Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer

Laparoscopy in the surgical treatment of rectal cancer in Germany 2000-2009

AIM

The goal of this registry study was to compare open surgery with planned laparoscopy and then with laparoscopic to open conversion for rectal cancer surgery.

METHOD

The study included 17,964 rectal cancer patients, operated on between 1 January 2000 and 31 December 2009, from 345 hospitals in Germany. All statistical tests were two-sided, with the χ(2) test (Pearson correlation) for patients and tumour characteristics. Fisher's exact test was used for complications and 30-day mortality.

RESULTS

Of the 17,964 rectal cancer patients, 16,308 (90.8%) had an open procedure and 1656 (9.2%) were started with a laparoscopy. The 1455 patients with completed laparoscopic operations had fewer intra-operative and postoperative complications (5.4%vs 7.0%, P = 0.020, and 20.5%vs 25.8%, P < 0.001, respectively) and a lower 30-day mortality rate (1.1%vs 1.9%, P = 0.023). Of the 1656 planned laparoscopies, 201 (12.1%) were converted to open. The converted group suffered more intra-operative complications (18.9%vs 3.6% for completed laparoscopy and 7.0% for open surgery, P < 0.0001) and postoperative complications (32.3%vs 18.9% for completed laparoscopy and 25.8% for open operations, P < 0.0001). The converted group also had a higher 30-day mortality rate (2.0%vs 1.0% for completed laparoscopy and 1.9% for open surgery, P = 0.043).

CONCLUSION

The more favourable patient profile provided justification for a laparoscopic procedure. For those converted to an open procedure, however, there were significantly more complications than planned open surgery patients. A move away from the standard open procedure for rectal cancer surgery and towards laparoscopy is not yet feasible.

Laparoscopy for rectal cancer reduces short-term mortality and morbidity: results of a systematic review and meta-analysis

BACKGROUND

Although definitive long-term results are not yet available, the global safety of laparoscopic surgery for rectal cancer treatment remains controversial. We evaluated differences in the safety of laparoscopic rectal resection versus open surgery for cancer.

METHODS

A systematic review from 2000 to 2011 was performed searching the Medline and Embase databases (prospero registration CRD42012002406). We included randomized and prospective controlled clinical studies comparing laparoscopic and open resection for rectal cancer. Primary end points were 30-day mortality and overall morbidity. Then a meta-analysis was conducted by a fixed-effect model, performing a sensitivity analysis by a random-effect model. Relative risk (RR) was used as an indicator of treatment effect; a RR of less than 1.0 was in favor of laparoscopy. Publication bias was assessed by funnel plot and heterogeneity by the I (2) test and subgroup analysis on surgical and medical complications.

RESULTS

Twenty-three studies, representing 4,539 patients, met the inclusion criteria; eight were randomized for a total of 1,746 patients. Mortality was observed in 1.0 % of patients in the laparoscopic group and in 2.4 % of patients in the open group. The overall RR was 0.46 (95 % confidence interval 0.21-0.99, p = 0.048). The raw incidence of overall complications was lower in the laparoscopic group (31.8 %) compared to the open group (35.4 %). The overall RR was 0.83 (95 % confidence interval 0.76-0.91, p < 0.001).

CONCLUSIONS

On the basis of evidence of both randomized and prospective controlled series, mortality and morbidity RR, including subgroup analysis, were significantly lower after laparoscopic compared to open surgery.

Colorectal cancer surgery: what is evidence based and how should we do it?

Evidence-based medicine was first defined by Sackett as 'the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients'. This requires good quality studies with a high level of proof. However, these studies are often lacking in colorectal surgery. Nevertheless, the topics on which there is general agreement will be discussed. There is now good evidence that the laparoscopic approach is at least equivalent in oncological terms to the conventional open approach in colonic surgery. The question, however, remains unanswered for rectal cancer surgery, which is technically more demanding. Although there are no randomized studies, the introduction of total mesorectal excision for rectal cancer has achieved a major reduction in local recurrence and has been adopted as the gold standard by all colorectal surgeons. Extending this concept to colonic cancer surgery is currently under discussion. The different types of reconstruction in sphincter-preserving surgery which achieve a better functional result than straight anastomosis, including colonic pouch, transverse coloplasty and side-to-end anastomosis, will be discussed. The benefit of temporary fecal diversion in low anastomosis has now been demonstrated with a good level of evidence. The technique of abdominoperineal resection has evolved in the last years and now aims at obtaining a cylindrical specimen, which has resulted in a significant reduction of the local recurrence rate. In early rectal cancer, the technique of local resection has been improved by the introduction of transanal endoscopic microsurgery.

Combined endoscopic-laparoscopic resection of colon polyps

AIMS

To analyze the current literature on combined endoscopic-laparoscopic resection of colon polyps and to compare this new approach to standard laparoscopic colonic resection for polyps not suitable for endoscopic resection.

RESULTS

Several studies demonstrated that with a combined endoscopic-laparoscopic approach, polyps were successfully resected in 82-91% with a low morbidity of 3-10% and a short hospital stay of 1-2 days. Segmental laparoscopic resection was necessary in only 9-12%, but had a conversion rate to open surgery of 15% with an average hospital stay of 6-11 days. A cancerous polyp was found in 6-13% after a combined approach, with lymph node metastasis in 6%. Recurrent polyps after a combined endoscopic-laparoscopic resection seem to be rare, but follow-up of most studies is short and incomplete.

CONCLUSION

Combined endoscopic-laparoscopic resection of colon polyps is feasible, safe, and has a high success rate. Malignant lesions can be treated laparoscopically during the same operation, avoiding the need for a second procedure, and with good long-term oncologic outcome.

Contemporary perioperative care strategies

Background

Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes.

Methods

A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German.

Results

Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine–alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy.

Conclusion

Multidisciplinary management of perioperative patient care has improved outcomes.

What is the established contribution of laparoscopy in the treatment of rectal cancer?

The results of laparoscopic treatment of rectal cancer have been evaluated in several randomized trials. Still, the validity of this approach remains controversial because of concerns regarding its oncological safety. In this review, oncological results of laparoscopic rectal resection were similar to those of laparotomy, with no observed survival difference. Conversion from laparoscopy to laparotomy seemed to be associated with worse oncological results and an increased post-operative morbidity including nervous sequelae. Intra-operative blood loss was significantly reduced with the laparoscopic approach, but post-operative morbidity was not different. Post-operative pain and length of hospital stay were decreased by the laparoscopic approach, and short-term quality of life was improved. There was no demonstration of significant reduction in late morbidity such as incisional hernia and bowel adhesions.

Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer

BACKGROUND

Laparoscopic resection is used widely in the management of colorectal cancer; however, the data on long-term outcomes, particularly those related to rectal cancer, are limited. The results of long-term follow-up of the UK Medical Research Council trial of laparoscopically assisted versus open surgery for colorectal cancer are presented.

METHODS

A total of 794 patients from 27 UK centres were randomized to laparoscopic or open surgery in a 2:1 ratio between 1996 and 2002. Long-term follow-up data were analysed to determine differences in survival outcomes and recurrences for intention-to-treat and actual treatment groups.

RESULTS

Median follow-up of all patients was 62·9 (interquartile range 22·9 - 92·8) months. There were no statistically significant differences between open and laparoscopic groups in overall survival (78·3 (95 per cent confidence interval (c.i.) 65·8 to 106·6) versus 82·7 (69·1 to 94·8) months respectively; P = 0·780) and disease-free survival (DFS) (89·5 (67·1 to 121·7) versus 77·0 (63·3 to 94·0) months; P = 0·589). In colonic cancer intraoperative conversions to open surgery were associated with worse overall survival (hazard ratio (HR) 2·28, 95 per cent c.i. 1·47 to 3·53; P < 0·001) and DFS (HR 2·20, 1·31 to 3·67; P = 0·007). In terms of recurrence, no significant differences were observed by randomized procedure. However, at 10 years, right colonic cancers showed an increased propensity for local recurrence compared with left colonic cancers: 14·7 versus 5·2 per cent (difference 9·5 (95 per cent c.i. 2·3 to 16·6) per cent; P = 0·019).

CONCLUSION

Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer.

Neoadjuvant Therapy and Mini-Invasive Total Mesorectal Excision for Rectal Cancer: Feasibility and Outcome Analysis from a Single Institution Prospectively Collected Data Base

Aim and background

Neoadjuvant treatment for rectal adenocarcinoma improves local control and represents the standard for locally advanced disease. Laparoscopic and robotic total mesorectal excision has been increasingly adopted. It provides magnified visualization of the pelvic cavity, thereby facilitating the mesorectal dissection.

Methods

Consecutive patients with locally advanced/ultralow rectal adenocarcinoma received neoadjuvant treatment and mini-invasive total mesorectal excision at our center. We retrospectively reviewed the clinical records by using a prospectively collected data base and focusing on feasibility, tumor response and treatment outcomes.

Results

In a 13-year period, 117 rectal adenocarcinoma patients (80 males and 37 females) received neoadjuvant treatment and mini-invasive total mesorectal excision. Median age at diagnosis was 67 years; pre-treatment stage was I in 10 (9%); IIA in 58 (50%); IIC in 5 (4%); IIIA in 10 (9%); IIIB in 31 (26%) and IV in 3 (2%) patients. All patients received external beam radiation therapy, 79 (67%) combined with fluorouracil-based chemotherapy. One-hundred and three patients underwent laparoscopic surgery and 14 robotic surgery. Overall, 90 patients (77%) had anterior resection and 27 (23%) had abdominoperineal resection. Down-staging was obtained in 70 patients (66%). No major intraoperative nor delayed surgical complications were observed. At a median follow up of 52 months, 8 patients (7%) had a local relapse, 7 of them along with distant relapse, and 16 (14%) had distant relapse. The 5-year relapse-free survival was 76.5%.

Conclusions

Our data suggest that in a community hospital mini-invasive surgery after neoadjuvant treatment is feasible in real clinical practice and achieves consistent results in term of disease control rate.

Early postoperative and long-term oncological outcomes of laparoscopic treatment for patients with familial adenomatous polyposis

Purpose

We evaluated the short- and long-term outcomes of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (TPC/IPAA) for treatment of familial adenomatous polyposis (FAP). Also, we assessed the oncologic outcomes in FAP patients with coexisting malignancy.

Methods

From August 1999 to September 2010, 43 FAP patients with or without coexisting malignancy underwent TPC/IPAA by a laparoscopic-assisted or hand-assisted laparoscopic surgery.

Results

The median age was 33 years (range, 18 to 58 years) at the time of operation. IPAA was performed by a hand-sewn method in 21 patients (48.8%). The median operative time was 300 minutes (range, 135 to 610 minutes), which reached a plateau after 22 operations. Early postoperative complications within 30 days occurred in 7 patients (16.3%) and long-term morbidity occurred in 15 patients (34.9%) including 6 (14.0%) with desmoid tumors and 3 (7.0%) who required operative treatment. Twenty-two patients (51.2%) were diagnosed with coexisting colorectal malignancy. The median follow-up was 58.5 months (range, 7.9 to 97.8 months). There was only 1 case of local recurrence in the pelvic cavity. No cases of adenocarcinoma at the residual rectal mucosa developed. 5-year disease-free survival rate for 22 patients who had coexisting malignancy was 86.5% and 5-year overall survival rate was 92.6%. Three patients died from pulmonary or hepatic metastasis.

Conclusion

Laparoscopic TPC/IPAA in patients with FAP is feasible and offers favorable postoperative outcomes. It also delivered acceptable oncological outcomes in patients with coexisting malignancy. Therefore, laparoscopic TPC/IPAA may be a favorable treatment option for FAP.

Treatment of locally advanced rectal cancer: Controversies and questions

Rectal cancers extending through the rectal wall, or involving locoregional lymph nodes (T3/4 or N1/2), have been more difficult to cure. The confines of the bony pelvis and the necessity of preserving the autonomic nerves makes surgical extirpation challenging, which accounts for the high rates of local and distant relapse in this setting. Combined multimodality treatment for rectal cancer stage II and III was recommended from National Institute of Health consensus. Neoadjuvant chemoradiation using fluoropyrimidine-based regimen prior to surgical resection has emerged as the standard of care in the United States. Optimal time of surgery after neoadjuvant treatment remained unclear and prospective randomized controlled trial is ongoing. Traditionally, 6-8 wk waiting period was commonly used. The accuracy of studies attempting to determine tumor complete response remains problematic. Currently, surgery remains the standard of care for rectal cancer patients following neoadjuvant chemoradiation, whereas observational management is still investigational. In this article, we outline trends and controversies associated with optimal pre-treatment staging, neoadjuvant therapies, surgery, and adjuvant therapy.

Cost-effectiveness of laparoscopic vs open resection for colon and rectal cancer

BACKGROUND

Whether laparoscopic surgery for colon and rectal cancer is cost-effective in comparison with open surgery remains unclear, because laparoscopic surgery results in shorter hospital stays but is associated with increased equipment costs.

OBJECTIVE

This study aimed to investigate the cost-effectiveness of laparoscopic versus open surgery for colon and rectal cancer, incorporating factors not included in previous cost-effectiveness studies.

DESIGN

A decision analysis model was constructed, and extensive sensitivity analyses were performed to test the assumptions of the model.

SETTING

Data were taken from previously published studies; data from large randomized trials were used whenever possible as inputs into the model.

PATIENTS

Patients enrolled in the trials from which data were gathered for the model.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

The primary outcome measured was the cost-effectiveness of laparoscopic versus open surgery for colon and rectal cancer, expressed as cost per quality-adjusted life-year.

RESULTS

Laparoscopic resection results in savings of $4283 and essentially no difference in quality-adjusted life-years (0.001 more quality-adjusted life-years than open resection). Sensitivity analyses indicate that laparoscopic surgery is cost-effective at <$50,000 per quality-adjusted life-year under almost all conditions. The only circumstance that affects the cost-effectiveness of laparoscopic surgery is postoperative hernia rates. Because of the additional time off work for hernia repair, laparoscopic resection is cost-effective only if it results in a hernia rate less than or equal to open surgery. For all other variables, the laparoscopic approach remains less costly than the open approach with no difference in quality of life.

LIMITATIONS

The model relies on data from other studies, rather than being an independent trial designed to specifically collect these data.

CONCLUSIONS

Laparoscopic resection for colon and rectal cancer results in decreased costs and equivalent quality of life, making it the preferred approach in suitable patients.

Laparoscopic sigmoid resection with transrectal specimen extraction: a systematic review

AIM

A systematic review was performed to identify differences in surgical technique, postoperative morbidity, length of hospital stay and safety for procedures involving left-sided laparoscopic colectomy with natural orifice specimen extraction.

METHOD

A PubMed search was performed to retrieve studies reporting on left-sided laparoscopic colorectal resection with transrectal specimen extraction. The quality of the different reports was assessed according to the Newcastle-Ottawa Scale. Six studies were included and all but one were cohort studies. Studies on transanal, transvaginal or transcolonic specimen extraction were excluded, as were reports on paediatric surgery.

RESULTS

Six papers (including 94 patients) fulfilled the search criteria. The techniques reported were not standardized and this technical heterogeneity hampered pooled analysis. A meta-analysis could also not be performed because of differences in inter-study methods, study population and results. All studies showed, nevertheless, that the technique is feasible with low morbidity and short postoperative hospital stay. No anal dysfunction was reported.

CONCLUSION

To date, the evidence in favour of left-sided laparoscopic colectomy with transrectal specimen extraction is weak (level IV-V). Future clinical research should focus on standardization of the technique. Randomized controlled trials are necessary to show the superiority of this approach with regard to postoperative pain and morbidity, hospital stay, recovery, function and cosmesis.

Outcome of abdominosacral resection for locally advanced primary and recurrent rectal cancer

Background

The aim was to assess the indications for and outcomes of abdominosacral resection for patients with locally advanced primary and recurrent rectal cancer.

Methods

Consecutive patients undergoing abdominosacral resection between January 2006 and December 2011 were identified from a prospectively maintained database. The main endpoints were 3-year local recurrence-free (LRFS) and disease-free (DFS) survival.

Results

Thirty patients underwent abdominosacral resection, 22 for recurrent rectal cancer and eight for locally advanced primary cancer. Sacrectomy was performed at S1/2 in five, S3 in 11 and S4/5 in 14 patients. R0 resection was achieved in 23 patients; all seven positive margins (R1) were in patients with recurrent disease. There were no deaths in hospital or within 30 days. S1/2 sacrectomy was associated with the highest rate of major complications (60 per cent versus 27 and 29 per cent for S3 and S4/5 respectively) and long-term complications (60, 36 and 14 per cent). Overall 3-year LRFS was 66 per cent and 3-year DFS was 55 per cent. Both were significantly better in patients with negative compared with positive margins (LRFS: 87 versus 0 per cent, P &lt; 0·001; DFS: 71 versus 0 per cent, P = 0·033).

Conclusion

Abdominosacral resection was associated with long-term survival in carefully selected patients with advanced rectal cancer. Postoperative complications were common and often multiple. Sacrectomy for locally advanced primary rectal cancer was associated with a low margin-positive rate and should be considered as an acceptable treatment. Margin-positive resection was associated with poor survival outcomes and should be avoided.

Single port laparoscopic right colonic resection using a 'vessel-first' approach

AIM

Single port laparoscopic colorectal surgery (SPLC), performed through a single incision of ≤ 3 cm, has been shown to be feasible. This study aimed to assess its safety and efficacy when used as the method of choice for right hemicolectomy.

METHOD

A prospective study was carried out of patients undergoing right hemicolectomy using a single port laparoscopic technique. They were compared with a historical series of patients undergoing right hemicolectomy using a multiport laparoscopic technique. Between December 2009 and September 2010, single port surgery replaced conventional laparoscopic colorectal surgery (LCS) for radical medial to lateral right hemicolectomy performed by a single surgeon. Histology, length of hospital stay, complications, conversions and readmissions were recorded.

RESULTS

Fourteen patients were treated using single port laparoscopic surgery (SPLC): 10 for carcinoma (Dukes A1, B6, C3) and four for Crohn's disease. Twelve patients were treated using multiport laparoscopic colorectal surgery (LCS): eight for carcinoma (Dukes B4, C3, Carcinoid 1), three for Crohn's disease and one for adenoma. The median (interquartile range) operative time for the SPLC group was 120 (90-135) min and for the LCS group was 135 (116-150) min. The median (interquartile range) length of hospital stay was 3.5 (2.0-5.0) days for the SPLC group and for the LCS group was 4.0 (3.8-7.0) days. The median (interquartile range) number of lymph nodes removed for SPLC patients was 14.5 (9.8-19.5) and for the LCS patients was 14.5 (13.0-19.5). There were no conversions, no complications and no readmissions in either group.

CONCLUSION

These data confirm the feasibility of the technique. Furthermore they suggest that it is safe and efficacious.

Intra-operative tumour detection and staging in colorectal cancer surgery

AIM

Surgical resection for colorectal cancer involves segmental resection and regional lymphadenectomy. The appropriateness of this 'one-size-fits-all' strategy is questioned as bowel cancer screening programmes result in a shift to earlier stage disease. Currently, the nodal status of a colorectal cancer can only be reliably determined by histopathological examination of the resected specimen. New methods of intra-operative staging are required to allow surgical resection to be tailored to the stage of the disease.

METHOD

A literature search was performed of PubMed and Embase databases using the terms 'colon' OR 'colorectal' AND 'intra-operative detection' OR 'intra-operative staging' OR 'intra-operative detection' OR 'radioimmunoguided surgery'. Articles published between January 1980 and January 2012 were included. Technologies that have the potential to allow intra-operative staging and treatment stratification were identified and further searches performed.

RESULTS

Established techniques such as sentinel lymph node mapping and radioimmunoguided surgery have benefited from combination with other technologies to allow real-time intra-operative staging. Intra-operative fluorescence, using naturally fluorescent biomarkers or fluorescent tumour probes, probably offers the most practical means of intra-operative lymph node staging and may be facilitated using nanotechnology. Optical coherence tomography and real-time elastography have the potential to provide an in vivo'virtual biopsy'.

CONCLUSION

Technological advances may allow accurate intra-operative lymph node staging to facilitate tailored surgical resection. This may become the next paradigm shift in colorectal cancer surgery.

Technical aspects of robotic proctectomy

Robotic proctectomy is at the forefront of surgical innovation, and interest in this technique is rapidly increasing. The advantages of robotic techniques, such as enhanced visualization and improved dexterity along with tireless retraction and the addition of a "fourth arm" are reported to confer an advantage in the pelvis. It is unknown what long-term outcomes may emerge from ongoing clinical trials; however, early studies suggest improved perioperative and oncologic outcomes. Proponents of robotics suggest that robot-assisted procedures are associated with decreased complication rates and fewer conversions to open. This article reviews the pertinent literature on robotic total mesorectal excision and the early reported outcomes. The 3-arm, 4-arm laparoscopic-assisted, and the 4-arm totally robotic techniques for performing robotic proctectomy are described in detail, including port placement and patient position as well as robot docking.

Open versus robot-assisted sphincter-saving operations in rectal cancer patients: techniques and comparison of outcomes between groups of 100 matched patients

BACKGROUND

Although open resection using a sphincter-saving operation (SSO) remains the standard of care for rectal cancer, few studies have compared open and robot-assisted (RA) SSOs. This study aimed to compare the operative features, functional outcomes, and oncological validity of open and RA SSO for rectal cancer.

METHODS

A total of 200 rectal cancer patients undergoing curative SSO were enrolled prospectively. The open and RA groups (n = 100, respectively) were matched for clinical stage and operation type.

RESULTS

The mean operation time was significantly longer in the RA group than in the open group (188 vs. 103 min, P < 0.001), but it was significantly reduced in the latter half of the RA patients compared with that in the first half (164 vs. 214 min, P < 0.001). The mean distal resection margin was significantly longer in the RA than in the open group (2.7 vs. 1.9 cm; P = 0.001), but only one patient in either group had positive circumferential resection margin. Bowel peristalsis returned one day earlier in the RA than in the open group (P < 0.001). Postoperative complication rates and anorectal functional outcomes were comparable between the two groups. The operator's physical discomfort, assessed on a visual analog scale, was significantly lower in the RA than in the open group (P < 0.001).

CONCLUSIONS

According to this short-term study, the RA SSO showed equivalent oncological safety, functional outcome, and morbidities to open SSO. Although the operation takes longer, the robotic system enables a technically versatile SSO with fine dissection in a limited surgical field.

The current state of robotic-assisted pancreatic surgery

Pancreatic surgery is challenging for both surgeon and patient. With the advent of minimally invasive surgical techniques, patient morbidity could be reduced. However, these techniques must conform to established principles of open pancreatic surgery with regards to meticulous dissection, haemostasis and oncologic results. The robotic platform is utilized in all facets of surgery, and is being increasingly applied in pancreatic surgery. As with the introduction of any new technology, this approach must undergo rigorous examination before widespread adoption of the technique. In this article, we review the techniques and outcomes of robotic-assisted pancreatic resections, focusing on robotic-assisted pancreaticoduodenectomy, robotic-assisted distal pancreatectomy and robotic-assisted central pancreatectomy. As the outcomes of robotic-assisted surgery have yet to be rigorously evaluated against the gold standard of open surgery, this Review also highlights major laparoscopic pancreatic series in an effort to summarize the available literature on minimally invasive pancreatic surgery.

Oncological outcome after laparoscopic abdominoperineal excision of the rectum

AIM

Abdominoperineal excision of the rectum (APER) for cancer has been associated with higher circumferential resection margin (CRM) involvement and failure of local disease control. The aim of this study was to investigate whether the introduction of laparoscopic APER altered the incidence of CRM involvement.

METHOD

Consecutive patients undergoing open or laparoscopic APER for adenocarcinomas of the rectum were studied. Patient demographics, preoperative staging, neoadjuvant treatment, operative findings, length of stay and pathological details were collected from operative and radiology databases and compared.

RESULTS

There were 16 laparoscopic and 25 open APER performed over a 3-year period. Neoadjuvant therapy was given to 43.8% (7/16) of the laparoscopic group and 56.0% (14/25) of the open group. Complete laparoscopic resection was possible in 14 (87.5%) of 16 patients. The median harvested number of nodes was 14 (4-33) in both groups. The median length of stay was 7 (3-13) and 15 (9-40) days in the laparoscopic and open groups (P < 0.001). The CRM was clear in all cases. There was no local recurrence in either group at a median follow-up of 23 months. There were no in-hospital deaths and no significant differences in overall survival. There were no significant differences in preoperative or postoperative histopathological T stage between the two groups (P = 0.057 and P = 0.121).

CONCLUSION

Laparoscopic APER for selected rectal cancers can achieve comparable oncological outcome to open surgery but is associated with a much shorter length of stay. Patient and tumour characteristics must be taken into consideration when deciding on a laparoscopic approach for low rectal cancer.

Current state of the art in laparoscopic colorectal surgery for cancer: Update on the multi-centric international trials

Laparoscopic colectomy is now widely applied to cases of malignancy, supported by early data from several large randomized controlled trials. Long-term follow-up is now available from those trials, supporting equivalency of cancer-free and overall survival for open and laparoscopic resections. This promising data has inspired further exploration of other applications of laparoscopic techniques, including use of single incision laparoscopy. This article reviews recent reports of long-term data for colorectal cancer resection from four randomized, prospective international trials.

Laparoscopic TME for rectal cancer: a case series

PURPOSE

Laparoscopic colonic resection for cancer is becoming well established within the surgical community. However, the current evidence for laparoscopic total mesorectal excision (TME) is scanty but does point toward a potential for improved short-term outcomes and oncological equivalency to open resection.

METHODS

Patients undergoing laparoscopic TME for rectal cancer in 1 hospital between October 2003 and December 2010 were analyzed. Data were collated from a prospective database. Survival analysis was calculated using the Kaplan-Meier method.

RESULTS

79 patients were analyzed (96.3% of all TMEs). There was a median length of stay of 5 days, with no postoperative mortality. The 5-year overall survival was 70% and the 5-year disease-free survival was 65.5%. There was a conversion rate of 10.1%. The 5-year overall survival for completed laparoscopic cases was 70.6% versus 62.5% for converted cases (P=0.041).

CONCLUSIONS

There seems to be increasing evidence that laparoscopic TME is equivalent to open TME for rectal cancer. Conversion may be deleterious to overall survival.

Approach to rectal cancer surgery

Rectal cancer is a distinct subset of colorectal cancer where specialized disease-specific management of the primary tumor is required. There have been significant developments in rectal cancer surgery at all stages of disease in particular the introduction of local excision strategies for preinvasive and early cancers, standardized total mesorectal excision for resectable cancers incorporating preoperative short- or long-course chemoradiation to the multimodality sequencing of treatment. Laparoscopic surgery is also increasingly being adopted as the standard rectal cancer surgery approach following expertise of colorectal surgeons in minimally invasive surgery gained from laparoscopic colon resections. In locally advanced and metastatic disease, combining chemoradiation with radical surgery may achieve total eradication of disease and disease control in the pelvis. Evidence for resection of metastases to the liver and lung have been extensively reported in the literature. The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases is showing promise in achieving locoregional control of peritoneal dissemination. This paper summarizes the recent developments in approaches to rectal cancer surgery at all these time points of the disease natural history.

Laparoscopic and conventional resections for low rectal cancers: a retrospective analysis on perioperative outcomes, sphincter preservation, and oncological results

BACKGROUND

This study aims to compare the results of laparoscopic and conventional techniques in patients with low rectal cancers.

SUBJECTS AND METHODS

A retrospective data analysis was initiated in patients underwent laparoscopic or conventional surgery for cancers located in the low (<6 cm) rectum. Patient and tumor-related information, outcomes of operations, and survival were compared between the groups.

RESULTS

Among 142 patietns (91 men [64.1%]; mean±standard deviation age, 57.7±14.6 years) who had tumors located <6 cm from the dentate line, 92 (64.8%) were operated on with the laparoscopic technique. Demographics, tumor stage, and localization (2.9±2.0 versus 2.9±2.1 cm from the dentate line in laparoscopic and conventional arms, respectively; P=.968) were similar. However, there were more patients in the laparoscopic group who received neoadjuvant chemoradiation therapy (92.4% versus 80.0%; P=.03), since there were significantly fewer cases with stage I tumors in this group (3.3% versus 14%; P=.33). The conversion rate was 14.1% (n=13). The amount of bleeding and the requirement for transfusion decreased (P<.05 for both), and the possibility of sphincter-saving procedures (66.3% versus 34.0%; P<.001) increased, in the laparoscopy group. Other parameters were identical. In the laparoscopy group, the number of harvested lymph nodes (10.2±5.4 versus 12.4±6.0; P=.025) and the rate of vascular invasion (27.5% versus 47.8%; P=.021) were less, and Kaplan-Meier analysis revealed an improved survival (P=.042), although the follow-up period was significantly shorter in this group (P<.001).

CONCLUSIONS

Laparoscopic surgery for low rectal cancers may be technically feasible and oncologically safe. Laparoscopy may increase the possibility of sphincter preservation.

The transverse colon cancer with the reversed rotation of the midgut treated with single incision laparoscopic colectomy

BACKGROUND

Reversed rotation of the midgut is a rare type of intestinal malrotation. Moreover, synchronous colon cancer has rarely been reported. Preliminary experience with single-incision laparoscopic colectomy (SILC) for colon cancer with reversed rotation of the midgut is reported.

CASE

An 82-year-old woman was admitted because of a fecal occult blood. A colonoscopy revealed transverse colon cancer. An air-barium contrast enema showed the right-sided sigmoid colon and the left-sided cecum. A computed tomography revealed that the duodenum and the transverse colon were situated at the ventral side of the superior mesenteric artery, and a preoperative diagnosis of suspicion of reversed rotation of the midgut was made.

SURGICAL PROCEDURES

First, a lap protector was inserted through a 4.0 cm transumbilical incision. Four 5 mm ports were placed in the lap protector. On the observation of laparoscopy, the cecum and the ascending colon were not fixed with the retroperitoneum and situated on the left, and the sigmoid colon was situated on the right. We successfully mobilized the transverse colon using a single-incision laparoscopic approach. Resection was achieved following extracorporealization, and the anastomosis was performed extracorporeally using staplers. The patient was discharged on the thirteenth postoperative day. Postoperative follow-up did not reveal any umbilical wound complications.

CONCLUSION

SILC for colon cancer associated with malrotation of the midgut is feasible and a promising alternative method because of its less invasiveness and its adaptability to the malrotation without extending the skin incision.

Laparoscopic vs open resection for rectal cancer: a meta-analysis of randomized clinical trials

AIM

Laparoscopic and open rectal resection for cancer were compared by analysing a total of 26 end points which included intraoperative and postoperative recovery, short-term morbidity and mortality, late morbidity and long-term oncological outcomes.

METHOD

We searched for published randomized clinical trials, presenting a comparison between laparoscopic and open rectal resection for cancer using the following electronic databases: PubMed, OVID, Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE.

RESULTS

Nine randomized clinical trials (RCTs) were included in the meta-analysis incorporating a total of 1544 patients, having laparoscopic (N = 841) and open rectal resection (N = 703) for cancer. Laparoscopic surgery for rectal cancer was associated with a statistically significant reduction in intraoperative blood loss and in the number of blood transfusions, earlier resuming solid diet, return of bowel function and a shorter duration of hospital stay. We also found a significant advantage for laparoscopy in the reduction of post-operative abdominal bleeding, late intestinal adhesion obstruction and late morbidity. No differences were found in terms of intra-operative and late oncological outcomes.

CONCLUSION

The meta-analysis indicates that laparoscopy benefits patients with shorter hospital stay, earlier return of bowel function, reduced blood loss and number of blood transfusions and lower rates of abdominal postoperative bleeding, late intestinal adhesion obstruction and other late morbidities.

Influence of surgical manipulation and surgical modality on the molecular detection of circulating tumor cells from colorectal cancer

Purpose

The aim of this study was to evaluate the relationship between the detection of circulating tumor cell molecular markers from localized colorectal cancer and the time-course of a surgical manipulation or surgical modality.

Methods

From January 2010 to June 2010, samples from the peripheral blood and the inferior mesenteric vein were collected from 42 patients with cancer of the sigmoid colon or rectum. Pre-operative, intra-operative (both pre-mobilization and post-mobilization), and post-operative samples were collected. We examined carcinoembryonic antigen (CEA) mRNA and cytokeratin-20 (CK20) mRNA by real-time reverse-transcriptase polymerase chain reaction. Changes in mRNA detection rates were analyzed according to the time of blood sample collection, the surgical modality, and patient clinicopathological features.

Results

mRNA expression rates before surgical resection did not differ between blood samples from the peripheral and inferior mesenteric veins. The detection rate for CEA and CK20 mRNA showed a tendency to increase after operative mobilization of the cancer-bearing bowel segment. Furthermore, the cumulative detection rates for CEA and CK20 mRNA increased significantly over the course of surgery (pre-mobilization vs. post-mobilization). The cumulative detection rate decreased significantly after surgical resection compared with the pre-operative rates. However, no significant difference was observed in the detection rates between different surgical modalities (laparoscopy vs. open surgery).

Conclusion

The results of this study suggest that surgical manipulation has a negative influence on the dissemination of circulating tumor cells during operations on localized colorectal cancer. However, the type of surgical technique did not affect circulating tumor cells.

Risk factor analysis of postoperative complications after robotic rectal cancer surgery

BACKGROUND

The robotic system has been adopted as the new modality for minimally invasive surgery for rectal cancer. However, analysis of risk factors for complications after robotic rectal cancer surgery (RRS) has been limited. This study aimed to identify the risk factors for complications after RRS.

METHODS

The records of 389 consecutive patients who underwent RRS between June 2006 and October 2010 were retrieved from our prospectively collected database.

RESULTS

The overall complication rate was 19%. The most common complication was anastomotic leakage (7.0%), followed by voiding difficulty, intrapelvic abscess, and ileus/obstruction. Multivariate analysis revealed the following as risk factors for postoperative complications: male gender, history of previous abdominal surgery, and lower tumor level (hazard ratio [HR] = 1.8, 95% confidence interval [CI] = 1.0-3.1, p = 0.041; HR = 2.3; 95% CI = 1.2-4.6, p = 0.012; and HR = 1.9, 95% CI = 1.1-3.3, p = 0.020, respectively). With regard to pelvic septic complications, lower tumor level, large tumor size, and preoperative chemoradiation remained variables that retained their statistical significance in multivariate analysis (HR = 2.6, 95% CI = 1.1-6.1, p = 0.029; HR = 2.7, 95% CI = 1.1-6.1, p = 0.017; HR = 2.9, 95% CI = 1.3-6.5, p = 0.007, respectively). The rate of postoperative complications was not influenced by the difference in laparoscopic surgery experience or the technique of robotic surgery.

CONCLUSION

Surgeons should be more cautious with these patient factors to optimize the benefits of robotic rectal resection.

Comparative study of safety and outcomes of single-port access versus conventional laparoscopic colorectal surgery

BACKGROUND

Single-port access (SPA) offers cosmetic advantages in addition to the well-recognised benefits of conventional multi-port laparoscopic (CL) surgery, and can be carried out using standard straight instruments. We report the outcomes of our early experience with SPA colorectal resections in comparison with CL surgery.

METHODS

We compared the following data, patient characteristics, operating time, morbidity, operative mortality, length of hospital stay and tumour variables, of patients who underwent SPA right, left, sigmoid and total colon resections, as well as high anterior resections and panproctocolectomies, with that of patients who underwent equivalent conventional laparoscopic (CL) operations. The 40 SPA and 78 CL patients studied underwent surgery between February 2008 and September 2011.

RESULTS

There was no difference between the SPA and CL operations, as regards the patient's sex (55.0 vs. 62.8% males, p = 0.411), comorbidity (ASA I 10.0 vs. 12.8%; ASA II 57.5 vs. 59.0%; ASA III 32.5 vs. 25.6%; ASA IV 0 vs. 2.6%, p = 0.722) and body mass index (26.2 vs. 28.0 kg/m(2), p = 0.073). However, SPA patients were younger (mean age 54.1 vs. 64.8 years, p = 0.001), and malignancy was a less common indication for surgery (25.0 vs. 71.8%, p < 0.001). There were no conversions to open surgery, and one death occurred in the CL group (1.3%). Mean operating time (162 vs. 170 min, p = 0.547), median post-operative hospital stay (4 vs. 4 days, p = 0.255) and morbidity (7.5 vs. 12.8%, p = 0.538) were comparable.

CONCLUSIONS

SPA laparoscopic surgery appears safe in the hands of experienced laparoscopic surgeons, with no increase in operating time, length of stay, morbidity and mortality. Selection of patients with indications for surgery for benign disease may be of importance to ensure an oncologically safe initial uptake of SPA colorectal practice.

Radiofrequency versus ultrasonic energy in laparoscopic colorectal surgery: a metaanalysis of operative time and blood loss

BACKGROUND

Various energy sources are available for tissue dissection and vessel sealing in laparoscopic colorectal surgery. The electrothermal bipolar vessel sealing system (EBVS) and ultrasonic energy (UE) devices are widely used to provide hemostatic dissection in laparoscopic procedures. Nevertheless, available evidenced-based data comparing their operative results still are scarce. This study conducted a metaanalysis of controlled clinical trials comparing EBVS and UE in terms of operative time and intraoperative blood losses in laparoscopic colorectal surgery.

METHODS

The MEDLINE and Embase databases were searched using medical subject headings and free text words. All randomized controlled trials (RCTs) and controlled clinical trials using EBVS and UE in laparoscopic colorectal surgery were considered for inclusion in the study. Random effects models were used in case of heterogeneity to obtain summary statistics for the overall difference in operating time and blood loss between instruments.

RESULTS

Four studies comparing EBVS with UE for 397 patients (200 EBVS vs. 197 UE patients) were included in the study. The findings showed that EBVS was associated with a significantly shorter operative time and less intraoperative blood loss than UE (p < 0.05).

CONCLUSIONS

The metaanalysis indicated that EBVS is associated with a shorter operative time and less blood loss than UE in laparoscopic colorectal surgery. However, these results should be interpreted with caution due to the high heterogeneity of the included trials and the limited number of studies with a high level of evidence. More adequately designed RCTs with a larger number of patients are required to confirm the results of this metaanalysis.

Surgical oncology issues in locally advanced rectal cancer

The management of locally advanced (T3/4) rectal cancer is evolving. Randomized trials have shaped the current adjuvant treatment options, but yet there remain many unanswered questions. These include how best to define which patients to treat and choosing between short-course radiotherapy and long-course chemoradiotherapy. With respect to surgery, the optimal timing, the surgical approach in abdominoperineal resections and the role of laparoscopic surgery remain active areas of research. The possibility of avoiding surgery in selected patients is also a topic of great interest. A multidisciplinary team approach in managing rectal cancer patients is popular where possible and recommended in some guidelines.

Totally laparoscopic versus laparoscopic assisted right colectomy for cancer

INTRODUCTION

Colorectal cancer (CRC) is one of the leading causes of cancer death all over the world and right-sided colon cancer represents approximately 15% of all cases of CRC. Laparoscopic colectomies produce advantages in short-term outcome compared to open procedures and have recently benefited by a long term oncologic validation. This study was designed to compare the short- and medium-term surgical outcomes of totally laparoscopic (TLRC) and laparoscopic-assisted right colectomy (LARC) for neoplasia, hypothesizing they may be at least similar.

METHODS

A consecutive unselected series of 72 patients undergone elective surgery for right-sided colon cancer from April 2006 to April 2011 was retrospectively evaluated. All patients were treated by laparoscopic medial-to-lateral right colectomy. In 42 patients a TLRC was performed, in 30 a LARC. Perioperative care plan, operative steps and surgical instrumentations were standardized. All the operations were performed or supervised by the same Surgeon (I.S.). Data on the patients' demographics, disease features, operative details and follow up were recorded and analyzed. Complications were classified using the Clavien-Dindo classification system. Continuous variables were expressed as mean ± standard deviation and analyzed with the Student t test. Categorical ones were expressed as percent value and analyzed with Fischer test or Chi-square test, where appropriate. P < 0.05 were considered statistically significant.

RESULTS

There was no significant difference in term of age, sex, body mass index and American Society of Anesthesiology score between the two groups. Comorbidities, site of tumor and stage of disease were similar too. No conversion to laparotomy was registered. Median operative time (186.3 ± 40.1 min vs 176.5 ± 40.0 min; not significant (NS)) and estimated blood loss (43.3 ± 89.8 ml vs 31.2 ± 51.3 ml; NS) were statistically comparable in both groups. Timing of first defecation (3.4 ± 0.9 dd vs 2.9 ± 0.9; P = 0.023) and length of hospital stay (7.2 ± 1.3 dd vs 6.2 ± 1.1 dd; P < 0.001) were statistically lower in TLRC cohort. A significantly longer length of skin incision characterized LARC group compared with TLRC group (71.0 ± 13.5 mm vs 48.2 ± 10.2 mm; P < 0.001). Both groups achieved an adequate number of lymph nodes harvested (22.0 ± 8.2 vs 25.9 ± 9.0; P = 0.036) and oncological resection of the tumor (proximal margin 7.6 ± 7.7 vs 6.1 ± 3.8; NS - distal margin 13.3 ± 7.7 vs 13.6 ± 5.8; NS). Post-operative complications according to Clavien-Dindo classification were statistically comparable in both cohorts. No readmission within 60 days of discharge was observed. The mean follow-up recorded was 27.7 ± 16.6 months. Late complications consisted in 1 case of incisional hernia (3.8%) in LARC group.

CONCLUSIONS

Although more appropriate indications must be set by future studies, we encourage the choice of a TLRC for the treatment of cancer of the right colon. TLRC is actually a feasible and safe technique, which has resulted in an encouraging short-term outcome, low incidence of major complications and preservation of oncologic principles, without affecting operative times.

Laparoscopic complete mesocolic excision for right colon cancer

Laparoscopic colectomy for colon cancer has become a standard of care, with a number of publications highlighting its safety, improved postoperative recovery, and excellent oncologic outcomes. Complete mesocolic excision, recently reemphasized, is associated with superior oncologic outcomes, although this has not been discussed for laparoscopic surgery. A laparoscopic approach was performed for right colon cancer using a four-trocar technique. The key steps demonstrated are identification and high division of the ileocolic pedicle, medial-to-lateral mobilization of the ascending colon preserving the posterior mesocolic fascia, identification and high division of the right branch of the middle colic artery, mobilization of the greater omentum and hepatic flexure, completion of lateral mobilization of the ascending colon from the retroperitoneum, and mobilization of the small bowel mesentery up to the duodenum. A prospective series of 52 consecutive patients with right colon cancer underwent laparoscopic complete mesocolic excision with high-vessel ligation. Four of the patients required laparoscopic en bloc extended resections for local invasion. The median operative time was 136 min (interquartile range [IQR], 105-167 min), and the median blood loss was 20 ml (IQR, 10-45 ml). The median hospital stay was 3 days (IQR, 3-5 days). All the patients had an R0 oncologic resection with median margins of 12 cm, and a median of 22 lymph nodes (IQR, 18-29 lymph nodes) was retrieved. The median follow-up period was 38 months (IQR, 23-54 months). Of 14 patients with tumor-positive lymph nodes, 2 experienced distant recurrence. There were no local recurrences, but four patients experienced metastatic disease at a median of 37 months (IQR, 22-46 months). The median overall survival time was 38 months (IQR, 23-54 months). The embedded didactic video demonstrates a straight laparoscopic complete mesocolic excision with high-vessel ligation for a patient who had a right colon cancer. Laparoscopic right complete mesocolic excision is a safe and effective procedure associated with excellent 3-year oncologic outcomes and accelerated postoperative recovery.

Lymph node harvested in laparoscopic versus open colorectal cancer approaches: a meta-analysis

Increasing researches have reported the safety and efficacy of laparoscopic versus open approach for colorectal cancer resection; however, the number of lymph nodes harvested in the 2 approaches is still unclear. This meta-analysis is to compare the number of lymph node harvested in these 2 methods. We searched the PUBMED, the EMBASE, and the Cochrane Library up to July 1, 2011 for relevant studies. Twenty-four randomized controlled trials, comprising 6264 participants, met our criterion. We found no difference in the number of lymph nodes harvested in these 2 approaches (weighted mean difference=-0.25; 95% confidence interval, -0.57 to 0.08; P=0.542), as well as in subgroups of colon cancer and of rectal cancer. Our meta-analysis suggests that laparoscopic surgery could achieve the same effectiveness with open surgery in relation to lymph node harvested. Surgeons should pay appropriate attention on the excision of lymph nodes, which are associated with long-term benefits of patients.

Laparoscopic versus open colorectal resections in patients with symptomatic stage IV colorectal cancer

BACKGROUND

The purpose of this study was to evaluate short-term and oncologic outcomes of laparoscopic resection (LR) for patients with symptomatic stage IV colorectal cancer compared with open resection (OR).

METHODS

This study is a retrospective analysis of a prospective database. Patients with a minimum follow-up of 12 months after LR or OR for metastatic colorectal cancer were included. All analyses were performed on an "intention-to-treat" basis.

RESULTS

A total of 162 consecutive patients submitted to LR and 127 submitted to OR were included. In the LR group, conversion rate was 26.5 %, mostly due to locally advanced disease (88.4 %). A greater risk of conversion was observed among patients with a tumor size greater than 5 cm regardless the tumor site (P = 0.07). Early postoperative outcome was significantly better for LR group, with a shorter hospital stay (P = 0.008), earlier onset of adjuvant treatment, and similar postoperative complications (P = 0.853) and mortality rates (P = 0.958). LR for rectal cancer was associated with a higher morbidity compared with colon cancer (P = 0.058). During a median follow-up time of 72 months, there was no significant difference in overall survival between the two groups (P = 0.622).

CONCLUSIONS

LR for symptomatic metastatic CRC is safe and, compared with OR, is associated with a shorter hospital stay and with similar survival rates. Concerns remain about LR of bulky tumors and rectal cancers due to the increased risk of conversion and postoperative complications.

The Importance of the Pathologist's Role in Assessment of the Quality of the Mesorectum

Total mesorectal excision (TME) is considered standard of care for rectal cancer treatment. Failure to remove the mesorectal fat envelope entirely may explain part of observed local and distant recurrences. Several studies suggest quality of the mesorectum after TME surgery as determined by pathological evaluation may influence prognosis. We aimed to determine the prognostic value of the plane of surgery as well as factors influencing the likelihood of a high-quality specimen by reviewing the literature. A pooled meta-analysis of relevant outcome data was performed where appropriate. A muscularis propria resection plane was found to increase the risk of local recurrence (RR 2.72 [95 % CI 1.36 to 5.44]) and overall recurrence (RR 2.00 [95 % CI 1.17 to 3.42]) compared to an (intra)mesorectal plane. Plane of surgery is an important factor in rectal cancer treatment and the documentation by pathologists is essential for the improvement of TME quality and patient outcome.

The Importance of the Pathologist's Role in Assessment of the Quality of the Mesorectum

Total mesorectal excision (TME) is considered standard of care for rectal cancer treatment. Failure to remove the mesorectal fat envelope entirely may explain part of observed local and distant recurrences. Several studies suggest quality of the mesorectum after TME surgery as determined by pathological evaluation may influence prognosis. We aimed to determine the prognostic value of the plane of surgery as well as factors influencing the likelihood of a high-quality specimen by reviewing the literature. A pooled meta-analysis of relevant outcome data was performed where appropriate. A muscularis propria resection plane was found to increase the risk of local recurrence (RR 2.72 [95 % CI 1.36 to 5.44]) and overall recurrence (RR 2.00 [95 % CI 1.17 to 3.42]) compared to an (intra)mesorectal plane. Plane of surgery is an important factor in rectal cancer treatment and the documentation by pathologists is essential for the improvement of TME quality and patient outcome.

Complete versus partial mobilization of splenic flexure during laparoscopic low anterior resection for rectal tumors: a comparative study

BACKGROUND

The aim of the current study is to compare the results after partial and complete splenic flexure mobilization (SFM).

SUBJECTS AND METHODS

The records of laparoscopic and hand-assisted laparoscopic procedures for primary rectal tumor patients were abstracted from a prospectively designed database. The phrenicocolic and splenocolic ligaments were divided via a four-trocar technique in the partial SFM group, and dissection was continued with the separation of gastrocolic and pancreaticomesocolic attachments via a five-trocar procedure in the complete SFM group. The following data were compared between the groups: Demographics, intra- and postoperative information, and pathological features.

RESULTS

In total, 122 cases (77 [63.1%] male, 58.2±13.2 years old) who underwent a partial (n=36, 29.5%) or a complete (n=86, 70.5%) SFM were included. Reservoir creation (48.8% versus 19.4%, P=.003) was more common and conversion (8.1% versus 22.2%, P=.039) was less frequent in the complete SFM group, but there were significantly more T4 tumors in the partial group (16.7% versus 2.3%, P=.008). Demographics, other intra- and postoperative parameters, and pathological features were identical.

CONCLUSIONS

In our study, complete SFM decreased conversion rates, but this finding may be related to the higher rate of T4 tumors in the partial SFM group. Complete SFM assures an increase in reservoir creation in patients receiving a low anterior resection. Because other parameters are identical, the decision for the level of SFM is better left to the surgeon in cases undergoing a low anterior resection, but complete SFM may be preferred in cases who are candidates for a reservoir formation.

Colon cancer in the splenic flexure: comparison of short-term outcomes of laparoscopic and open colectomy

BACKGROUND

Laparoscopic surgery for colon cancer in the splenic flexure (SF cancer) is technically demanding and has not been evaluated in randomized clinical trials. This study aimed to evaluate the safety and feasibility of laparoscopic surgery for SF cancer.

METHODS

Thirty-three patients undergoing laparoscopic surgery for SF cancer (LAC group) were retrospectively compared with 22 patients undergoing open surgery for SF cancer (OC group) between April 2003 and June 2010.

RESULTS

Left hemicolectomy was the most performed procedure in both groups (79% vs. 82%). Median operating time was significantly longer (209 vs. 178 min) and estimated blood loss was significantly lower (15 vs. 113 mL) in the LAC group than in the OC group. Conversion to open surgery was needed for 1 (3%) patient because of bleeding near the pancreas. Tumor stage was more advanced in the OC group than in the LAC group, but N stages were similar between groups. The median number of lymph nodes harvested was significantly higher in the LAC group than in the OC group (16 vs. 12). The rate of postoperative complications was significantly lower in the LAC group than in the OC group (6% vs. 36%). Time to flatus (1 vs. 3 d), time to liquid diet (2 vs. 5 d), and hospital stay (12 vs. 16 d) were significantly shorter in the LAC group than in the OC group.

CONCLUSIONS

Laparoscopic surgery for SF cancer is feasible.

Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis

BACKGROUND

Robot-assisted laparoscopic surgery is being performed more frequently for the minimally invasive management of rectal cancer. The objective of this meta-analysis was to compare the clinical and oncologic safety and efficacy of robot-assisted versus conventional laparoscopic surgery.

METHODS

A search of the Medline and Embase databases was performed for studies that compared clinical or oncologic outcomes of conventional laparoscopic proctectomy with robot-assisted laparoscopic proctectomy for rectal cancer. The methodological quality of the selected studies was critically assessed to identify studies suitable for inclusion. Meta-analysis was performed by a random effects model and analyzed by Review Manager. Clinical outcomes evaluated were conversion rates, operation times, length of hospital stay, and complications. Oncologic outcomes evaluated were circumferential margin status, number of lymph nodes collected, and distal resection margin lengths.

RESULTS

Eight comparative studies were assessed for quality, and seven studies were included in the meta-analysis. Two studies were matched case-control studies, and five were unmatched. A total of 353 robot-assisted laparoscopic surgery proctectomy cases and 401 conventional laparoscopic surgery proctectomy cases were analyzed. Robotic surgery was associated with a significantly lower conversion rate (P=0.03; 95% confidence interval 1-12). There was no difference in complications, circumferential margin involvement, distal resection margin, lymph node yield, or hospital stay (P=NS).

CONCLUSIONS

Robot-assisted surgery decreased the conversion rate compared to conventional laparoscopic surgery. Other clinical outcomes and oncologic outcomes were equivalent. The benefits of robotic rectal cancer surgery may differ between population groups.

Oncologic Outcomes of a Laparoscopic Right Hemicolectomy for Colon Cancer: Results of a 3-Year Follow-up

PURPOSE

The purpose of the study is to evaluate the oncologic outcomes of a laparoscopic-assisted right hemicolectomy for the treatment of colon cancer and compare the results with those of previous randomized trials.

METHODS

From June 2006, to December 2008, 156 consecutive patients who underwent a laparoscopic right hemicolectomy with a curative intent for colon cancer were evaluated. The clinicopatholgic outcomes and the oncologic outcomes were evaluated retrospectively by using electronic medical records.

RESULTS

There were 84 male patients and 72 female patients. The mean possible length of stay was 7.0 ± 1.5 days (range, 4 to 12 days). The conversion rate was 3.2%. The total number of complications was 30 (19.2%). Anastomotic leakage was not noted. There was no mortality within 30 days. The 3-year overall survival rate of all stages was 93.3%. The 3-year overall survival rates according to stages were 100% in stage I, 97.3% in stage II, and 84.8% in stage III. The 3-year disease-free survival rate of all stages was 86.1%. The 3-year disease-free survival rates according to stage were 96.2% in stage I, 90.3% in stage II, and 75.6% in stage III. The mean follow-up period was 36.3 (3 to 60) months.

CONCLUSION

A laparoscopic right hemicolectomy for the treatment of colon cancer is technically feasible and safe to perform in terms of oncologic outcomes. The present data support previously reported randomized trials.

An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer

PURPOSE

There is growing enthusiasm for robotic-assisted laparoscopic operations across many surgical specialities, including colorectal surgery, often not supported by robust clinical or cost-effectiveness data. A proper assessment of this new technology is required, prior to widespread recommendation or implementation.

METHODS/DESIGN

The ROLARR trial is a pan-world, prospective, randomised, controlled, unblinded, superiority trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. It will investigate differences in terms of the rate of conversion to open operation, rate of pathological involvement of circumferential resection margin, 3-year local recurrence, disease-free and overall survival rates and also operative morbidity and mortality, quality of life and cost-effectiveness. The primary outcome measure is the rate of conversion to open operation. For 80% power at the 5% (two-sided) significance level, to identify a relative 50% reduction in open conversion rate (25% to 12.5%), 336 patients will be required. The target recruitment is 400 patients overall to allow loss to follow-up. Patients will be followed up at 30 days and 6 months post-operatively and then annually until 3 years after the last patient has been randomised.

DISCUSSION

In many centres, robotic-assisted surgery is being implemented on the basis of theoretical advantages, which have yet to be confirmed in practice. Robotic surgery is an expensive health care provision and merits robust evaluation. The ROLARR trial is a pragmatic trial aiming to provide a comprehensive evaluation of both robotic-assisted and standard laparoscopic surgery for the curative resection of rectal cancer.

A century of abdominoperineal excision for rectal cancer

SUMMARY Abdominoperineal excision (APE) for rectal cancer was described by Miles over 100 years ago. The technique and approach have undergone a number of modifications, however, the essence of the procedure remains essentially unchanged. Management of rectal cancer has changed significantly over the century as surgery and adjuvant therapies have evolved, with improved outcome and a marked decline in incidence of APE. It has been widely recognized that tumors requiring APE are associated with higher rates of local recurrence and positive resection margins compared with anterior resection. The modern challenge remains in obtaining oncological equivalence for both procedures. This article reviews the history and evolution of APE, assesses its current status and explores modern perspectives on optimizing the surgical approach.

A meta-analysis of the short- and long-term results of randomized controlled trials that compared laparoscopy-assisted and open colectomy for colon cancer

PURPOSE

We conducted a meta-analysis to evaluate and compare the short- and long-term results of laparoscopy-assisted colectomy (LAC) and open colectomy (OC) for colon cancer.

METHODS

We searched MEDLINE, EMBASE, Science Citation Index, and Cochrane Controlled Trial Register for relevant papers published between January 1990 and October 2011 by using the search terms "laparoscopy," "laparoscopy-assisted," "surgery," "colectomy," "colon cancer," and "randomized clinical trials (RCTs)". We analyzed the outcomes of each type of surgery over short- and long-term periods.

RESULTS

We selected 12 papers reporting RCTs that compared LAC with OC for colon cancer. Our meta-analysis included 4614 patients with colon cancer; of these, 2444 had undergone LAC and 2170 had undergone OC. In the short-term period, we found that the rates of overall postoperative complications and ileus in LAC were lower than in OC groups. LAC was associated with a reduction in intraoperative blood loss, a shorter duration of time to resumption and hospital stay, and lower rates of overall complication and ileus over the short-term, but with similar long-term oncologic outcomes such as overall and cancer-related mortality, overall recurrence, local recurrence, distant metastasis, and wound-site recurrence, compared to OC.

CONCLUSIONS

It is suggested that LAC may be preferred to OC for colon cancer.

Laparoscopic-assisted versus open resection of right-sided colonic cancer--a prospective randomized controlled trial

PURPOSES

This study aims to compare the perioperative outcomes and survival between laparoscopic-assisted right hemicolectomy (LARH) and open right hemicolectomy (ORH) for right-sided colon cancer.

METHODS

Between July 1996 and October 2005, 145 patients were randomized to receive LARH (n = 71) or ORH (n = 74).

RESULTS

The median follow-up of living patients was 99.7 months. The demographic data of the two groups were similar. The time to resume diet (4 vs. 5 days, p = 0.045) and the hospital stay (7.8 vs. 10 days, p = 0.033) were significantly shorter in LARH group, but these benefits were at the expense of longer operating time (198 vs. 129 min, p = 0.002) and higher direct cost (USD8745 vs. USD6293, p < 0.001). The morbidity and mortality were comparable between the two groups. After curative resection, the probabilities of survival at 5 years of the LARH and ORH groups were 74.2% (SE 7.4%) and 75% (SE 7.1%), respectively. The probabilities of being disease free at 5 years were 82.3% (SE 6.9%) and 84.1% (SE 6.2%), respectively.

CONCLUSIONS

Laparoscopic-assisted resection of right-sided colonic cancer has the advantage over open surgery in allowing earlier recovery. However this is at the expense of a longer operating time and higher direct cost (registration number: NCT00485316 ( http://www.clinicaltrials.gov )).

Laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic surgery for colorectal cancer has undergone tremendous advancement in the last two decades, with maturation of techniques and integration into current practice.

SOURCES OF DATA

Worldwide English-language literature on laparoscopic surgery for the management of colon and rectal cancer was reviewed.

AREAS OF AGREEMENT

A large body of evidence has attested to the improved short-term outcomes and long-term oncological safety of laparoscopic surgery for colon cancer. Laparoscopic colectomy can be recommended to suitable patients where expertise is available. Laparoscopic resection for rectal cancer is feasible, with good evidence of faster post-operative recovery and adequate surgical quality, but requires more data on long-term oncological outcomes. This review examines the evidence and current practice of laparoscopic surgery for colorectal cancer.

AREAS OF CONTROVERSY

Does laparoscopic surgery confer a survival advantage for colorectal cancer patients?

GROWING POINTS

The role of single-incision laparoscopic surgery and robotic surgery in colorectal cancer.

AREAS TIMELY FOR DEVELOPING RESEARCH

Barriers to the adoption of the laparoscopic technique.