Mini-invasive vs open resection of colorectal cancer and liver metastases: A meta-analysis

BACKGROUND

The safety and feasibility of the simultaneous resection of primary colorectal cancer (CRC) and synchronous colorectal liver metastases (SCRLM) have been demonstrated in some studies. Combined resection is expected to be the optimal strategy for patients with CRC and SCRLM. However, traditional laparotomy is traumatic, and the treatment outcome of minimally invasive surgery (MIS) is still obscure.

AIM

To compare the treatment outcomes of MIS and open surgery (OS) for the simultaneous resection of CRC and SCRLM.

METHODS

A systematic search through December 22, 2018 was conducted in electronic databases (PubMed, EMBASE, Web of Science, and Cochrane Library). All studies comparing the clinical outcomes of MIS and OS for patients with CRC and SCRLM were included by eligibility criteria. The meta-analysis was performed using Review Manager Software. The quality of the pooled study was assessed using the Newcastle-Ottawa scale. The publication bias was evaluated by a funnel plot and the Begg’s and Egger’s tests. Fixed- and random-effects models were applied according to heterogeneity.

RESULTS

Ten retrospective cohort studies involving 502 patients (216 patients in the MIS group and 286 patients in the OS group) were included in this study. MIS was associated with less intraoperative blood loss [weighted mean difference (WMD) = -130.09, 95% confidence interval (CI): -210.95 to -49.23, P = 0.002] and blood transfusion [odds ratio (OR) = 0.53, 95%CI: 0.29 to 0.95, P = 0.03], faster recovery of intestinal function (WMD = -0.88 d, 95%CI: -1.58 to -0.19, P = 0.01) and diet (WMD = -1.54 d, 95%CI: -2.30 to -0.78, P < 0.0001), shorter length of postoperative hospital stay (WMD = -4.06 d, 95%CI: -5.95 to -2.18, P < 0.0001), and lower rates of surgical complications (OR = 0.60, 95%CI: 0.37 to 0.99, P = 0.04). However, the operation time, rates and severity of overall complications, and rates of general complications showed no significant differences between the MIS and OS groups. Moreover, the overall survival and disease-free survival after MIS were equivalent to those after OS.

CONCLUSION

Considering the studies included in this meta-analysis, MIS is a safe and effective alternative technique for the simultaneous resection of CRC and SCRLM. Compared with OS, MIS has less intraoperative blood loss and blood transfusion and quicker postoperative recovery. Furthermore, the two groups show equivalent long-term outcomes.

Factors Associated With Minimally Invasive Surgery for Colorectal Cancer in Emergency Settings

BACKGROUND

Minimally invasive surgery (MIS) is associated with improved colorectal cancer (CRC) outcomes, but it is used less frequently in emergency settings. We aimed to assess patient-level factors associated with emergency presentation for CRC and the use of MIS in emergency versus elective settings.

METHODS

This retrospective study examined the clinical data of patients who underwent emergency and elective resections for CRC from 2013 to 2015 using the Florida Inpatient Discharge Dataset. Multivariable analyses were performed to assess differences in gender, age, race, urbanization, region, insurance, and clinical characteristics associated with mode of presentation and surgical approach. In-hospital mortality and length of stay by mode of presentation were recorded.

RESULTS

Of 16,277 patients identified, 10,224 (61%) had elective surgery and 6503 (39%) had emergency surgery. Emergency presentations were more likely to be black (14.2% versus 9.5%), Hispanic (18.9% versus 15.4%), Medicaid-insured (9.7% versus 4.2%), and have metastatic cancer (34.4% versus 20.2%) or multiple comorbidities (12.6% versus 4.0%). MIS was the surgical approach in 31.8% of emergency cases versus 48.1% of elective cases. Factors associated with lower odds of MIS for emergencies include Medicaid (odds ratio (OR) 0.79, 95% confidence interval (CI) 0.63-0.99), metastases (OR 0.56, CI 0.5-0.63), and multiple comorbidities (OR 0.53, CI 0.4-0.7). Emergency cases experienced higher in-hospital mortality (3.7% versus 1.0%) and a longer median length of stay (10 d versus 5 d).

CONCLUSIONS

Emergency CRC presentations are associated with racial minorities, Medicaid insurance, metastatic disease, and multiple comorbidities. Odds of MIS in emergency settings are lowest for patients with Medicaid insurance and highest clinical disease burden.

Application of the cuff rectum drainage tube in total mesorectal excision for low rectal cancer: A retrospective case-controlled study

To investigate therapeutic effect of cuff rectum drainage tube (CDT) in preventing the postoperative complications of total mesorectal excision (TME) and promoting the recovery of the patients.The clinical data of 84 cases of low rectal cancer performed TME from June 2015 to June 2017 in the First Affiliated Hospital of Xiamen University were analyzed retrospectively. All the cases were performed anus-retained operation without preventive colostomy. Patients were divided into 2 groups according to the material of the anorectal drainage tube placed in the colonic cavity. Group I (CDT group) was transanal cuff rectal drainage tube placement (Patent No. ZL 201320384337.8) (n = 48), and group II (conventional group) was transanal clinical conventional drainage tube placement (n = 36). Anastomotic fistula incidence, the time of anal exsufflation, postoperative first ambulation time, intestinal function recovery time, the incidence of interrelated complications of drainage tube and postoperative hospital stay between 2 groups were analyzed retrospectively.Both postoperative first ambulation and anal exhaust time in CDT group were shorter than those in the conventional group ([2.3 ± 0.4] d vs [3.0 ± 0.2] d, P < .05; [3.3 ± 0.3] d vs [3.9 ± 0.5] d, P < .05). Meanwhile, the postoperative hospital stay of CDT group was significantly decreased than that in the conventional group ([10.3 ± 1.6] d vs [11.8 ± 1.1] d, P < .05). Significant different occurrence of complications existed in anastomotic fistula (2.1% [1/48] vs 16.7% [6/36], P < .05), frequent defecation (8.3% [4/48] vs 27.8% [10/36], P < .05), defecating unfinished feeling (12.5% [6/48] vs 30.6% [11/36], P < .05), drainage tube complication (4.2% [2/48] vs 22.2% [8/36], P < .05).The cuff rectum drainage tube may reduce incidence of anastomotic fistula after TME, shorten postoperative first ambulation and anal exsufflation time, enable faster recovery with good toleration and decrease postoperative hospital stay.

Laparoscopic and open surgery in rectal cancer patients in Germany: short and long-term results of a large 10-year population-based cohort

Background

Rectal cancer is frequent in Germany and worldwide. Several studies have assessed laparoscopic surgery as a treatment option and most have shown favorable results. However, long-term oncologic safety remains a controversial issue.

Methods

The current dataset derives from 30 clinical cancer registries in Germany and includes 16,378 patients diagnosed with rectal cancer between 2007 and 2016. Outcomes were 90-day mortality, overall survival (OS), local recurrence-free survival (RFS) and relative survival of patients treated with either open or laparoscopic surgery. Multivariable logistic regression was used to evaluate factors that affected the probability of a patient undergoing laparoscopic surgery as well as to evaluate short-term mortality. OS and RFS were analyzed by Kaplan–Meier plots and multivariable Cox regression conducted separately for UICC stages I–III, tumor location, and sex as well as by propensity score matching followed by univariable and multivariable survival analysis.

Results

Of 16,378 patients, 4540 (27.7%) underwent laparoscopic surgery, a trend which increased during the observation period. Patients undergoing laparoscopy attained better results for 90-day mortality (odds ratio, OR 0.658, 95% confidence interval, CI 0.526–0.822). The 5-year OS rate in the laparoscopic group was 82.6%, vs. 76.6% in the open surgery group, with a hazard ratio (HR) of 0.819 in multivariable Cox regression (95% CI 0.747–0.899, p < 0.001). The laparoscopic group showed a better 5-year RFS, with 81.8 vs. 74.3% and HR 0.770 (95% CI 0.705–0.842, p < 0.001). The 5-year relative survival rates were also in favor of laparoscopy, with 93.1 vs. 88.4% (p = 0.012).

Conclusion

Laparoscopic surgery for rectal cancer can be performed safely and, according to this study, is associated with an oncological outcome superior to that of the open procedure. Therefore, in the absence of individual contraindications, it should be considered as a standard approach.

Multicentre, randomised trial comparing acellular porcine collagen implant versus gluteus maximus myocutaneous flap for reconstruction of the pelvic floor after extended abdominoperineal excision of rectum: study protocol for the Nordic Extended Abdominoperineal Excision (NEAPE) study

INTRODUCTION

Different surgical techniques are used to cover the defect in the floor of the lesser pelvis after an 'extralevator' or 'extended' abdominoperineal excision for advanced rectal cancer. However, these operations are potentially mutilating, and the reconstruction method of the pelvic floor has been studied only sparsely. We aim to study whether a porcine-collagen implant is superior or equally beneficial to a gluteus maximus myocutaneous flap as a reconstruction method.

METHODS AND ANALYSIS

This is a multicentre non-blinded randomised controlled trial with the experimental arm using a porcine-collagen implant and the control arm using a gluteus maximus muscle and skin rotation flap. Considered for inclusion are patients with rectal cancer, who are operated on with a wide abdominoperineal rectal excision including most of the levator muscles and where the muscle remnants cannot be closed in the midline with sutures. Patients with a primary or recurrent rectal cancer with an estimated survival of more than a year are eligible. The randomisation is computer generated with a concealed sequence and stratified by participating hospital and preoperative radiotherapy regimen. The main outcome is physical performance 6 months after surgery measured with the timed-stands test. Secondary outcomes are perineal wound healing, surgical complications, quality of life, ability to sit and other outcomes measured at 3, 6 and 12 months after surgery. To be able to state experimental arm non-inferiority with a 10% margin of the primary outcome with 90% statistical power and assuming 10% attrition, we aim to enrol 85 patients from May 2011 onwards.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethical Review board at Umeå University (protocol no: NEAPE-2010-335-31M). The results will be disseminated through patient associations and conventional scientific channels.

TRIAL REGISTRATION NUMBER

NCT01347697; Pre-results.

[Laparoscopic surgery of total mesorectal excision based on pelvic membrane anatomy]

Total mesorectal excision (TME) is the basic principle of surgery in rectal cancer which requires en bloc removal of the tumor and its regional lymph nodes. This conincides with the theory of membrane anatomy that emphasizes en bloc resection and avoids cancer leakage. The basis of membrane anatomy is the fusion of peritoneum and three key pointsare needed to understand the fusion and fusion fascia:(1) the fusion only occursin peritoneum; (2) the inside of fusion fascia cannot be separated; (3) the fusion can be diversiform. Only mastering these key points can we comprehend and apply this theory dialectically. The membrane anatomy in rectum is different from stomach or colon because of its specific location. The posterior space of rectum is filled with the loose connective tissue which is the degeneration of peritoneum fusion. In this space, the anterior lay of presacral fascia fuses with the proper fascia of rectum at the S4 level and separates the space into the retrorectal space and the supralevator space. Denonvilliers fascia is the fusion fascia in front of rectum, which forms the prerectal space and retroprostatic space, and extends to lateral pelvic wall with fusion of the parietal fascia of pelvis, covering the neurovascular bundle (NVB) together. The proper fascia of rectum surrounds the middle rectal artery, the pelvic plexus rectal branch and the adipose tissue to form the lateral rectal pedicle at 10 o'clock and 2 o'clock near the pelvic floor. At the level of levator ani hiatus, the fusion of levator ani muscle fascia and the proper fascia of rectum forms the Hiatal ligament, which fixs the anal canal and closes the levator ani hiatus.This article intends to discuss the above points from the perspective of membrane anatomy, in order to better guide surgeons to complete laparoscopic total mesorectal excision for rectal cancer.

Splenic Flexure Mobilization in Sigmoid and Rectal Resections: A Systematic Review and Meta-Analysis of Observational Studies

OBJECTIVE

There is no consensus regarding whether splenic flexure mobilization (SFM) should be performed selectively or routinely for sigmoid and rectal resections. The aim of this study was to evaluate the impact of SFM on anastomotic leak and surgical site infection rates in sigmoid and rectal resections.

METHODS

PubMed, MEDLINE, EMBASE, Cochrane Library, and Scopus databases were searched by two independent researchers. Anastomotic leak was the primary endpoint. Inclusion criteria were clinical studies comparing SFM to non-SFM during sigmoid and rectal resections. The Mantel-Haenszel method with a random-effects model was used. The odds ratio (OR) was used for dichotomous variables, whereas the mean difference (MD) was used for continuous variables.

RESULTS

Six of 74 potentially eligible studies totaling 12,398 patients (4,356 with SFM and 8,042 without SFM) were selected for further examination. The overall bias risk was found to be high. There was no significant difference in anastomotic leak rates when SFM patients were compared to their non-SFM counterparts [OR (95%CI) = 2.00 (0.95, 4.18); p=0.07]. SFM patients had a longer operating time [MD (95%CI) = 31.62 (24.51, 38.72); p<0.001] and increased incisional SSI rates compared to their non-SFM counterparts [11.1% vs. 9.1%; OR (95%CI) = 1.23 (1.09, 1.40); p=0.0008]. A subgroup analysis of rectal cancer cases found significantly higher anastomotic leak rates with SFM [5.4% vs. 1.5%; OR (95%CI) = 2.37 (1.09, 5.16); p=0.03].

CONCLUSION

This systematic review found that SFM was not associated with significantly decreased anastomotic leak rates. SSI rates were significantly increased in patients undergoing SFM.

Endoscopic Treatment of Anastomotic Bleeding in Laparoscopic Colorectal Surgery

Bleeding from the stapled line is a rare but potentially lethal complication that requires a proper and immediate management. Treatment for stapled anastomotic hemorrhage may be operative or conservative. We report three cases of anastomotic stapled line bleeding after colorectal surgery successfully treated endos-copically. Laparoscopic High Anterior Resection with a trans anal anastomosis according to Knight-Griffen with circular a stapler was performed for adenocarcinoma, rectal endometriosis and diverticular disease. All three patients had major rectal bleeding within 24 hours from surgery. 1 patients had endoscopy before the end of the surgical procedure. Endoscopic wash out with removal of the clots and infiltration of the bleeding sites along the stapled line with Adrenaline 1 : 10000 (2 ml) was performed achieving a good hemostasis. Early endoscopy is a safe and efficient treatment in colorectal anastomotic bleeding.

Low Anterior Resection - Emergency Versus Elective Surgery in Rectal Cancer Treatement - Comparative Analysis

Background: Rectal cancer is a public health problem, being one of the most prevalent neoplastic localizations. The current surgical management of this pathology includes low anterior resection with colorectal anastomosis. The presentation as an emergency of these patients and the need for immediate intervention make it impossible to follow the necessary multimodal management. The present study proposes a comparative assessment of a series of cases where the intervention was elective, respectively emergency. Methods: This is a retrospective, observational, descriptive, unicentric study, that took place between 1st of January 2010 and 31st of December 2018 in the 3rd Department of General Surgery of the University Emergency Hospital Bucharest. We included in the study patients with the discharge diagnosis of rectal neoplasm who underwent curative surgical treatment consisting of low anterior resection performed in compliance with oncological safety principles. Conclusion: The emergency nature of the surgery influences whether or not a R0 type resection is obtained due to lack of adequate preoperative assessment (stadialization) and the presence or absence of neoadjuvant treatment rather than a technical defect.

Analysis of Clinical Efficiency and Safety of Laparoscopic Anus-Conserving Operation for Ultralow Rectal Cancer

To explore the efficiency and safety of laparoscopic anus-conserving operation for ultralow rectal cancer, we retrospectively reviewed 236 patients with ultralow rectal cancer who underwent laparoscopic anus-conserving operation (experimental group, n = 124) or conventional open surgery (control group, n = 112). Operation-related indexes, pathological results of mesentery, incidence rates of postoperative complications, anus preservation rates, anal sphincter controllability after surgery, and survival rates of the first, second, and third years after operation were compared between the two groups. The amount of intraoperative bleeding, first postoperative exhaust time, abdominal drainage, pain score, and hospital stay in the experimental group were significantly less than those in the control group (P < 0.05). There were no significant differences in the postoperative circumferential resection margin, distal resection margin, number of dissected lymph nodes, successful resection rate, and quality of mesorectum between the two groups (P > 0.05). The total incidence rate of postoperative complications, anal sphincter controllability, and survival rates after surgery were similar between the two groups (P > 0.05). The anus preservation rate of the experimental group (84.7%) was significantly higher than that of the control group (69.6%) (P < 0.05). Laparoscopic anus-conserving operation is effective and safe in treatment of patients with ultralow rectal cancer, which has advantages such as small trauma, less intraoperative bleeding, short hospital stay, rapid recovery, a low incidence rate of postoperative complications, and a high anus-preserving rate, so it is worthy of clinical application.

Rectal Surgery Evaluation Trial: protocol for a parallel cohort trial of outcomes using surgical techniques for total mesorectal excision with low anterior resection in high-risk rectal cancer patients

AIM

Total mesorectal excision (TME) is the standard of care for rectal cancer, which can be combined with low anterior resection (LAR) in patients with mid-to-low rectal cancer. The narrow pelvic space and difficulties in obtaining adequate exposure make surgery technically challenging. Four techniques are used to perform the surgery: open laparotomy, laparoscopy, robot-assisted surgery and transanal surgery. Comparative data for these techniques are required to provide clinical data on the surgical management of rectal cancers.

METHODS

The Rectal Surgery Evaluation Trial will be a prospective, observational, case-matched, four-cohort, multicentre trial designed to study TME with LAR using open laparotomy, laparoscopy, robot-assisted surgery or transanal surgery in high-surgical-risk patients with mid-to-low non-metastatic rectal cancer. All surgeries will be performed by surgeons experienced in at least one of the techniques. Oncological, morbidity and functional outcomes will be assessed in a composite primary outcome, with success defined as circumferential resection margin ≥ 1 mm, TME Grade III and minimal postoperative morbidity (absence of Clavien-Dindo Grade III-IV complications within 30 days after surgery). Secondary end-points will include the co-primary end-points over the long term (2 years), quality of surgery, quality of life, length of hospital stay, operative time and rate of unplanned conversions.

DISCUSSION

This will be the first trial to study all four surgical techniques currently used for TME with LAR in a specific group of high-risk patients. The knowledge obtained will contribute towards helping physicians determine the advantages of each technique and which may be the most appropriate for their patients.

Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer

BACKGROUND

Low anterior resection syndrome (LARS) has a significant impact on postoperative quality of life. Although early closure of an ileostomy is safe in selected patients, functional outcomes have not been investigated. The aim was to compare bowel function and the prevalence of LARS in patients who underwent early or late closure of an ileostomy after rectal resection for cancer.

METHODS

Early closure (8-13 days) was compared with late closure (after 12 weeks) of the ileostomy following rectal cancer surgery in a multicentre RCT. Exclusion criteria were: signs of anastomotic leakage, diabetes mellitus, steroid treatment and postoperative complications. Bowel function was evaluated using the LARS score and the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI).

RESULTS

Following index surgery, 112 participants were randomized (55 early closure, 57 late closure). Bowel function was evaluated at a median of 49 months after stoma closure. Eighty-two of 93 eligible participants responded (12 had died and 7 had a permanent stoma). Rates of bowel dysfunction were higher in the late closure group, but this did not reach statistical significance (major LARS in 29 of 40 participants in late group and 25 of 42 in early group, P = 0·250; median BFI score 63 versus 71 respectively, P = 0·207). Participants in the late closure group had worse scores on the urgency/soiling subscale of the BFI (14 versus 17; P = 0·017). One participant in the early group and six in the late group had a permanent stoma (P = 0·054).

CONCLUSION

Patients undergoing early stoma closure had fewer problems with soiling and fewer had a permanent stoma, although reduced LARS was not demonstrated in this cohort. Dedicated prospective studies are required to evaluate definitively the association between temporary ileostomy, LARS and timing of closure.

Simultaneous Colon and Liver Laparoscopic Resection for Colorectal Cancer with Synchronous Liver Metastases: A Single Center Experience

Background: The one-stage approach for colorectal cancer (CRC) with synchronous liver metastases (SLM) has demonstrated advantages, when feasible, in terms of oncological radicality and reduction in sanitary costs. The simultaneous laparoscopic approach to both colon cancer and liver metastases joins the advantages of mini-invasiveness to the one-stage approach. Methods: During the period from February 2011 to July 2017, a single surgeon performed 17 laparoscopic colorectal operations with simultaneous liver resection for CRC with SLM. Colorectal procedures included 9 rectal resections, 6 left colectomies, and 2 right colectomies. Associated hepatic resections included 1 left hepatectomy, 1 right posterior sectionectomy, 2 segmentectomies, and 13 wedge resections. We analyzed retrospectively the patient's short-term outcome and operative and oncologic results. Results: There was no conversion to open surgery. Six patients (35%) had minor complications (Clavien-Dindo grade I-II), whereas only 2 patients (12%) had major complications (Clavien-Dindo grade III-IV) and no mortality occurred. The median time of discharge was 8.6 (range 5-36) days. We obtained 94% of R0 resection margin on the liver specimen and 100% of negative distal and circumferential margin in case of rectal resection. An average of 20 lymphnodes were retrieved in the colorectal specimen. Conclusions: Simultaneous mini-invasive colorectal and liver resection is a challenging but feasible procedure. The advantages of treating primary cancer and metastases in the same recovery justify the morbidity rate, especially because the most of the complications are minor and no cases of mortality occurred. Further experience is needed to better understand how to reduce the morbidity rate.

A Comparison of Pathologic Outcomes of Open, Laparoscopic, and Robotic Resections for Rectal Cancer Using the ACS-NSQIP Proctectomy-Targeted Database: a Propensity Score Analysis

BACKGROUND

There is ongoing debate regarding the benefits of minimally invasive techniques for rectal cancer surgery. The aim of this study was to compare pathologic outcomes of patients who underwent rectal cancer resection by open surgery, laparoscopy, and robotic surgery using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) proctectomy-targeted database.

METHODS

All patients from the 2016 ACS-NSQIP proctectomy-targeted database who underwent elective proctectomy for rectal cancer were identified. Patients were divided into three groups based on initial operative approach: open surgery, laparoscopy, and robotic surgery. Pathologic and 30-day clinical outcomes were then compared between the groups. A propensity score analysis was performed to control for confounders, and adjusted odds ratios for pathologic outcomes were reported.

RESULTS

A total of 578 patients were included-211 (36.5%) in the open group, 213 (36.9%) in the laparoscopic group, and 154 (26.6%) in the robotic group. Conversion to open surgery was more common among laparoscopic cases compared to robotic cases (15.0% vs. 6.5%, respectively; p = 0.011). Positive circumferential resection margin (CRM) was observed in 4.7%, 3.8%, and 5.2% (p = 0.79) of open, laparoscopic, and robotic resections, respectively. Propensity score adjusted odds ratios for positive CRM (open surgery as a reference group) were 0.70 (0.26-1.85, p = 0.47) for laparoscopy and 1.03 (0.39-2.70, p = 0.96) for robotic surgery.

CONCLUSIONS

The use of minimally invasive surgical techniques for rectal cancer surgery does not appear to confer worse pathologic outcomes.

Outcomes of a Single Surgeon-Based Transanal-Total Mesorectal Excision (TATME) for Rectal Cancer

BACKGROUND

Several studies have shown the transanal total mesorectal excision (TATME) is emerging as a safe and effective technique for proctectomy. The majority of these studies to date, however, is based on procedures done in centers with teams of two surgeons working simultaneously. Few were performed by single-surgeon teams with sizeable case load. The objective of our study was to identify the feasibility and safety of a single-surgeon TATME.

METHODS

Chart review of prospectively collected data on 27 patients who underwent TATME at our institution from June 2015 to September 2016 were included in this study. Indications for TATME included mid and low rectal cancers. Only patients who underwent surgery for neoplastic lesions were included in the study. Outcomes assessed included mesorectal integrity, margin status, operative time, complications, morbidity, LOS, and 30-day readmission.

RESULTS

A total of 27 cases were available for inclusion. A single surgeon performed all procedures. The average BMI was 27.2 ± 1.3 kg/m². The average tumor distance from anal verge was 6.8 ± 0.6 cm. The median operative time was 283 min. No intraoperative complications, including injuries and conversions, occurred. Circumferential resection margin (CRM) and distal resection margin (DRM) were R0 in 96 and 100% of patients, respectively. Mesorectal integrity was "Complete" in 67% and "Near complete" in 33% of patients. There were no incomplete specimens. The total lymph node (LN) harvest was 26 ± 2. The average LOS was 4 days for 75% of all patients. There were no mortalities. The overall morbidity was 33% (9/27). There were 4/27 anastomotic leaks, one required a laparoscopic ileostomy, one had laparoscopic drainage of an abscess, and the other two were endoscopically washed and trans-rectal drains inserted.

CONCLUSION

TATME performed by a one-surgeon team is oncologically adequate, and it is safe and feasible. Morbidities are comparable with existing literature data from two-surgeon teams. In addition, resection margins, mesorectal integrity, and LN harvests are also comparable or superior to some of the existing studies.

[A single center retrospective study on surgical efficacy of T3NxM0 middle-low rectal cancer without neoadjuvant therapy]

OBJECTIVE

To investigate the surgical efficacy and prognostic factors of T3NxM0 middle-low rectal cancer without neoadjuvant therapy.

METHODS

Clinical data of patients with middle-low rectal cancer undergoing TME surgery with T3NxM0 confirmed by postoperative pathology at Colorectal Surgery Department of Changhai Hospital from January 2008 to December 2010 were analyzed retrospectively.

INCLUSION CRITERIA

(1)no preoperative neoadjuvant chemoradiotherapy (nCRT); (2) complete preoperative evaluation, including medical history, preoperative colonoscopy or digital examination, blood tumor marker examination, and imaging examination; (3) distance between tumor lower margin and anal verge was ≤ 10 cm; (4) negative circumferential resection margin (CRM-). Finally, a total of 331 patients were included in this study. According to the number of metastatic lymph node confirmed by postoperative pathology, the patients were divided into N0 group without regional lymph node metastasis (190 cases) and N+ group with regional lymph node metastasis (141 cases). The perioperative conditions, local recurrence, distant metastasis and prognostic factors were analyzed.

RESULTS

Compared to N0 group in the perioperative data, N+ group had higher ratio of tumor deposit [29.8%(42/141) vs. 0, χ²=64.821, P<0.001] and vascular invasion [7.1%(10/141) vs. 0.5%(1/190),χ²=10.860, P<0.001]. There were no significant differences in tumor diameter, number of lymph nodes detected, positive nerve invasion, degree of tumor differentiation, morbidity of postoperative complication and postoperative adjuvant chemotherapy rate between the two groups (all P>0.05). The median follow-up period was 73.4 months. The merged 5-year local recurrence rate was 2.7%(9/331), 5-year distant metastasis rate was 23.3% (77/331), 5-year disease-free survival (DFS) rate was 73.4%, and 5-year overall survival (OS) rate was 77.2%. Multivariate analysis showed that lymph node metastasis (HR=3.120, 95%CI: 1.918 to 5.075, P<0.001), nerve invasion (HR=0.345, 95%CI: 0.156 to 0.760, P=0.008) and vascular invasion (HR=0.428, 95%CI: 0.189 to 0.972, P=0.043) were independent risk factors for DFS in patients with T3NxM0 rectal cancer after operation. Preoperative carcinoembryonic antigen level (HR=1.858, 95%CI:1.121 to 3.079, P=0.016), lymph node metastasis (HR=3.320, 95%CI: 1.985 to 5.553, P<0.001) and nerve invasion (HR=0.339, 95%CI: 0.156 to 0.738, P=0.006) were independent risk factors for OS in patients with T3NxM0 rectal cancer after operation.

CONCLUSIONS

Optimal local control rate of middle-low rectal cancer patients with T3NxM0 and CRM- can be achieved by standard TME surgery alone. For patients with preoperative elevated blood carcinoembryonic antigen level, regional lymph node metastasis, or neurovascular invasion confirmed by pathology after surgery, adjuvant chemoradiotherapy should be actively applied after surgery to improve prognosis.

Non-surgical complications in oncological colorectal surgery: a comparison between open and laparoscopic techniques

BACKGROUND

Most of the studies on laparoscopic surgery in the treatment of colorectal cancer analyzed the oncological or surgical outcome. It remains to be clarified, if laparoscopic surgery leads to a significant reduction in the incidence of systemic complications in the postoperative period.

MATERIALS AND METHODS

We undertook a quantitative and qualitative assessment of non-surgical complications arising in our patients during the postoperative stay ,in relation to laparoscopic surgery compared to open surgery for colorectal cancer. In the study, 426 patients were recruited. The interventions were performed by an open technique for 225 patients, in VL for 145 patients and 56 patients were subjected to intraoperative conversion.

RESULTS

The correlation between surgical technique and onset cardiac complications showed a higher rate of onset of these in open (11.7%) than the VL technique (5.5%). Same result for pulmonary complications (open 13.2%, VL 3.4%) and renal (open 5.7%, VL 1.4%). Average age of patients treated with open surgery 75 years, average operating time duration 169 minutes. Average age patients treated in VL 69 years, average operating time duration 175 minutes. A possible benefit of videolaparoscopic rectal surgery on non-surgical complications has also been investigated, but a significant conclusion has not been reached due to the small number of adverse events found in the reference sample. The evaluation of the duration of the operating session in relation to non-surgical complications showed an increase in the occurrence of pulmonary, renal and systemic adverse events. There was also a significantly greater risk of pulmonary complications in male patients (M 12.7%, F 6.8%). Finally, by stratifying patients by age, a significant positive correlation emerged in the onset of pulmonary complications in the subgroup of patients aged ≥ 70 years, operated with open technique (open 14.6%, vl 3.8).

CONCLUSIONS

The data analysed shows a reduction of pulmonary and renal cardiac adverse events after laparoscopic oncological surgery, it has not come to a conclusion for rectal cancer. There is also an increase in adverse events related to the duration of the operating session, the male sex and the age ≥ 70 years, thus enhancing the hypothesis that elderly patients are actually the population who can ultimately benefit more of minimally invasive surgical techniques.

KEY WORDS

Adverse eventColectomy, Colorectal cancer, Laparoscopy, Open surgery.

Synchronous liver metastases of rectal cancer and the possibility of simultaneous resection

Treatment of metastatic rectal cancer and liver metastases continues to pose a major challenge. Synchronous liver metastases are present in up to one fifth of patients diagnosed with rectal carcinoma. Multidisciplinary cooperation is essential for determination of the consequent diagnostic and therapeutic plan. Only tight collaboration of experts from different medical fields allows for optimal timing of various medical procedures leading to a maximal benefit for the patient. Given the complexity of the problem, different specific methods and combinations thereof are applied in the course of the therapy, making the design of straightforward guidelines impossible. Since open surgery is complicated by the vastly distant locations of the rectum and liver, minimally invasive approach brings more perspectives in simultaneous surgery. A novel possibility of robotic and/or laparoscopic surgery performed by two teams is currently being developed. Despite the progress in surgical technology, optimal strategy has not yet been established.

The effect of proctoring on the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms

BACKGROUND

The current method of choice for local resection of benign and selected malignant rectal tumors is transanal endoscopic microsurgery. Transanal minimally invasive surgery (TAMIS) yields similar oncological results and better patient reported outcomes when compared to transanal endoscopic micro surgery. However, due to the technical complexity of TAMIS, a significant learning curve has been suggested. Data on the surgical learning curve are limited. The aim of our study was to investigate surgeon specific learning curves for TAMIS procedures for the local excision of selected rectal tumors, and analyze the effects of proctoring on operating time and outcome.

METHODS

The current study was prospective of all TAMIS procedures performed by two surgeons from October 2010 to November 2017. Margin positivity, specimen fragmentation, adverse events and operative time were evaluated with a cumulative sum analysis to determine the number of procedures required to reach proficiency. Cumulative sum (CUSUM) analysis was used to determine trends in changes over time.

RESULTS

The earliest adopter, surgeon A, performed 103 procedures, was not proctored and developed the standardized institutional program. Surgeon B, performed 26 cases, had the benefit of a proctorship and availability of a standardized program. The CUSUM curve for operative time showed a change after 36 cases for surgeon A and after 10 cases for surgeon B. For margin positivity proficiency was reached after 31 and 6 cases for surgeon A and B, respectively. The complications curve for surgeon A showed a three-phase learning curve with a decrease after the 26th case whereas surgeon B only had one (3.8%) complication in the learning phase with no change point in the CUSUM curve. Comparing pre- and post-proficiency periods there was a decrease in operating time for both surgeon A (84.4 ± 47.3 to 55.9 ± 30.1 min) and surgeon B (90.6 ± 64.to 53 ± 26.5 min; p < 0.001). Overall margin positivity rates decreased non significantly from 21.7 to 4.8% (p = 0.23). Complications were higher in the pre-proficiency period (21.7% vs. 13.0%; p = 0.02). Surgeon A had significantly more postoperative complications in pre-proficiency phase when compared to surgeon B (25% vs. none, p < 0.001), in the post-proficiency phase there was no statistically significant difference between both surgeons (p = 0.08).

CONCLUSIONS

Our results suggest that to reach satisfactory results for TAMIS, 18-31 procedures are required. Standardized institutional operative protocols together with proficient proctorship may contribute to a shorter learning curve with fewer cases (6-10) required to reach proficiency.

National Surgical Quality Improvement Program analysis of unplanned reoperation in patients undergoing low anterior resection or abdominoperineal resection for rectal cancer

BACKGROUND

The rate of unplanned reoperation for rectal cancer can provide information about surgical quality. We sought to determine factors associated with unplanned reoperation after low anterior resection and abdominoperineal resection for patients with rectal cancer and outcomes after these reoperations.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to conduct this retrospective study. Patients who underwent elective low anterior resection and abdominoperineal resection for rectal cancer from 2012-2014 were identified. The primary outcomes were 30-day reoperation rates and postoperative complications.

RESULTS

A total of 454 low anterior resection patients (5.9%) and 289 abdominoperineal resection patients (8.1%) required reoperation within 30 days of their index operation. The most common reasons for reoperation were infection, bleeding, and bowel obstruction. Multivariate analysis revealed that male sex (odds ratio: 1.5, P = .001), poor functional status (odds ratio: 2.2, P = .04), operative time (odds ratio: 1.001, P = .01), low preoperative albumin (odds ratio: 0.79, P = .04), and lack of ostomy (odds ratio, 0.66, P = .005) were independent risk factors for reoperation after low anterior resection. Smoking (odds ratio: 1.7, P = .001), chronic obstructive pulmonary disease (odds ratio: 1.8, P = .03), poor functional status (odds ratio: 2.1, P = .032), operative time (odds ratio: 1.003, P < .001), low preoperative albumin (odds ratio: 0.69, P = .007), and open approach (odds ratio: 1.5, P = .02) were independent risk factors for reoperation after abdominoperineal resection. Postoperative complication rates are high for those undergoing reoperation, often leading to non-home discharge (P < .001) after reoperation.

CONCLUSION

Reoperation after low anterior resection and abdominoperineal resection for rectal cancer is not uncommon. This study highlights the indications for reoperation, potentially modifiable preoperative risk factors for reoperation, and the morbidity associated with such operations.

Requiem for Nigro or is anal squamous carcinoma still a surgical problem: Abdominoperineal excision rather than a defunctioning stoma?

BACKGROUND

Combined multimodal treatment (CMT) is the preferred treatment for anal squamous carcinoma with radical surgery reserved for treatment failure. Some patients require a defunctioning stoma prior to CMT. Successful closure of such a stoma is unlikely. Abdominoperineal excision (APE) may be suitable as primary treatment in these patients.

METHOD

A retrospective review of all patients with anal squamous carcinoma was undertaken. Patients who required defunctioning colostomies prior to CMT were analysed for potential resectability of tumour prior to CMT and rate of permanent stoma.

OBJECTIVE

To evaluate organ preservation in the treatment of anal squamous cancer and the closure rate of pre-treatment, temporary diverting colostomy, thereby assessing whether APE could be offered as primary treatment in those requiring a pre-treatment colostomy.

RESULTS

One hundred and twenty-five patients were included of which 58 were males. The mean age was 56 years. 107 were treated with curative intent. Six received primary APE and 12 salvage APE. Thirty (22 males) required pretreatment diverting colostomies. Three (10%) stomas were successfully reversed. Forty-eight (38%) of the 125 completed treatment with a permanent colostomy. Six patients who needed a stoma prior to CMT were deemed resectable.

CONCLUSION

Organ preservation was not possible in about a third of patients. Defunctioning stomas prior to CMT were likely to be permanent. We propose that APE could be considered as an alternative in selective cases where the tumour is resectable with low morbidity and a stoma is indicated.