Robotic versus laparoscopic surgery for mid-low rectal cancer after neoadjuvant chemoradiation therapy: comparison of oncologic outcomes

Cost-effectiveness of robotic surgery for rectal cancer focusing on short-term outcomes: a propensity score-matching analysis

Although the total cost of robotic surgery (RS) is known to be higher than that of laparoscopic surgery (LS), the cost-effectiveness of RS has not yet been verified. The aim of the study is to clarify the cost-effectiveness of RS compared with LS for rectal cancer.From January 2007 through December 2011, 311 and 560 patients underwent totally RS and conventional LS for rectal cancer, respectively. A propensity score-matching analysis was performed with a ratio of 1:1 to reduce the possibility of selection bias. Costs and perioperative short-term outcomes in both the groups were compared. Additional costs due to readmission were also analyzed.The characteristics of the patients were not different between the 2 groups. Most perioperative outcomes were not different between the groups except for the operation time. Complications within 30 days of surgery were not significantly different. Total hospital charges and patients' bill were higher in RS than in LS. The total hospital charges for patients who recovered with or without complications were higher in RS than in LS, although their short-term outcomes were similar. In patients with complications, the postoperative course after RS appeared to be milder than that of LS. Total hospital charges for patients who were readmitted due to complications were similar between the groups.RS showed similar short-term outcomes with higher costs than LS. Therefore, cost-effectiveness focusing on short-term perioperative outcomes of RS was not demonstrated.

Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes

The aim of our study was to compare short-term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid-low RC after NCRT.

A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery

BACKGROUND

Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness.

METHODS

This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality.

RESULTS

A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups.

CONCLUSIONS

When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

Feasibility and oncological outcomes of laparoscopic rectal resection following neo-adjuvant chemo-radiotherapy: A systematic review

AIM: To study the feasibility and oncological outcomes following laparoscopic total mesorectal excision (LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy (LCRT).

METHODS: A protocol driven systematic review of published literature was undertaken to assess the feasibility and oncological outcomes following LTME in patients receiving LCRT. The feasibility was assessed using peri-operative outcomes and short term results. The oncological outcomes were assessed using local recurrence, disease free survival and overall survival.

RESULTS: Only 8 studies-1 randomized controlled trial, 4 Case Matched/Controlled Studies and 3 Case Series were identified matching the search criteria. The conversion rate was low (1.2% to 28.1%), anastomotic leak rates were similar to open total mesorectal excision (0%-4.1% vs 0%-8.3%). Only 3 studies reported on local recurrence rates (5.2%-7.6%) at median 34 mo follow-up. A single study described disease free survival and overall survival at 3 years as 78.8% and 92.1% respectively.

CONCLUSION: LTME following LCRT is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.

Surgical stress response after colorectal resection: a comparison of robotic, laparoscopic, and open surgery

BACKGROUND

The perioperative immune status of colorectal robotic surgery (RS), laparoscopic surgery (LS), and open surgery (OS) patients has not been compared. Our aim was to evaluate perioperative stress and immune response after RS, LS and OS.

METHODS

This prospective study included 46 colorectal surgery patients from the Department of Surgical Oncology of the University of Tokyo Hospital. Peripheral venous blood samples were obtained preoperatively and on postoperative days 1, 3, and 6. We evaluated expression of HLA-DR (marker of immune competence), C-reactive protein (CRP) levels, and lymphocyte subset counts (natural killers, cytotoxic T cells and helper T cells).

RESULTS

Fifteen, 23, and 8 patients underwent RS, LS and OS, respectively. HLA-DR expression was the lowest on day 1 and gradually increased on days 3 and 6 in all the groups. There was no significant difference in postoperative HLA-DR expression between the RS and LS group. However, on day 3, HLA-DR expression in the RS group was significantly higher than in the OS group (p = 0.04). On day 1, CRP levels in the LS group were significantly lower than in the RS group (p = 0.038). There were no significant perioperative changes in the lymphocyte subset cell count between the three groups.

CONCLUSIONS

Perioperative surgical stress, as evaluated by immunological parameters, was comparable between robotic and laparoscopic surgery and higher with open surgery. Robotic surgery may be an alternative to laparoscopic surgery, as a minimally invasive surgery option for colorectal cancer.

Robotic right colectomy: A worthwhile procedure? Results of a meta-analysis of trials comparing robotic versus laparoscopic right colectomy

BACKGROUND:

Robotic right colectomy (RRC) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach is worthwhile in enhancing patient recovery and reducing post-operative complications, compared with laparoscopic right colectomy (LRC). Literature is still fragmented and no meta-analyses have been conducted to compare the two procedures. This work aims at reducing this gap in literature, in order to draw some preliminary conclusions on the differences and similarities between RRC and LRC, focusing on short-term outcomes.

MATERIALS AND METHODS:

A systematic literature review was conducted to identify studies comparing RRC and LRC, and meta-analysis was performed using a random-effects model. Peri-operative outcomes (e.g., morbidity, mortality, anastomotic leakage rates, blood loss, operative time) constituted the study end points.

RESULTS:

Six studies, including 168 patients undergoing RRC and 348 patients undergoing LRC were considered as suitable. The patients in the two groups were similar with respect to sex, body mass index, presence of malignant disease, previous abdominal surgery, and different with respect to age and American Society of Anesthesiologists score. There were no statistically significant differences between RRC and LRC regarding estimated blood loss, rate of conversion to open surgery, number of retrieved lymph nodes, development of anastomotic leakage and other complications, overall morbidity, rates of reoperation, overall mortality, hospital stays. RRC resulted in significantly longer operative time.

CONCLUSIONS:

The RRC procedure is feasible, safe, and effective in selected patients. However, operative times are longer comparing to LRC and no advantages in peri-operative and post-operative outcomes are demonstrated with the use of the robotic surgical system.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.