Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review

doi:10.4240/wjgs.v16.i3.777

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Study

World J Gastrointest Surg. Mar 27, 2024; 16(3): 777-789
Published online Mar 27, 2024. doi: 10.4240/wjgs.v16.i3.777

Table 1 Clinical demographics of patients who underwent multivisceral resection, n (%)

	Total (n = 46)	Minimally invasive (n = 34)	Open (n = 12)	P value^a
Age, yr	68.0 (44.0-85.0)	68.0 (44.0-85.0)	67.5 (45.0-85.0)	0.573
Sex, male (%)	21 (45.7)	15 (44.1)	6 (50)	0.725
BMI, kg/m²	22.5 (12.6-37.9)	22.0 (12.6-32.1)	23.3 (16.4-37.9)	0.708
ASA score, median	2.0 (1.0-3.0)	2.0 (1.0-3.0)	2.0 (1.0-3.0)	0.966
1	13 (28.3)	10 (29.4)	3 (25.0)
2	27 (58.7)	19 (55.9)	8 (66.7)
3	6 (13.0)	5 (14.7)	1 (8.3)
Co-morbidities
Hypertension	23 (50.0)	17 (50.0)	6 (50.0)	1.000
Hyperlipidemia	18 (39.1)	14 (41.2)	4 (33.3)	0.632
Diabetes mellitus	11 (23.9)	9 (26.5)	2 (16.7)	0.494
Ischemic heart disease	3 (6.5)	3 (8.8)	0 (0)	0.287
Previous abdominal surgery	7 (15.2)	5 (14.7)	2 (16.7)	0.871
Neoadjuvant chemotherapy	31 (67.4)	25 (73.5)	6 (50.0)	0.135
Neoadjuvant radiotherapy	36 (78.3)	29 (85.3)	7 (58.3)	0.052
Previous local recurrence	3 (6.5)	2 (5.9)	1 (8.3)	0.768

^aStatistical significance is expressed as P < 0.05.

All continuous variables were expressed as median (range) unless specified. All categorical variables were expressed as n (%) unless otherwise specified. ASA: American Society of Anesthesiologists; BMI: Body mass index.

Table 2 Intra-operative characteristics of patients who underwent multivisceral resection, n (%)

	Total (n = 46)	Minimally invasive (n = 34)	Open (n = 12)	P value
Surgical access				N/A
Laparoscopic	13 (28.3)	13 (38.2)	-
Robotic	21 (45.7)	21 (61.8)	-
Urgency of surgery				0.015^a
Elective	44 (95.7)	34 (100)	10 (83.3)
Emergency	2 (4.3)	0 (0)	2 (16.7)
Type of surgery				0.147
ULAR with DI	30 (65.2)	25 (73.5)	5 (41.7)
APR	11 (23.9)	6 (17.6)	5 (41.7)
Hartmann’s procedure	3 (6.5)	2 (5.9)	1 (8.3)
LAR	1 (2.2)	0 (0)	1 (8.3)
taTME	1 (2.2)	1 (2.9)	0 (0)
Extent of resection				-
En-bloc seminal vesicles	5 (10.9)	5 (14.7)	0 (0)
Posterior vaginectomy	4 (8.7)	4 (11.8)	0 (0)
Salpingo-oopherectomy	1 (2.2)	1 (2.9)	0 (0)
Bladder sparing prostatectomy	5 (10.9)	4 (11.8)	1 (8.3)
Posterior exanteration	22 (47.8)	16 (47.1)	6 (50.0)
Total pelvic exanteration	9 (19.6)	4 (11.8)	5 (41.7)
Small bowel resection	1 (2.2)	1 (2.9)	0 (0)
Sacrectomy	3 (6.5)	0 (0)	3 (25.0)
Initial stoma creation	35 (76.1)	27 (79.4)	7 (58.3)	0.153
Eventual reversal	18 (51.4)	15 (55.6)	3 (42.9)
Intra-operative ureteric injury	2 (4.3)	2 (5.9)	0 (0)	0.390
Operating time, min	562 (225-900)	566.5 (275-900)	502.5 (225-751)	0.150
Estimated blood loss, mL	500 (0-4000)	450 (0-2400)	1200 (200-4000)	0.008^a
Pathological TNM stage				0.836
Complete pathological response	1 (2.2)	1 (2.9)	0 (0)
1	1 (2.2)	1 (2.9)	0 (0)
2	20 (43.5)	15 (44.1)	5 (41.7)
3	17 (37.0)	11 (32.4)	6 (50.0)
4	7 (15.2)	6 (17.6)	1 (8.3)
R0 resection	37 (80.4)	27 (79.4)	10 (83.3)	0.768

^aP < 0.05. Values indicate statistical significance, where P < 0.05.

All continuous variables were expressed as median (range) unless specified. All categorical variables were expressed as n (%) unless otherwise specified. APR: Abdominoperineal resection; DI: Defunctioning ileostomy; N/A: Not applicable; LAR: Low anterior resection; taTME: Transanal total mesorectal excision; TNM: Tumour, Node, Metastasis; ULAR: Ultra-low anterior resection.

Table 3 Post-operative outcomes of patients who underwent multivisceral resection, n (%)

	Total (n = 46)	Minimally invasive (n = 34)	Open (n = 12)	P value
Short-term complications
Anastomotic leak	7 (15.2)	4 (11.8)	3 (25.0)	0.272
Intra-abdominal collection	10 (21.7)	4 (11.8)	6 (50.0)	0.006^a
Ileus	19 (41.3)	11 (32.4)	8 (66.7)	0.038^a
SSI	10 (21.7)	4 (11.8)	6 (50.0)	0.006^a
Pneumonia	2 (5.9)	2 (5.9)	0 (0)	0.390
Overall complications	30 (65.2)	20 (58.8)	10 (83.3)	0.125
Major morbidity	11 (23.9)	5 (14.7)	6 (50.0)	0.014^a
Length of stay, d	12.0 (3.0-62.0)	10.0 (3.0-42.0)	30.0 (6.0-62.0)	< 0.001^a
30-d readmission	11 (23.9)	8 (23.5)	3 (25.0)	0.918
30-d mortality	0 (0)	0 (0)	0 (0)	N/A
Adjuvant chemotherapy	31 (67.4)	24 (70.6)	7 (58.3)	0.436
Follow-up, months	32.2 (1.1-100.8)	29.2 (1.1-100.8)	36.2 (2.2-73.9)	0.582
Overall survival
Median, months	43.2 (41.5-N/A)	43.1 (40.4-N/A)	47.1 (14.5-N/A)	0.257
1-year	93.2 (80.3-97.8)	93.9 (77.6-98.4)	91.3 (52.4-98.7)	0.774
3-year	71.5 (54.1-83.3)	71.1 (49.8-84.6)	72.1 (35.9-90.1)	0.473
5-year	36.5 (18.2-55.0)	32.1 (11.9-54.6)	45.9 (13.6-73.8)	0.446
Recurrence-free survival
Median, months	43.2 (19.5-N/A)	43.2 (15.4-N/A)	47.1 (3.6-N/A)	0.501
1-year	77.3 (61.9-87.1)	75.4 (56.8-86.9)	82.6 (46.5-95.3)	0.800
3-year	60.8 (43.8-74.1)	56.1 (36.0-72.2)	72.9 (37.1-90.4)	0.879
5-year	37.1 (19.0-55.3)	33.7 (13.1-55.8)	17.2 (13.8-74.2)	0.371

^aP < 0.05. Values indicate statistical significance, where P < 0.05.

All continuous variables were expressed as median (range) unless specified. All categorical variables were expressed as n (%) unless otherwise specified. N/A: Not applicable; SSI: Surgical site infection.

Table 4 Subgroup analysis comparing outcomes of patients who had minimally invasive multivisceral resection, n (%)

	Robotic (n = 21)	Laparoscopic (n = 13)	P value
Intra-operative ureteric injury	1 (4.8)	1 (7.7)	0.724
Open conversion	1 (4.8)	3 (23.1)	0.107
Surgical complexity			0.004^a
Simple	9 (42.9)	12 (92.3)
Complex	12 (57.1)	1 (7.7)
Short-term complications
Anastomotic leak	1 (4.8)	3 (23.1)	0.107
Intra-abdominal collection	1 (4.8)	3 (23.1)	0.107
Ileus	6 (28.6)	5 (38.5)	0.549
SSI	1 (4.8)	3 (23.1)	0.107
Pneumonia	1 (4.8)	1 (7.7)	0.724
Overall complications	12 (57.1)	8 (61.5)	0.800
Major morbidity	3 (14.3)	2 (15.4)	0.930
Length of stay, d		11.0 (4.0-28.0)	0.807
30-d readmission	5 (23.8)	3 (23.1)	0.961
30-d mortality	0 (0)	0 (0)	N/A
Adjuvant chemotherapy	15 (71.4)	9 (69.2)	0.891
Follow-up, months	24.2 (4.8-100.8)	41.5 (1.1-76.5)	0.158
Overall survival
Median, months	43.2 (43.1-N/A)	40.4 (12.9-53.0)	0.149
1-year	95.0 (69.5-99.3)	92.0 (55.3-98.8)	0.083
3-year	83.1 (56.1-94.3)	58.6 (27.2-80.2)	0.008^a
5-year	49.9 (13.1-78.8)	21.0 (3.7-47.9)	0.175
Recurrence-free survival
Median, months	43.2 (19.5-N/A)	12.9 (2.6-53.0)	0.096
1-year	85.0 (60.4-94.9)	60.0 (29.0-81.0)	0.607
3-year	72.9 (46.2-87.8)	34.3 (10.8-59.8)	0.002^a
5-year	40.5 (9.3-70.9)	22.9 (4.3-50.1)	0.070

^aP < 0.05. Values in bold indicate statistical significance, where P < 0.05.

Citation: Chan KS, Liu B, Tan MNA, How KY, Wong KY. Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review. World J Gastrointest Surg 2024; 16(3): 777-789
URL: https://www.wjgnet.com/1948-9366/full/v16/i3/777.htm
DOI: https://dx.doi.org/10.4240/wjgs.v16.i3.777