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

Evaluation of Three-Dimensional Versus Conventional Laparoscopy for Kidney Transplant Procedures in a Human Cadaveric Model

OBJECTIVES

There are increased reports that kidney transplant can be performed by laparoscopic surgery. The further development of this technique could revolutionize human kidney transplant surgery. However, laparoscopic kidney transplant demands a high level of skill for vascular anastomoses. The emerging technology of the three-dimensional, high-definition laparoscopic system may facilitate the application of this technique. Therefore, in this study, we evaluated this system in performing kidney transplant surgery versus the two-dimensional laparoscopic system.

MATERIALS AND METHODS

Four fresh-frozen human cadavers were used in this study, with 2 for the 3-dimensional and 2 for the 2-dimensional system. Kidneys were retrieved by using the retroperitoneoscopic technique for living donor nephrectomy from the same cadaver. The kidney graft was transplanted at the right iliac fossa using a laparoscopic technique by extraperitoneal approach. The procedure was recorded, and the vessel anastomotic time was analyzed.

RESULTS

Kidney transplant procedures were conducted successfully in the 3-dimensional, high-definition and the 2-dimensional groups. We recorded no significant differences in terms of vessel anastomotic time between the 2 groups. The total surgery time was shorter in the 3-dimensional, high-definition group than in the 2-dimensional group (P = .02).

CONCLUSIONS

This pilot study reinforces that kidney transplant with either the 3-dimensional, high-definition or 2-dimensional laparoscopy is feasible in a human cadaveric model. The operation was the same as open kidney transplant, but the procedure was performed by a laparoscopic approach with a smaller incision.

Evaluation of the robotic approach concerning pitfalls in rectal surgery

INTRODUCTION

The feasibility and advantages of robotic rectal surgery (RRS) in comparison to conventional open or laparoscopic rectal resections have been postulated in several reports. But well-known challenges and pitfalls of minimal invasive rectal surgery have not been evaluated by a prospective, multicenter setting so far. Aim of this study was to analyze the perioperative outcome of patients following RRS especially in regard to the pitfalls such as obesity, male patients and low tumors by a European multicenter setting.

METHODS

This prospective study included 348 patients undergoing robotic surgery due to rectal cancer in six major European centers. Clinicopathological parameters, morbidity, perioperative recovery and short-term outcome were analyzed.

RESULTS

A total of 283 restorative surgeries and 65 abdominoperineal resections were carried out. The conversion rate was 4.3%, mean blood loss was 191 ml, and mean operative time was 315 min. Postoperative complications with a Clavien-Dindo score >2 were observed in 13.5%. Obesity and low rectal tumors showed no significant higher rates of major complications or impaired oncological parameters. Male patients had significant higher rates of major complications and anastomotic leakage (p = 0.048 and p = 0.007, respectively).

DISCUSSION

RRS is a promising tool for improvement of rectal resections. The well-known pitfalls of minimal-invasive rectal surgery like obesity and low tumors were sufficiently managed by RRS. However, RRS showed significantly higher rates of major complications and anastomotic leakage in male patients, which has to be evaluated by future randomized trials.

[Minimally invasive surgery and robotic surgery: surgery 4.0?]

Surgery can only maintain its role in a highly competitive environment if results are continuously improved, accompanied by further reduction of the interventional trauma for patients and with justifiable costs. Significant impulse to achieve this goal was expected from minimally invasive surgery and, in particular, robotic surgery; however, a real breakthrough has not yet been achieved. Accordingly, the new strategic approach of cognitive surgery is required to optimize the provision of surgical treatment. A full scale integration of all modules utilized in the operating room (OR) into a comprehensive network and the development of systems with technical cognition are needed to upgrade the current technical environment passively controlled by the surgeon into an active collaborative support system (surgery 4.0). Only then can the true potential of minimally invasive surgery and robotic surgery be exploited.

Laparoscopic versus open surgery for rectal cancer: A meta-analysis of classic randomized controlled trials and high-quality Nonrandomized Studies in the last 5 years

OBJECTIVE

To present a meta-analysis of high-quality published reports comparing laparoscopic rectal resection (LRR) and open rectal resection (ORR) for rectal cancer.

METHODS

Studies that compared LRR and ORR and were published within the last 5 years were identified. All eligible randomized controlled trials (RCTs) and non-randomized comparative trials (NRCTs) were evaluated based on the Jadad score, the Cochrane risk of bias assessment tool and modified Methodological Indices for Nonrandomized Studies (MINORS). The mean differences (MD) and odds ratios (OR) were used to compare the operative time, blood loss, mortality, complications, harvested lymph nodes, hospital stay, distal resection margin, and circumferential resection margin. The risk ratio (RR) method was used to examine recurrence and survival.

RESULTS

Fourteen studies were identified and included 7 RCTs and 7 NRCTs and 4353 patients (2251 LRR, 2102 ORR). Although the operation time of the LRR group was obviously longer than that of the conventional surgery group (MD = 25.64, 95%CI = [5.17,46.10], P = 0.01), LRR was associated with fewer overall complications (OR = 0.67, 95%CI = [0.52,0.87], P = 0.002), less blood loss (MD = -66.49, 95%CI = [-88.31, -44.66], P < 0.00001), shorter postoperative hospital stays (OR = -1.26,95%CI = [-2.45, -0.07],P = 0.004) and shorter bowel function recovery times (MD = -0.93, 95%CI = [-1.27,-0.58], P < 0.00001). Moreover, the difference in the DRM was statistically clear (MD = 0.14, 95%CI = [0.02,0.27], P = 0.03). However, no significant differences between the LRR and ORR groups were observed in terms of the number of lymph nodes harvested, mortality, positive CRM, local and distal recurrence, or overall and disease-free survival.

CONCLUSIONS

This study indicates that there are no significant differences between LRR and ORR in terms of survival and pathological outcomes with the exception of the DRM. Moreover, this study suggests that LRR can be performed safely and elicits faster recovery times compared with conventional surgery.

The influence of obesity and body mass index on the outcome of laparoscopic colorectal surgery: a systematic literature review

AIM

The relationship between obesity, body mass index (BMI) and laparoscopic colorectal resection is unclear. Our object was to assess systematically the available evidence to establish the influence of obesity and BMI on the outcome of laparoscopic colorectal resection.

METHOD

A search of PubMed/Medline databases was performed in May 2015 to identify all studies investigating the impact of BMI and obesity on elective laparoscopic colorectal resection performed for benign or malignant bowel disease. Clinical end-points examined included operation time, conversion rate to open surgery, postoperative complications including anastomotic leakage, length of hospital stay, readmission rate, reoperation rate and mortality. For patients who underwent an operation for cancer, the harvested number of lymph nodes and long-term oncological data were also examined.

RESULTS

Forty-five studies were analysed, the majority of which were level IV with only four level III (Oxford Centre for Evidence-based Medicine 2011) case-controlled studies. Thirty comparative studies containing 23 649 patients including 17 895 non-obese and 5754 obese showed no significant differences between the two groups with respect to intra-operative blood loss, overall postoperative morbidity, anastomotic leakage, reoperation rate, mortality and the number of retrieved lymph nodes in patients operated on for malignancy. Most studies, including 15 non-comparative studies, reported a longer operation time in patients who underwent a laparoscopic procedure with the BMI being an independent predictor in multivariate analyses for the operation time.

CONCLUSION

Laparoscopic colorectal resection is safe and technically and oncologically feasible in obese patients. These results, however, may vary outside of high volume centres of expertise.

Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO)

In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.

Robotic versus laparoscopic low anterior resection for rectal cancer: a meta-analysis

BACKGROUND

The objective of this meta-analysis was to compare the clinical and oncologic outcomes of robotic low anterior resection (R-LAR) with conventional laparoscopic low anterior resection (L-LAR).

METHODS

A search in the MEDLINE, Embase, and Ovid databases was performed for studies published before July 2014 that compared the clinical and oncologic outcomes of R-LAR and L-LAR. The methodological quality of the selected studies was assessed. Depending on statistical heterogeneity, a fixed or random effects model was used for the meta-analysis. The clinical and oncologic outcomes evaluated included operative time, estimated blood loss, length of hospital stay, rate of conversion to open surgery, post-operative complications, circumferential margin status, and number of lymph nodes collected.

RESULTS

Eight studies, including 324 R-LAR cases and 268 conventional L-LAR cases, were analyzed. The meta-analysis showed that R-LAR was associated with a shorter hospital stay (mean difference (MD) = -1.03; 95% confidence interval (CI) = -1.78, -0.28; P = 0.007), lower conversion rate (odds ratio (OR) = 0.08; 95% CI = 0.02, 0.31; P = 0.0002), lower rate of circumferential margin involvement (OR = 0.5; 95% CI = 0.25, 1.01; P = 0.05), and lower overall complication rate (MD = 0.65; 95% CI = 0.43, 0.99; P = 0.04) compared with L-LAR. There was no difference in operative time (MD = 28.4; 95% CI = -3.48, 60.27; P = 0.08), the number of lymph nodes removed (MD = -0.63; 95% CI = -0.78, 2.05; P = 0.38), and days to return of bowel function (MD = -0.15; 95% CI = -0.37, 0.06; P = 0.17).

CONCLUSIONS

R-LAR was shown to be associated with a shorter hospital stay, lower conversion rate, lower rate of circumferential margin involvement, and lower overall complication rate compared with L-LAR. There were no differences in operative time, the number of lymph nodes removed, and days to return of bowel function.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Laparoscopic versus open surgery for rectal cancer: a meta-analysis of 3-year follow-up outcomes

PURPOSE

We wished to evaluate the effectiveness of laparoscopic and open surgery for patients with rectum cancer through a meta-analysis.

METHODS

We searched PubMed, EMBASE, and Cochrane database until June 30, 2015, to identify eligible studies. Randomized controlled trials comparing laparoscopic with open surgery for rectum cancer were included. Meta-analysis was performed using the search strategy following the requirement of the Cochrane Library Handbook. Three-year overall survival (OS) and disease-free survival (DFS) were the main endpoints.

RESULTS

Eight randomized controlled trials comprising 3145 patients matched the selection criteria. Meta-analysis showed no significant difference between laparoscopic and open surgery in 3-year overall survival (OS) and disease-free survival (DFS) (hazard ratio (HR)3-year OS = 0.83, 95 % CI [0.68-1.01]; P = 0.06; HR3-year DFS = 0.89, 95 % CI [0.75,1.05]; P = 0.16). No evidence of publication bias was observed.

CONCLUSION

Our meta-analysis supported the notion that based on the 3-year DFS and OS, oncological outcomes are comparable after laparoscopic and open surgery for rectal cancer.

Does an enhanced recovery programme add value to laparoscopic colorectal resections?

PURPOSE

Enhanced recovery programmes (ERP) are now becoming integral to the management of patients undergoing colorectal resection. The benefits of ERP in patients undergoing open colorectal resections have been well recognized; however, the value of ERP in patients undergoing laparoscopic resections is still uncertain. This study was undertaken to assess the impact of ERP in our unit where nearly 90 % of elective colorectal resections are performed laparoscopically.

METHODS

A prospectively maintained database of all patients undergoing colorectal resections between Jan 2008 to December 2012 was analysed. The ERP programme was introduced in Aug 2010. The primary outcome measure was post-operative length of stay. Secondary outcome measures were post-operative morbidity and mortality.

RESULTS

A total of 506 patients underwent major colorectal resections in the study period (282 patients since introduction of ERP). There were no demographic differences between the pre-ERP and post-ERP groups of patients. The median length of stay prior to the introduction of ERP was 6 days (right-sided resections = 6, left-sided resections = 7.5 and rectal resections = 5.5). For post-ERP, the median length of stay was 5 days (right = 5.5, left = 5 and rectal = 4). Patients who had their laparoscopic procedure converted to open had a course similar to open resections. The morbidity and mortality was lesser in the ERP group but did not reach statistical significance.

CONCLUSION

The introduction of an ERP adds additional value in laparoscopic colorectal resections, with further reductions in morbidity and length of stay.

Transvaginal Surgical Management of Cesarean Scar Pregnancy II (CSP-II): An Analysis of 25 Cases

BACKGROUND

The aim of this study was to investigate the feasibility and clinical value of transvaginal surgical treatment for cesarean scar pregnancy (CSP-II).

MATERIAL AND METHODS

This study was a retrospective analysis of 25 CSP-II patients who received transvaginal surgical treatments. These patients were admitted in our hospital between January 2010 and June 2012.

RESULTS

All surgical treatments were successful without overt complications. The average operation time was 61.5 minutes, the average intraoperative blood loss was 60.5 ml, the average hospital stay was 9.4 days and the average time that blood β-human chorionic gonadotropin (β-HCG) returned to normal range was 15 days. In all 25 patients, the cesarean scar mass located at the anterior wall of the lower uterine segment disappeared by B-ultrasound examination within 1 or 2 weeks after surgery. Postoperatively, the normal menstrual period started again with an average time of 28.9 days. No menstruation-related abnormalities, such as menstrual dripping or an abnormal amount of blood, were reported after surgery.

CONCLUSIONS

Transvaginal surgery for CSP-II is a novel surgical approach. It has several advantages, including a thorough one-time treatment lesion clearance, short operation time, minimized trauma, minimal intraoperative blood loss, quick reduction of blood β-HCG, and rapid menstruation recovery. It is a simple and feasible surgical approach of great clinical value and few treatment-related complications.

Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial

IMPORTANCE

Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease.

OBJECTIVE

To determine whether laparoscopic resection is noninferior to open resection, as determined by gross pathologic and histologic evaluation of the resected proctectomy specimen.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, balanced, noninferiority, randomized trial enrolled patients between October 2008 and September 2013. The trial was conducted by credentialed surgeons from 35 institutions in the United States and Canada. A total of 486 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge were randomized after completion of neoadjuvant therapy to laparoscopic or open resection.

INTERVENTIONS

Standard laparoscopic and open approaches were performed by the credentialed surgeons.

MAIN OUTCOMES AND MEASURES

The primary outcome assessing efficacy was a composite of circumferential radial margin greater than 1 mm, distal margin without tumor, and completeness of total mesorectal excision. A 6% noninferiority margin was chosen according to clinical relevance estimation.

RESULTS

Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis of the 486 enrolled. Successful resection occurred in 81.7% of laparoscopic resection cases (95% CI, 76.8%-86.6%) and 86.9% of open resection cases (95% CI, 82.5%-91.4%) and did not support noninferiority (difference, -5.3%; 1-sided 95% CI, -10.8% to ∞; P for noninferiority = .41). Patients underwent low anterior resection (76.7%) or abdominoperineal resection (23.3%). Conversion to open resection occurred in 11.3% of patients. Operative time was significantly longer for laparoscopic resection (mean, 266.2 vs 220.6 minutes; mean difference, 45.5 minutes; 95% CI, 27.7-63.4; P < .001). Length of stay (7.3 vs 7.0 days; mean difference, 0.3 days; 95% CI, -0.6 to 1.1), readmission within 30 days (3.3% vs 4.1%; difference, -0.7%; 95% CI, -4.2% to 2.7%), and severe complications (22.5% vs 22.1%; difference, 0.4%; 95% CI, -4.2% to 2.7%) did not differ significantly. Quality of the total mesorectal excision specimen in 462 operated and analyzed surgeries was complete (77%) and nearly complete (16.5%) in 93.5% of the cases. Negative circumferential radial margin was observed in 90% of the overall group (87.9% laparoscopic resection and 92.3% open resection; P = .11). Distal margin result was negative in more than 98% of patients irrespective of type of surgery (P = .91).

CONCLUSIONS AND RELEVANCE

Among patients with stage II or III rectal cancer, the use of laparoscopic resection compared with open resection failed to meet the criterion for noninferiority for pathologic outcomes. Pending clinical oncologic outcomes, the findings do not support the use of laparoscopic resection in these patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00726622.

Do elderly patients have the most to gain from laparoscopic surgery?

Populations are aging worldwide, people are living longer, and the surgical needs of elderly patients are rising. Laparoscopic techniques have become more common with improved training, surgeon skill and evidence of improved outcomes. Benefits of laparoscopy include decreased blood loss, postoperative pain, and hospital length of stay; improved mobilization, quicker return to normal activity; and fewer pulmonary, thrombotic, and abdominal wall complications. Indeed, for many common pathologies laparoscopy has become the gold standard, unless contraindicated. It has been questioned as to whether elderly patients can reap the same benefits from laparoscopic surgery. The concern in elderly patients is that physiologic demands may outweigh the benefit seen in younger patients. This question stems from concerns related to longer operative times, increased technical challenge, as well as the impact of physiologic demands of pneumoperitoneum and patient positioning. However, with anesthesia and adequate perioperative cardiac care, there is no evidence that these factors lead to worse clinical outcomes in elderly patients. In contrast, perhaps elderly patients - with increased prevalence of multi-morbidity, geriatric syndromes and diminished physiologic reserve - have the most to gain from a laparoscopic approach.

Laparoscopic transperitoneal lateral adrenalectomy for malignant and potentially malignant adrenal tumours

Background

Laparoscopic adrenalectomy is still controversial in cases where malignancy is suspected. However, many proponents of this technique argue that in the hands of an experienced surgeon, laparoscopy can be safely performed. The aim of this study is to present our own experience with the application of laparoscopic surgery for the treatment of malignant and potentially malignant adrenal tumours.

Methods

Our analysis included 52 patients who underwent laparoscopic adrenalectomy in 2003–2014 due to a malignant or potentially malignant adrenal tumour. Inclusion criteria were primary adrenal malignancy, adrenal metastasis or pheochromocytoma with a PASS score greater than 6. We analyzed the conversion rate, intra- and postoperative complications, intraoperative blood loss and R0 resection rate. Survival was estimated using the Kaplan-Meier method.

Results

Conversion was necessary in 5 (9.7 %) cases. Complications occurred in a total of 6 patients (11.5 %). R0 resection was achieved in 41 (78.8 %) patients and R1 resection in 9 (17.3 %) patients. In 2 (3.9 %) cases R2 resection was performed. The mean follow-up time was 32.9 months. Survival depended on the type of tumour and was comparable with survival after open adrenalectomy presented in other studies.

Conclusions

We consider that laparoscopic surgery for adrenal malignancy can be an equal alternative to open surgery and in the hand of an experienced surgeon it guarantees the possibility of noninferiority. Additionally, starting a procedure with laparoscopy allows for minimally invasive evaluation of peritoneal cavity. The key element in surgery for any malignancy is not the surgical access itself but the proper technique.

Laparoscopic simultaneous resection of colorectal primary tumor and liver metastases: a propensity score matching analysis

BACKGROUND

Preliminary series have shown the feasibility of combined laparoscopic resection of colorectal cancer (CRC) and synchronous colorectal liver metastases (SCRLM). The aim of this study was to compare the short- and long-term outcomes for matched patients undergoing combined resections.

METHODS

An international multicenter database of 142 patients that underwent combined laparoscopic resection of CRC and SCRLM between 1997 and 2013 was compared to a database of 241 patients treated by open during the same period. Comparison of short- and long-term outcomes was performed after propensity score adjustment.

RESULTS

After matching, 89 patients were compared in each group including mostly ASA I-II patients, presenting with mean number of 1.5 CRLM, with a mean diameter of 30 mm, and resectable by a wedge resection or a left lateral sectionectomy. A rectal resection was required in 46 and 43 % of laparoscopic and open procedures, respectively (p = 0.65). There was no difference in global operative time, blood loss and transfusion rates between the two groups. A conversion was required in 7 % of the laparoscopic procedures. Morbidity rates were similar in the two groups (p = 1.0). The 3-year overall survival in the laparoscopy and open groups were 78 and 65 %, respectively (p = 0.17).

CONCLUSIONS

In patients without severe comorbidities presenting with one, small (≤3 cm), CRLM resectable by a wedge resection or a left lateral sectionectomy, combined laparoscopic resection of CRC and SCRLM allowed similar short- and long-term outcomes compared with the open approach.

Laparoscopic simultaneous resection of colorectal primary tumor and liver metastases: a propensity score matching analysis

BACKGROUND

Preliminary series have shown the feasibility of combined laparoscopic resection of colorectal cancer (CRC) and synchronous colorectal liver metastases (SCRLM). The aim of this study was to compare the short- and long-term outcomes for matched patients undergoing combined resections.

METHODS

An international multicenter database of 142 patients that underwent combined laparoscopic resection of CRC and SCRLM between 1997 and 2013 was compared to a database of 241 patients treated by open during the same period. Comparison of short- and long-term outcomes was performed after propensity score adjustment.

RESULTS

After matching, 89 patients were compared in each group including mostly ASA I-II patients, presenting with mean number of 1.5 CRLM, with a mean diameter of 30 mm, and resectable by a wedge resection or a left lateral sectionectomy. A rectal resection was required in 46 and 43 % of laparoscopic and open procedures, respectively (p = 0.65). There was no difference in global operative time, blood loss and transfusion rates between the two groups. A conversion was required in 7 % of the laparoscopic procedures. Morbidity rates were similar in the two groups (p = 1.0). The 3-year overall survival in the laparoscopy and open groups were 78 and 65 %, respectively (p = 0.17).

CONCLUSIONS

In patients without severe comorbidities presenting with one, small (≤3 cm), CRLM resectable by a wedge resection or a left lateral sectionectomy, combined laparoscopic resection of CRC and SCRLM allowed similar short- and long-term outcomes compared with the open approach.

Laparoscopic versus open surgery for rectal cancer: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Laparoscopic and open rectum surgery for rectal cancer remains controversial. This systematic review compared the short-term and long-term efficiency and complications associated with laparoscopic and open resection for rectal cancer.

MATERIALS AND METHODS

We searched PubMed, Embase, Cochrane Library, ISI Web of Knowledge and the China Biology Medicine Database to identify potential randomized controlled trials from their inception to March 31, 2014 without language restriction. Additional articles were identified from searching bibliographies of retrieved articles. Two reviewers independently assessed the full-text articles according to the pre-specified inclusion and exclusion criteria as well as the methodological quality of included trials. The meta-analysis was performed using RevMan 5.2.

RESULTS

A total of 16 randomized controlled trials involving 3,045 participants (laparoscopic group, 1,804 cases; open group, 1,241 cases) were reviewed. Laparoscopic surgery was associated with significantly lower intraoperative blood loss, earlier return of bowel movement and reduced length of hospital stay as compared to open surgery, although with increased operative time. It also showed an obvious advantage for minimizing late complications of adhesion-related bowel obstruction. Importantly, there were no significant differences in other postoperative complications, oncological clearance, 3-year and 5-year or 10 year recurrence and survival rates between two procedures.

CONCLUSIONS

On the basis of this meta-analysis we conclude that laparoscopic surgery has advantages of earlier postoperative recovery, less blood loss and lower rates of adhesion-related bowel obstruction. In addition, oncological outcome is comparable after laparoscopic and open resection for rectal cancer.

Impact of introduction of an acute surgical unit on management and outcomes of small bowel obstruction

BACKGROUND

The acute surgical unit (ASU) is a recently established model of care in Australasia and worldwide. Limited data are available regarding its effect on the management of small bowel obstruction. We compared the management of small bowel obstruction before and after introduction of ASU at a major tertiary referral centre. We hypothesized that introduction of ASU would correlate with improved patient outcomes.

METHODS

A retrospective review of prospectively maintained databases was performed over two separate 2-year periods, before and after the introduction of ASU. Data collected included demographics, co-morbidity status, use of water-soluble contrast agent and computed tomography. Outcome measures included surgical intervention, time to surgery, hospital length of stay, complications, 30-day readmissions, use of total parenteral nutrition, intensive care unit admissions and overall mortality.

RESULTS

Total emergency admissions to the ASU increased from 2640 to 4575 between the two time periods. A total of 481 cases were identified (225 prior and 256 after introduction of ASU). Mortality decreased from 5.8% to 2.0% (P = 0.03), which remained significant after controlling for confounders with multivariate analysis (odds ratio = 0.24, 95% confidence interval 0.08-0.73, P = 0.012). The proportion of surgically managed patients increased (20.9% versus 32.0%, P = 0.003) and more operations were performed within 5 days from presentation (76.6% versus 91.5%, P = 0.02). Fewer patients received water-soluble contrast agent (27.1% versus 18.4%, P = 0.02), but more patients were investigated with a computed tomography (70.7% versus 79.7%, P = 0.02).

CONCLUSION

The ASU model of care resulted in decreased mortality, shorter time to intervention and increased surgical management. Overall complications rate and length of stay did not change.

Outcome of tumor-specific mesorectal excision for rectal cancer: the impact of laparoscopic resection

OBJECTIVE

The study aimed to compare the outcomes of laparoscopic and open resection for rectal cancer in 1,063 consecutive cases in a single center.

METHODS

We performed an analysis of 11 years of experience in rectal cancer surgery and compared the outcome of laparoscopic and open surgery. Multivariate and subgroup analysis was performed to look at the effect of the level of tumor and stage of disease on short-term outcomes like conversion rate, anastomotic leak rate, length of stay, complication rate, 30-day mortality, and long-term outcomes like local recurrence and survival.

RESULTS

A total of 1,063 patients underwent rectal resection with 470 (44.2%) patients undergoing the laparoscopic approach. Groups were comparable in terms of age, sex, or co-morbidities, and the operating time was longer in the laparoscopic group (210 vs. 150 min; p value < 0.001). A conversion rate of 6.8% was noted, with an anastomotic leak rate of 3.87% in the open group and 2.97% in the laparoscopic group. The laparoscopic group had a lower blood loss (100 vs. 350 ml; p < 0.001), lower complication rates, and shorter length of stay (6 vs. 9 days). The local recurrence rate was comparable, and the laparoscopic approach had better overall and cancer-specific survival, even after adjusting for stages. The laparoscopic approach was an independent factor associated with better overall and cancer-specific survival on multivariate analysis.

CONCLUSION

We confirmed the oncological safety of laparoscopic rectal cancer surgery. Laparoscopic surgery also showed superiority in the short-term and long-term outcomes of rectal cancer.

Possible benefits of robot-assisted rectal cancer surgery regarding urological and sexual dysfunction: a systematic review and meta-analysis

AIM

Robot-assisted surgery for rectal cancer may result in lower rates of urogenital dysfunction compared with laparoscopic surgery. A systematic review was conducted of studies reporting urogenital dysfunction after robot-assisted rectal cancer surgery.

METHOD

PubMed, Embase and the Cochrane Library were systematically searched in February 2014. All studies investigating urogenital function after robot-assisted rectal cancer surgery were identified. The inclusion criteria for meta-analysis studies required comparison of robot-assisted with laparoscopic surgery and the evaluation of urological and sexual function by validated questionnaire. The outcome was evaluated using the International Prostate Symptom Score (IPSS), the International Index of Erectile Function (IIEF) and the Female Sexual Function Index.

RESULTS

Ten studies including 689 patients were included. For the meta-analysis this fell to four including 152 patients in the robotic group and 161 in the laparoscopic group, without heterogeneity. The IPSS score at 3 and 12 months favoured robot-assisted surgery [mean difference (MD) -1.58; 95% CI (-3.1, -0.0), [P = 0.04; and MD -0.90 (-1.81, -0.02), P = 0.05]. IIEF scores at 3 months' follow-up [MD -2.59 (-4.25, -0.94),] P = 0.002] and 6 months' follow-up [MD -3.06 (-4.53, -1.59), P = 0.0001] were better after robot-assisted than laparoscopic surgery.

CONCLUSION

Although there were few data and no randomized controlled trials the results of the review suggested that robot-assisted surgery resulted in improved urogenital function than after laparoscopy.

The incidence and risk of early postoperative small bowel obstruction after laparoscopic resection for colorectal cancer

BACKGROUND

Early postoperative small bowel obstruction is associated with considerable morbidity and mortality but has not been well documented in the era of laparoscopic surgery for colorectal cancer.

SUBJECTS AND METHODS

Consecutive patients who had undergone laparoscopic resection for colorectal cancer were studied.

RESULTS

In total, 1787 patients (105 with and 1682 without early postoperative small bowel obstruction) with colorectal cancer requiring laparoscopic colorectal surgery were evaluated in this study. Ten patients (0.56% among the total patient population, 9.5% among patients who experienced early postoperative small bowel obstruction) who did not respond to conservative treatment for more than 14 days required surgical intervention. Multivariate analysis showed that male sex (adjusted odds ratio [AOR]=2.27), combined operation (AOR=2.23), and diverting stoma (AOR=4.79) were associated with a higher early postoperative small bowel obstruction rate. For factors related to surgical difficulty, open conversion (AOR=2.85), blood transfusion (AOR=3.51), and an operation time longer than 180 minutes (AOR=1.91) were independent factors associated with an increased early postoperative small bowel obstruction rate.

CONCLUSIONS

Early postoperative small bowel obstruction following laparoscopic resection for colorectal cancer occurred in 5.9% of patients. Factors for predicting the development of early postoperative small bowel obstruction in patients with colorectal cancer are variables reflective of a more difficult surgery, rather than pathologic disease severity or anatomical location. In addition, most patients with early postoperative small bowel obstruction improved with conservative treatment, and surgical treatment was rarely needed.

Toward the end of abdominoperineal resection for rectal cancer? An 8-year experience in 189 consecutive patients with low rectal cancer

OBJECTIVES

To assess whether recent advances, such as intersphincteric resection (ISR) or local excision (LE) if a suspicion of complete tumor response after radiochemotherapy (RCT), could have modified the rate of end stoma (ES) in low rectal cancer treatment.

BACKGROUND

ES rate remains around 30% to 50% in patients with low rectal cancer.

METHODS

From 2005 to 2013, all patients with low rectal cancer undergoing laparoscopic total mesorectal excision, with or without neoadjuvant RCT, and patients undergoing LE after RCT were included.

RESULTS

A total of 189 patients presented a low rectal cancer; 162 (86%) underwent RCT; total mesorectal excision was performed in 172 (90%), followed by stapled colorectal anastomosis (n=26; 15%), manual coloanal anastomosis with partial (n=92; 53%) or total ISR (n=32; 19%), or ES that included abdominoperineal resection (n=21; 12%) and low Hartmann procedure (n=1; 1%). LE after RCT was performed in 19 of 189 (10%) patients with a suspicion of complete tumor response. Among them 2 of 19 (11%) underwent immediate secondary total mesorectal excision (1 abdominoperineal resection and 1 coloanal anastomosis with total ISR) because of poor pathological criteria.

CONCLUSIONS

Management of rectal cancer with colorectal anastomosis and coloanal anastomosis with partial ISR allowed to obtain a 38% ES rate (71/189); the additional use of total ISR decreased this rate to 22% (39/189). Selective use of LE reduced this rate to only 12% (22/189). Nowadays, recent advances lead to a paradigm shift, with only 12% ES rate in low rectal cancer.

Robotic surgery vs conventional laparoscopy for the treatment of rectal cancer: Review of the literature

Laparoscopic surgery has established itself as a safe and effective alternative to open surgery for the treatment of colorectal cancer. However, laparoscopic resection of rectal cancer, and in particular of the lower rectum, remains challenging in view of the limitations of operating in the confined pelvic space, limited movement of instruments with fixed tips, assistant-dependant two-dimensional view, easy camera fogging, and poor ergonomics. The introduction of robotic surgery and its application in particular to pelvic surgery, has potentially resolved many of these issues. To define the role of robotic surgery in total mesorectal excision for rectal cancer, a review of the current literature was performed using PubMed, Embase, Cochrane Library, and Google databases, identifying clinical trials comparing short-term outcomes of conventional laparoscopic total mesorectal excision with the robotic approach. Robotic surgery for rectal cancer is a safe alternative to conventional laparoscopy. However, randomised trials are needed to clearly establish its role.

Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of eight studies

BACKGROUND

Robotic surgery has been used successfully in many branches of surgery, but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis of randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) to evaluate whether the safety and efficacy of robotic total mesorectal excision (RTME) in patients with RC are equivalent to those of laparoscopic TME (LTME).

METHODS

Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated.

RESULTS

Eight studies were identified that included 1229 patients in total, 554 (45.08 %) in the RTME group and 675 (54.92 %) in the LTME group. Compared with LTME, RTME was associated with lower conversion rate (OR 0.23, 95 % CI [0.10, 0.52]; P = 0.0004), lower positive rate of circumferential resection margins (CRM) (2.74 % vs 5.78 %, OR 0.44, 95 % CI [0.20, 0.96], P = 0.04), and lesser incidence of erectile dysfunction (ED) (OR 0.09, 95 % CI [0.02, 0.41]; P = 0.002). Operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, number of lymph nodes harvested, distal resection margin (DRM), proximal resection margin (PRM), and local recurrence had no significant differences between the two groups.

CONCLUSIONS

RTME is safe and feasible and may be an alternative treatment for RC. More international multicenter prospective large sample RCTs investigating the long-term oncological and functional outcomes are needed to determine the advantages of RTME over LTME in RC.

Comparison of long-term oncologic outcomes of stage III colorectal cancer following laparoscopic versus open surgery

Purpose

The oncologic outcomes after performing laparoscopic surgery (LS) compared to open surgery (OS) are still under debate and a concern when treating patients with colon cancer. The aim of this study was to compare the long-term oncologic outcomes of LS and OS as treatment for stage III colorectal cancer patients.

Methods

From January 2001 to December 2007, 230 patients with stage III colorectal cancer who had undergone LS or OS in this single center were assessed. Data were analyzed according to intention-to-treat. The primary endpoints were disease-free survival and overall survival.

Results

A total of 230 patients were entered into the study (114 patients had colon cancer-33 underwent LS and 81 underwent OS; 116 patients had rectal cancer-44 underwent LS and 72 underwent OS). The median follow-up periods for the colon and rectal cancer groups were 54 and 53 months, respectively. The overall conversion rate was 12.1% (n = 4) for colon cancer, and 4.5% (n = 2) for rectal cancer. Disease-free 5-year survival of colon cancer was 84.3% and 90% in LS group (LG) and OS group (OG), respectively, and that of rectal cancer was 83% and 74.6%, respectively (P > 0.05). Overall 5-year survival for colon cancer was 72.2% and 71.3% for LG and OG, respectively, and that for rectal cancer was 67.6% and 59.2%, respectively (P > 0.05).

Conclusion

The long-term analyses for oncologic aspects of our study may confirm the safety of LS compared to OS in stage III colorectal cancer patients.

Robotic Rectal Cancer Resection: A Retrospective Multicenter Analysis

BACKGROUND

Conventional laparoscopy has been applied to colorectal resections for more than 2 decades. However, laparoscopic rectal resection is technically demanding, especially when performing a tumor-specific mesorectal excision in a difficult pelvis. Robotic surgery is uniquely designed to overcome most of these technical limitations. The aim of this study was to confirm the feasibility of robotic rectal cancer surgery in a large multicenter study.

METHODS

Retrospective data of 425 patients who underwent robotic tumor-specific mesorectal excision for rectal lesions at seven institutions were collected. Outcome data were analyzed for the overall cohort and were stratified according to obese versus non-obese and low versus ultra-low resection patients.

RESULTS

Mean age was 60.9 years, and 57.9 % of patients were male. Overall, 51.3 % of patients underwent neoadjuvant therapy, while operative time was 240 min, mean blood loss 119 ml, and intraoperative complication rate 4.5 %. Mean number of lymph nodes was 17.4, with a positive circumferential margin rate of 0.9 %. Conversion rate to open was 5.9 %, anastomotic leak rate was 8.7 %, with a mean length of stay of 5.7 days. Operative times were significantly longer and re-admission rate higher for the obese population, with all other parameters comparable. Ultra-low resections also had longer operative times.

CONCLUSION

Robotic-assisted minimally invasive surgery for the treatment of rectal cancer is safe and can be performed according to current oncologic principles. BMI seems to play a minor role in influencing outcomes. Thus, robotics might be an excellent treatment option for the challenging patient undergoing resection for rectal cancer.

Transvaginal endoscopic surgery for tubal ectopic pregnancy

Transvaginal endoscopic salpingectomy for tubal ectopic pregnancy appears to be feasible and safe and may result in less postoperative pain compared with a laparoscopic approach.

Objective:

To explore the feasibility, safety, efficacy, and cosmetic outcomes of transvaginal endoscopic salpingectomy for tubal ectopic pregnancy.

Methods:

From May 2009 to May 2012, we prospectively enrolled 40 patients, each of whom had been scheduled for a salpingectomy because of a tubal ectopic pregnancy, and randomized them into two groups: transvaginal endoscopic surgery and laparoscopic approach. We recorded the estimated blood loss, time of anal exhaust, postoperative pain score, length of stay, and scar assessment scale associated with transvaginal endoscopic access (n = 18) (natural orifice transluminal endoscopic surgery) and laparoscopic salpingectomy (n = 20) (control group) for tubal ectopic pregnancy. The transvaginal salpingectomy was performed with a double-channel endoscope through a vaginal puncture. A single surgeon performed the surgical procedures in patients in both groups.

Results:

The group that underwent the transvaginal endoscopic procedure reported lesser pain at all postoperative visits than the group that underwent the laparoscopic approach. The duration of time for transvaginal endoscopic surgery was slightly longer than that for the laparoscopic approach. However, there was no statistically significant difference between the two groups in the duration of operative time. The group that underwent transvaginal endoscopic surgery was more satisfied with the absence of an external scar than the group that underwent the laparoscopic procedure, which left a scar. The estimated blood loss, time of anal exhaust, and length of stay were the same in both groups.

Conclusion:

The safety and efficacy of transvaginal endoscopic salpingectomy for tubal ectopic pregnancy are equivalent to those of the laparoscopic procedure. Lesser postoperative pain and a more satisfactory cosmetic outcome were found with the transvaginal endoscopic procedure, making it the more preferred method and superior to the laparoscopic approach.

Hostile Abdomen Index Risk stratification and laparoscopic complications

A hostile abdomen index presents a way to stratify risk and help track laparoscopic surgical complications.

Background:

Common life-threatening complications associated with laparoscopy, including bleeding and inadvertent enterotomy, are described in the literature. We investigated the application of the Hostile Abdomen Index related to these complications. We hypothesize that the preoperative score may guide a surgeon in risk stratification.

Methods:

We used data from Monmouth Medical Center morbidity and mortality conferences and reviewed bleeding and enterotomy complications in laparoscopic abdominal surgery. Complications were tracked using the Hostile Abdomen Index compared between 2 periods: published early experience with laparoscopic surgery (1998–2003) and unpublished late experience (2004–2010). The index ascribes a number (1–4) before a laparoscope is inserted and another number (1–4) after the laparoscope is inserted into the abdomen.

Results:

From 1998 to 2010, 43 patients had bleeding complications (0.45%) and 28 had inadvertent enterotomies (0.29%). There was no difference in bleeding between the early and late experiences. Enterotomy complications decreased in the late experience (P < .001). Our rescue success was 97.2% over 13 years. Those laparoscopic cases with high preoperative scores (3–4) had a higher rate of conversion to open procedures.

Conclusions:

The Hostile Abdomen Index can be used to track 2 potentially life-threatening laparoscopic complications. The index score has been explained to our surgeons on numerous occasions. A higher chance of bleeding and enterotomy or risk stratification correlates with a preoperative 3 or 4 score and may lead to a more cautious approach toward initial laparotomy or earlier conversion.

Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years?

AIM

Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early postoperative complications in laparoscopic rectal cancer surgery have improved over the past 20 years.

METHOD

A literature search of the EMBASE and MEDLINE databases between August 1991 and August 2011 was conducted using the keywords laparoscopy, rectal cancer and postoperative complications. Data were analysed using linear regression ANOVA performed in GNUMERICS software.

RESULTS

Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in the rate of any early postoperative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (P = 0.01).

CONCLUSION

There was no evidence of a statistically significant change in early postoperative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, the limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of ongoing randomized clinical trials might show improved outcomes.

Evolution and future of laparoscopic colorectal surgery

The advances of laparoscopic surgery since the early 1990s have caused one of the largest technical revolutions in medicine since the detection of antibiotics (1922, Flemming), the discovery of DNA structure (1953, Watson and Crick), and solid organ transplantation (1954, Murray). Perseverance through a rocky start and increased familiarity with the chop-stick surgery in conjunction with technical refinements has resulted in a rapid expansion of the indications for minimally invasive surgery. Procedure-related factors initially contributed to this success and included the improved postoperative recovery and cosmesis, fewer wound complications, lower risk for incisional hernias and for subsequent adhesion-related small bowel obstructions; the major breakthrough however came with favorable long-term outcomes data on oncological parameters. The future will have to determine the specific role of various technical approaches, define prognostic factors of success and true progress, and consider directing further innovation while potentially limiting approaches that do not add to patient outcomes.

Current status of laparoscopy for the treatment of rectal cancer

Surgery for rectal cancer in complex and entails many challenges. While the laparoscopic approach in general and specific to colon cancer has been long proven to have short term benefits and to be oncologically safe, it is still a debatable topic for rectal cancer. The attempt to benefit rectal cancer patients with the known advantages of the laparoscopic approach while not compromising their oncologic outcome has led to the conduction of many studies during the past decade. Herein we describe our technique for laparoscopic proctectomy and assess the current literature dealing with short term outcomes, immediate oncologic measures (such as lymph node yield and specimen quality) and long term oncologic outcomes of laparoscopic rectal cancer surgery. We also briefly evaluate the evolving issues of robotic assisted rectal cancer surgery and the current innovations and trends in the minimally invasive approach to rectal cancer surgery.

Predicting blood transfusion in patients undergoing minimally invasive oesophagectomy

AIM

To evaluate predictors of allogenic blood transfusion requirements in patients undergoing minimal invasive oesophagectomy at a tertiary high volume centre for oesophago-gastric surgery.

METHODS

Retrospective analysis of all patients undergoing minimal access oesophagectomy in our department between January 2010 and December 2011. Patients were divided into two groups depending on whether they required a blood transfusion at any time during their index admission. Factors that have been shown to influence perioperative blood transfusion requirements in major surgery were included in the analysis. Binary logistic regression analysis was performed to determine the impact of patient and perioperative characteristics on transfusion requirements during the index admission.

RESULTS

A total of 80 patients underwent minimal access oesophagectomy, of which 61 patients had a laparoscopic assisted oesophagectomy and 19 patients had a minimal invasive oesophagectomy. Perioperative blood transfusion was required in 28 patients at any time during hospital admission. On binary logistic regression analysis, a lower preoperative haemoglobin concentration (p < 0.01), suffering a significant complication (p < 0.005) and laparoscopic assisted oesophagectomy (p < 0.05) were independent predictors of blood transfusion requirements.

DISCUSSION

It has been reported that requirement for blood transfusion can affect long-term outcomes in oesophageal cancer resection. Two factors which could be addressed preoperatively; haemoglobin concentration and type of oesophageal resection, may be valuable in predicting blood transfusions in patients undergoing minimally invasive oesophagectomy.

CONCLUSION

Our analysis revealed that preoperative haemoglobin concentration, occurrence of significant complications and type of minimal access oesophagectomy predicted blood transfusion requirements in the patient population examined.

Laparoscopy-assisted posterior low anterior resection of rectal cancer

Background

Laparoscopy-assisted low anterior resection (LAR) of colorectal cancer, using a posterior surgical approach, is a difficult and controversial procedure to perform. We report successful operations on 13 patients with clear surgical margins and no serious complications.

Methods

Thirteen patients [10 males and three females, age range: 48 to 69 years (median: 61 years)] with low adenocarcinoma confirmed by preoperative colonoscopic biopsy (four stage T1; nine stage T2) were resected. The distance from inferior edge of tumor to dentate line was 2 ~ 5 cm (average: 3.4 cm). Intraperitoneal laparoscopy was performed to isolate rectosigmoid and mesocolon moving toward distal end of the tumor. Perineal operation was performed in the prone clasp-knife position.

Results

The circumferential resection margin (CRM) was negative in all cases. No serious postoperative complications occurred. There were four cases of perineal wound infection, two cases with superficial perineal wound dehiscence, and two cases with persistent postoperative sacral pain. All 13 patients passed the Wexner continence test and had satisfactory anal function during a mean 18-month postoperative follow-up period.

Conclusion

Laparoscopic posterior LAR of colorectal cancer is a safe and reliable treatment for patients with low colorectal cancer, increasing the chance of anal functional recovery.

Trial registration

Chinese Clinical Trial Register ChiCTR-ONC-14005145. Registered 19 August 2014.

Simultaneous development of laparoscopy and robotics provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves

BACKGROUND

Laparoscopy offers some evidence of benefit compared to open rectal surgery. Robotic rectal surgery is evolving into an accepted approach. The objective was to analyze and compare laparoscopic and robotic rectal surgery learning curves with respect to operative times and perioperative outcomes for a novice minimally invasive colorectal surgeon.

METHODS

One hundred and six laparoscopic and 92 robotic LAR rectal surgery cases were analyzed. All surgeries were performed by a surgeon who was primarily trained in open rectal surgery. Patient characteristics and perioperative outcomes were analyzed. Operative time and CUSUM plots were used for evaluating the learning curve for laparoscopic versus robotic LAR.

RESULTS

Laparoscopic versus robotic LAR outcomes feature initial group operative times of 308 (291-325) min versus 397 (373-420) min and last group times of 220 (212-229) min versus 204 (196-211) min-reversed in favor of robotics; major complications of 4.7 versus 6.5 % (NS), resection margin involvement of 2.8 versus 4.4 % (NS), conversion rate of 3.8 versus 1.1 (NS), lymph node harvest of 16.3 versus 17.2 (NS), and estimated blood loss of 231 versus 201 cc (NS). Due to faster learning curves for extracorporeal phase and total mesorectal excision phase, the robotic surgery was observed to be faster than laparoscopic surgery after the initial 41 cases. CUSUM plots demonstrate acceptable perioperative surgical outcomes from the beginning of the study.

CONCLUSIONS

Initial robotic operative times improved with practice rapidly and eventually became faster than those for laparoscopy. Developing both laparoscopic and robotic skills simultaneously can provide acceptable perioperative outcomes in rectal surgery. It might be suggested that in the current milieu of clashing interests between evolving technology and economic constrains, there might be advantages in embracing both approaches.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Perioperative protocols in colorectal surgery

The reduction in health-care expenditures and more efficient use of medical resources are now overriding health policy priorities with the two-pronged goal of improving patient outcomes while decreasing overall cost. Current reports show colorectal surgery accounting for 25% of all operative complications and an average length of stay of 8 to 12 days for a standard elective colon resection. To combat this, Kehlet and colleagues introduced a concept of enhanced recovery after surgery (ERAS) or fast-track pathways, with the goal of using current evidence and multimodal therapies to decrease surgical stress, enhance postoperative recovery, and reduce length of stay. The benefits, safety, and cost-effectiveness of fast-track protocols are validated in multiple randomized controlled trials. In this review, the authors focus on the evidence regarding fast-track pathways, use of minimally invasive surgery and its role in fast-track pathways, newer perioperative interventions, and future directions.

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

BACKGROUND

The role of laparoscopy in the treatment of extraperitoneal rectal cancer is still controversial. The aim of the study was to evaluate differences in safety of laparoscopic rectal resection for extraperitoneal cancer, compared with open surgery.

MATERIALS AND METHODS

A systematic review from 2000 to July 2012 was performed searching the MEDLINE and EMBASE databases (PROSPERO registration number CRD42012002406). We included randomized and prospective controlled clinical studies comparing laparoscopic and open resection for rectal cancer. Primary endpoints were 30-day mortality and 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.

RESULTS

Eleven studies, representing 1684 patients, met the inclusion criteria: four were randomized for a total of 814 patients. Mortality was observed in 1.2% of patients in the laparoscopic group and in 2.3% of patients in the open group, with an RR of 0.56 (95% CI 0.19-1.64, p = 0.287). The overall incidence of short-term complications was lower in the laparoscopic group (31.5%) compared to the open group (38.2%), with an RR of 0.83 (95% CI 0.73-0.94, p = 0.004). Surgical complications, wound complications, blood loss and the need for blood transfusion, time for bowel movement recovery, food intake recovery, and hospital stay were significantly lower or less frequent in the laparoscopic group. The incidence of intra-operative injuries, anastomotic leakages, and surgical re-interventions was similar in the two groups. Only operative time was in favour of the open group.

CONCLUSIONS

Based on the evidence of both randomized and prospective controlled series, mortality was lower after laparoscopy although not significantly so, while the short-term morbidity RR, including subgroup analysis, was significantly lower after laparoscopy for extraperitoneal rectal cancer compared to open surgery.

Peritoneal adhesions after laparoscopic gastrointestinal surgery

Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation, only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue. Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis. Moreover, several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact. Experimental data in animal models have suggested that CO₂ pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration. Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO₂, N₂O and O₂ seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum. However, these experimental data have not had a significant impact on the modification of laparoscopic instrumentation. In contrast, surgeons should train themselves to perform laparoscopy quickly, and they should complete their learning curves before testing chemical anti-adhesive agents and anti-adhesion barriers. Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation, but when these agents are used alone, the concentrations needed to prevent adhesions are too high and could cause major post-operative side effects. Anti-adhesion barriers have been used mainly in open surgery, but some clinical data from laparoscopic surgeries are already available. Sprays, gels, and fluid barriers are easier to apply in laparoscopic surgery than solid barriers. Results have been encouraging with solid barriers, spray barriers, and gel barriers, but they have been ambiguous with fluid barriers. Moreover, when barriers have been used alone, the maximum protection against adhesion formation has been no greater than 60%. A recent small, randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100% effective in preventing post-operative adhesion formation. Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points, such as reduced incidences of bowel obstruction and abdominal pain and increased fertility.

Colorectal cancer

More than 1·2 million patients are diagnosed with colorectal cancer every year, and more than 600,000 die from the disease. Incidence strongly varies globally and is closely linked to elements of a so-called western lifestyle. Incidence is higher in men than women and strongly increases with age; median age at diagnosis is about 70 years in developed countries. Despite strong hereditary components, most cases of colorectal cancer are sporadic and develop slowly over several years through the adenoma-carcinoma sequence. The cornerstones of therapy are surgery, neoadjuvant radiotherapy (for patients with rectal cancer), and adjuvant chemotherapy (for patients with stage III/IV and high-risk stage II colon cancer). 5-year relative survival ranges from greater than 90% in patients with stage I disease to slightly greater than 10% in patients with stage IV disease. Screening has been shown to reduce colorectal cancer incidence and mortality, but organised screening programmes are still to be implemented in most countries.

Laparoscopic versus open total mesorectal excision for rectal cancer

BACKGROUND

Colorectal cancer including rectal cancer is the third most common cause of cancer deaths in the western world. For colon carcinoma, laparoscopic surgery is proven to result in faster postoperative recovery, fewer complications and better cosmetic results with equal oncologic results. These short-term benefits are expected to be similar for laparoscopic rectal cancer surgery. However, the oncological safety of laparoscopic surgery for rectal cancer remained controversial due to the lack of definitive long-term results. Thus, the expected short-term benefits can only be of interest when oncological results are at least equal.

OBJECTIVES

To evaluate the differences in short- and long-term results after elective laparoscopic total mesorectal excision (LTME) for the resection of rectal cancer compared with open total mesorectal excision (OTME).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 2), MEDLINE (January 1990 to February 2013), EMBASE (January 1990 to February 2013), ClinicalTrials.gov (February 2013) and Current Controlled Trials (February 2013). We handsearched the reference lists of the included articles for missed studies.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) comparing LTME and OTME, reporting at least one of our outcome measures, was considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality according to the CONSORT statement, and resolved disagreements by discussion. We rated the quality of the evidence using GRADE methods.

MAIN RESULTS

We identified 45 references out of 953 search results, of which 14 studies met the inclusion criteria involving 3528 rectal cancer patients. We did not consider the risk of bias of the included studies to have impacted on the quality of the evidence. Data were analysed according to an intention-to-treat principle with a mean conversion rate of 14.5% (range 0% to 35%) in the laparoscopic group.There was moderate quality evidence that laparoscopic and open TME had similar effects on five-year disease-free survival (OR 1.02; 95% CI 0.76 to1.38, 4 studies, N = 943). The estimated effects of laparoscopic and open TME on local recurrence and overall survival were similar, although confidence intervals were wide, both with moderate quality evidence (local recurrence: OR 0.89; 95% CI 0.57 to1.39 and overall survival rate: OR 1.15; 95% CI 0.87 to1.52). There was moderate to high quality evidence that the number of resected lymph nodes and surgical margins were similar between the two groups.For the short-term results, length of hospital stay was reduced by two days (95% CI -3.22 to -1.10), moderate quality evidence), and the time to first defecation was shorter in the LTME group (-0.86 days; 95% CI -1.17 to -0.54). There was moderate quality evidence that 30 days morbidity were similar in both groups (OR 0.94; 95% CI 0.8 to 1.1). There were fewer wound infections (OR 0.68; 95% CI 0.50 to 0.93) and fewer bleeding complications (OR 0.30; 95% CI 0.10 to 0.93) in the LTME group.There was no clear evidence of any differences in quality of life after LTME or OTME regarding functional recovery, bladder and sexual function. The costs were higher for LTME with differences up to GBP 2000 for direct costs only.

AUTHORS' CONCLUSIONS

We have found moderate quality evidence that laparoscopic total mesorectal excision (TME) has similar effects to open TME on long term survival outcomes for the treatment of rectal cancer. The quality of the evidence was downgraded due to imprecision and further research could impact on our confidence in this result. There is moderate quality evidence that it leads to better short-term post-surgical outcomes in terms of recovery for non-locally advanced rectal cancer. Currently results are consistent in showing a similar disease-free survival and overall survival, and for recurrences after at least three years and up to 10 years, although due to imprecision we cannot rule out superiority of either approach. We await long-term data from a number of ongoing and recently completed studies to contribute to a more robust analysis of long-term disease free, overall survival and local recurrence.