surgical site infections (SSIs) (OR 0.11; 95% CI [0.04 to 0.29]; I2 = 0%; P < 0.0001) than the CL group, while the anastomotic leakage showed no significant difference between the La-Nose group and the CL group (P = 0.19). 5-year disease-free survival (DFS) and 5-year overall survival (OS) were no significant difference between the La-Nose group and the CL group (P = 0.43, P = 0.40, respectively). CONCLUSIONS La-NOSE can achieve oncological and surgical safety comparable to that of CL for patients with sigmoid and rectal cancer. La-NOSE in patients was associated with a shorter hospital stay, shorter time to first flatus or defecation, less postoperative pain, and fewer surgical site infections (SSIs) and total perioperative complications. In general, the operative time in La-NOSE was longer than that in CL. The long-term oncological efficacy of La-NOSE seems to be equivalent to that of CL.
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Shimoni I, Venturero M, Shapiro R, Westrich G, Schtrechman G, Hazzan D, Nissan A, Zippel D, Segev L. Transanal total mesorectal excision for rectal cancer: Surgical outcomes and short-term oncological outcomes in a single-institution consecutive series. J Minim Access Surg 2021; 17:56-62. [PMID: 33047684 PMCID: PMC7945628 DOI: 10.4103/jmas.jmas_288_19] [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: 12/16/2019] [Accepted: 03/26/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Rectal cancer surgery is continuously evolving. Transanal total mesorectal excision (TaTME) is a relatively new surgical approach with possible advantages in comparison to current standard surgical techniques. Several studies in recent years have validated this approach regarding safety and effectiveness. We describe our initial experience with TaTME evaluating surgical parameters, post-operative outcomes and short-term oncological outcomes. METHODS This is a retrospective study reviewing all patients who underwent TaTME in a single institution from May 2015 to April 2018. RESULTS The cohort included 25 patients with an average age of 60.4 (range: 40-86), of which 13 (52%) patients were male. The average body mass index was 26.1. The overall 30-day morbidity rate was 40%, with 20% (five cases) being severe complications, defined by Clavien-Dindo Grade of 3b or above. There were three major interoperative complications. Four cases (16%) required reoperation during the first 30 post-operative days. The median length of stay was 8 days. The surgery duration was on average 296 min (range: 205-510). Negative resection margins were achieved in all patients. At a median follow-up period of 14 months, there were no local recurrences, and 4 cases (16%) had a distant recurrence. CONCLUSION This study describes our initial experience with TaTME, which requires a substantial learning curve to minimise complications and morbidity. Oncological outcomes as expressed by the resection margins, number of lymph nodes harvested and local recurrence rates were all comparable to previously published data.
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Affiliation(s)
- Irit Shimoni
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moris Venturero
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Shapiro
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gali Westrich
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Schtrechman
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Hazzan
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Nissan
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Douglas Zippel
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Segev
- Department of General and Oncological Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ramachandra C, Sugoor P, Karjol U, Arjunan R, Altaf S, Srinivas C, Prakash BV, Patil V. Robotic Total Mesorectal Excision for Rectal Cancer: Short-Term Oncological Outcomes of Initial 178 Cases. Indian J Surg Oncol 2020; 11:653-661. [PMID: 33281405 PMCID: PMC7714805 DOI: 10.1007/s13193-020-01212-5] [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: 05/20/2020] [Accepted: 09/03/2020] [Indexed: 11/06/2022] Open
Abstract
Emerging techniques in minimally invasive rectal resection include robotic total mesorectal excision (R-TME). The Da Vinci Surgical System offers precise dissection in narrow and deep confined spaces and is gaining increasing acceptance during recent times. The aim of this study is to analyse our initial experience of R-TME with Da Vinci Xi platform in terms of perioperative and oncological outcomes in the context of data from recently published randomised ROLARR trial amongst minimally invasive novice surgeons. Patients who underwent R-TME or tumour specific mesorectal excision for rectal cancer between May 2016 and November 2019 were identified from a prospectively maintained single institution colorectal database. Demographic, clinical-pathological and short-term oncological outcomes were analysed. Of the 178 patients, 117 (65.7%) and 31 (17.4%) patients had lower and mid third rectal cancer. Most of the tumours were locally advanced, cT3-T4: 138 (77.5%). One hundred/178 (56.2%) underwent sphincter preserving TME. Eighty-seven (48.8%) were grade II adenocarcinoma. Nonmucinous adenocarcinoma was the predominant histology, 138 (78.4%). One hundred one cases (56.7%) were pT3. The mean number of lymph node yield was 13 ± 5. Distal resection margin and circumferential resection margin were positive in 2 (1.12%), 12 cases (6.74%) respectively. Eleven cases (6.7%) had to be converted to open TME. Mean blood loss and duration of surgery was 170 ± 60 ml and 286 ± 45 min respectively. Five percent cases had an anastomotic leak. Grade IIIa-IIIb Clavien Dindo (CD) morbidity score was reported to be in 12 (6.75%) and 10 (5.61%) cases. Median length of hospitalisation was 7 days (range 4-14 days). Perioperative and pathologic outcomes following robotic rectal resection is associated with good short-term oncological outcomes and is safe, effective, and reproducible by a minimally invasive novice surgeon.
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Affiliation(s)
- C. Ramachandra
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - Pavan Sugoor
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - Uday Karjol
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - Ravi Arjunan
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - Syed Altaf
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - C. Srinivas
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - B. V. Prakash
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - Vijay Patil
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
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Somashekhar SP, Ashwin KR, Rohit Kumar C. Robotic Surgery for Rectal Cancer: Hype or Hope? (Indian Experience). Indian J Surg Oncol 2020; 11:604-612. [PMID: 33281402 PMCID: PMC7714808 DOI: 10.1007/s13193-020-01113-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 05/28/2020] [Indexed: 12/16/2022] Open
Abstract
The primary goal to achieve cure in oncology is to reduce recurrence, maximize disease-free survival, maintain function, and optimize quality of life. Surgery remains the mainstay treatment modality in rectal cancer. The current trend is to perform least invasive method of doing complex surgeries while not compromising in the oncological of functional outcomes of patients. Total mesorectal excision (TME) for rectal cancer surgery entails removal of the rectum with its fascia as an intact unit while preserving surrounding vital structures. The procedure is technically challenging because of the narrow and deep pelvic cavity housing the rectum encased by fatty lymph vascular tissue within the perirectal fascia, distally the anal sphincter complex, and an intimate surrounded by vital structures like ureter, vessels, and nerves. Robotic technology enables overcoming these difficulties caused by complex pelvic anatomy. This system can facilitate better preservation of the pelvic autonomic nerve and thereby achieve favorable postoperative sexual and voiding functions after rectal cancer surgery. The nerve-preserving TME technique includes identification and preservation of the superior hypogastric plexus nerve, bilateral hypogastric nerves, pelvic plexus, and neurovascular bundles.
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Affiliation(s)
- S. P. Somashekhar
- Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore, 560017 India
| | - K. R. Ashwin
- Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore, 560017 India
| | - C. Rohit Kumar
- Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore, 560017 India
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Risk factors for suboptimal laparoscopic surgery in rectal cancer patients. Langenbecks Arch Surg 2020; 406:309-318. [PMID: 33244719 DOI: 10.1007/s00423-020-02029-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 11/05/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Laparoscopic surgery for rectal cancer is technically complex. This study aimed to identify risk factors for suboptimal laparoscopic surgery (involved margins, incomplete mesorectal excision, and/or conversion to open surgery) in patients with rectal cancer. METHODS We included patients undergoing laparoscopic anterior resection for rectal cancer between June 2009 and June 2018. We defined the outcome variable suboptimal laparoscopic surgery as conversion to open surgery or inadequate histopathological specimens (margins < 1 mm or involved and/or poor-quality mesorectal excision). To identify independent predictors of suboptimal laparoscopic surgery, we analyzed 15 prospectively recorded demographic, clinical, and anthropometric variables obtained from our rectal cancer unit's database. Subanalyses examined the same variables with respect to conversion and to inadequate histopathological specimens. RESULTS Of the 323 patients included, 91 (28.2%) had suboptimal laparoscopic surgery. In the multivariate analysis, the independent factors associated with all suboptimal laparoscopic surgery were tumor location ≤ 5 cm from the anal verge (OR = 2.95, 0.95% CI 1.32-6.60; p = 0.008) and the intertuberous distance (OR = 0.79, 0.95% CI 0.65-0.96; p = 0.019). In the subanalyses, the promontorium-retropubic axis was an independent predictor of conversion (OR 0.70, 0.95% CI 0.51-0.96; p = 0.026), and tumor location ≤ 5 cm from the anal verge (OR 3.71, 0.95% 1.51-9.15; p = 0.004) was an independent predictor of inadequate histopathological specimens. CONCLUSIONS Predictive factors for suboptimal laparoscopic anterior resection for rectal cancer were tumor location and the intertuberous distance. These results could help surgeons decide whether to use other surgical approaches in complex cases. TRIAL REGISTRATION The study was registered at Clinicaltrials.org (No. NCT03107650).
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