Short-term and long-term outcomes of laparoscopic colectomy with multivisceral resection for surgical T4b colon cancer: Comparison with open colectomy

Minimally invasive versus open multivisceral resection for rectal cancer clinically invading adjacent organs: a propensity score-matched analysis

BACKGROUND

Minimally invasive surgery (MIS), such as laparoscopic and robotic surgery for rectal cancer, is performed worldwide. However, limited information is available on the advantages of MIS over open surgery for multivisceral resection for cases clinically invading adjacent organs.

PATIENTS AND METHODS

This was a retrospective propensity score-matching study of consecutive clinical T4b rectal cancer patients who underwent curative intent surgery between 2006 and 2021 at the University of Tokyo Hospital.

RESULTS

Sixty-nine patients who underwent multivisceral resection were analyzed. Thirty-three patients underwent MIS (the MIS group), while 36 underwent open surgery (the open group). Twenty-three patients were matched to each group. Conversion was required in 2 patients who underwent MIS (8.7%). R0 resection was achieved in 87.0% and 91.3% of patients in the MIS and open groups, respectively. The MIS group had significantly less blood loss (170 vs. 1130 mL; p < 0.0001), fewer Clavien-Dindo grade ≥ 2 postoperative complications (30.4% vs. 65.2%; p = 0.0170), and a shorter postoperative hospital stay (20 vs. 26 days; p = 0.0269) than the open group. The 3-year cancer-specific survival rate, relapse-free survival rate, and cumulative incidence of local recurrence were 75.7, 35.9, and 13.9%, respectively, in the MIS group and 84.5, 45.4, and 27.1%, respectively, in the open group, which were not significantly different (p = 0.8462, 0.4344, and 0.2976, respectively).

CONCLUSION

MIS had several short-term advantages over open surgery, such as lower complication rates, faster recovery, and a shorter hospital stay, in rectal cancer patients who underwent multivisceral resection.

Perioperative and oncological outcomes following robotic en bloc multivisceral resection for colorectal cancer

AIM

As multidisciplinary treatment strategies for colorectal cancer have improved, aggressive surgical resection has become commonplace. Multivisceral and extended resections offer curative-intent resection with significant survival benefit. However, limited data exist regarding the feasibility and oncological efficacy of performing extended resection via a minimally invasive approach. The aim of this study was to determine the perioperative and long-term outcomes following robotic extended resection for colorectal cancer.

METHOD

We describe the population of patients undergoing robotic multivisceral resection for colorectal cancer at our single institution. We evaluated perioperative details and investigated short- and long-term outcomes, using the Kaplan-Meier method to analyse overall and recurrence-free survival.

RESULTS

Among the 86 patients most tumours were T3 (47%) or T4 (47%) lesions in the rectum (78%). Most resections involved the anterior compartment (72%): bladder (n = 13), seminal vesicle/vas deferens (n = 27), ureter (n = 6), prostate (n = 15) and uterus/vagina/adnexa (n = 27). Three cases required conversion to open surgery; 10 patients had grade 3 complications. The median hospital stay was 4 days. Resections were R0 (>1 mm) in 78 and R1 (0 to ≤1 mm) in 8, with none being R2. The average nodal yield was 26 and 48 (55.8%) were pN0. Three-year overall survival was 88% and median progression-free survival was 19.4 months. Local recurrence was 6.1% and distant recurrence was 26.1% at 3 years.

CONCLUSION

Performance of multivisceral and extended resection on the robotic platform allows patients the benefit of minimally invasive surgery while achieving oncologically sound resection of colorectal cancer.

A Multicenter Analysis of Short-term and Long-term Outcomes Following Laparoscopic Multivisceral Resection for Advanced Colorectal Cancer

Background/Aim

Recent research has demonstrated that laparoscopic multivisceral resection (MVR) for advanced colorectal cancer is safe, practicable, and yields satisfactory oncological results, which is in line with the growing usage of laparoscopic surgery. The effectiveness of laparoscopic MVR is still debatable, though. The goal of this study was to compare the short- and long-term results of patients with advanced colorectal cancer treated with open MVR with laparoscopic procedures.

Patients and Methods

Data on 3,571 consecutive patients hospitalized at the Kyushu University National Kyushu Cancer Center for colorectal cancer surgery between 2004 and 2020 were gathered retrospectively. In the end, 84 individuals with advanced colorectal cancer who had a colectomy with MVR were examined. We evaluated invasiveness in terms of complications, blood loss, and operating time. Recurrence-free survival rates and overall 5-year survival were among the oncological outcomes.

Results

Of the 84 patients examined, 29 underwent laparoscopic treatment, and 55 underwent open treatment. The laparoscopic surgery group experienced shorter hospital stays (15 vs. 18 days, p<0.05) and much less blood loss (median volume: 167 vs. 1,058 g, p<0.005) than the open surgery group. Following the exclusion of patients with stage IV colorectal cancer from the study (groups undergoing laparoscopic surgery, n=25; open surgery, n=38), the groups displayed comparable pathologic results and no discernible variations in either the 5-year overall survival (p=0.87) or recurrence-free survival (p=0.86).

Conclusion

In certain individuals with advanced colorectal cancer, a laparoscopic method of manipulation with MVR may be less invasive than an open method without compromising the prognosis.

Comparison of short- and long-term outcomes between laparoscopic and open multivisceral resection for clinical T4b colorectal cancer: A multicentre retrospective cohort study in China

BACKGROUND

Laparoscopic surgery is controversial for patients with clinical T4b colorectal cancer (CRC) who require multivisceral resection (MVR). This study aims to explore and compare the safety and long-term oncological outcomes of laparoscopic surgery and open surgery for patients with clinical T4b CRC.

MATERIALS AND METHODS

This study was a retrospective cohort study based on a multicentre database. According to the operation method, the patients were divided into a laparoscopic MVR group and an open MVR group. The short-term and long-term outcomes were compared.

RESULTS

From January 2010 to December 2021, a total of 289 patients in the laparoscopic MVR group and 349 patients in the open MVR group were included. After propensity score matching, patients were stratified into a laparoscopic MVR group (n = 163) and an open MVR group (n = 163). Compared with the open MVR group, the laparoscopic MVR group had less blood loss (100 vs. 200, p < 0.001), a shorter time to first flatus (3 vs. 4, P < 0.001), a shorter postoperative hospital stay (10 vs. 12, P < 0.001), and a lower incidence of surgical site infection (2.5 % vs. 8.0 %, P = 0.043). The Kaplan-Meier curves showed that the two groups had similar overall survival (P = 0.283) and disease-free survival (P = 0.152).

CONCLUSION

Compared with open MVR, laparoscopic MVR had less blood loss, fewer surgical site infection complications, faster recovery and a shorter hospital stay. The long-term survival outcome of laparoscopic MVR was not inferior to that of open MVR.

Mid-term outcomes of laparoscopic vs open colectomy for pathological T4 and/or N2 colon cancer patients: Multicenter study using propensity score matched analysis

OBJECTIVES

We aimed to assess mid-term outcomes after laparoscopic surgery (LAP) vs open surgery (OP) for pathological T4 (pT4) and/or N2 (pN2) colon cancer.

METHODS

We retrospectively reviewed 255 primary tumor resections for pT4 and/or pN2 colon cancer performed from 2015 to 2020 at six hospitals, divided into LAP (n = 204) and OP groups (n = 51). After propensity score matching to minimize selection bias, 47 matched patients per group were assessed.

RESULTS

Before matching, the rate of males (53.9% vs. 37.3%, P = .042), left sided colon cancer (53.9% vs 37.3%, P = .042), D3 lymph node dissection (90.7% vs 68.6%, P < .001) and body mass index (kg/m2 ) (22.3 vs 21.8, P = .039) were significantly greater in the LAP group. The rate of pT4b (7.8% vs 40.4%, P < .001) was lower and pN2 was higher (57.4% vs 37.3%, P = .012) in the LAP group. After matching, preoperative characteristics and pathologic status were equivalent between the groups. The LAP and OP groups showed comparable overall survival (OS) (2-year OS, 84.5% vs 76.8%, P = .055) and recurrence-free survival (RFS) (2-year RFS, 73.9% vs 52.8%, P = .359). In the patients with pT4, OS (2-year OS, 79.4% vs 75.7%, P = .359) and RFS (2-year RFS, 71.3% vs 58.7%) were comparable. In the patients with pN2, OS (2-year OS, 83.4% vs 76.3%) and RFS (2-year RFS, 69.6% vs 36.2%) were also comparable.

CONCLUSIONS

LAP for pT4 and/or pN2 colon cancer showed comparable mid-term outcomes compared with OP. LAP was an acceptable surgical approach in this cohort.

The use of laparoscopy for T4a and T4b colon cancer: are we playing with fire?

BACKGROUND

The laparoscopic approach for colon cancer has become widely accepted. However, its safety for T4 tumors, and particularly for T4b tumors when local invasion to adjacent structures occurs, remains controversial. This study aimed to compare short and long-term outcomes in patients undergoing laparoscopic vs. open resection for T4a and T4b colon cancers.

METHODS

A prospectively maintained, single-institution database was queried to identify patients with pathological stage T4a and T4b colon adenocarcinomas electively operated on between 2000 and 2012. Patients were divided into two groups based on the use of laparoscopy. Patient characteristics, perioperative, and oncologic outcomes were compared.

RESULTS

One hundred and nineteen patients [41 laparoscopic (L), 78 open surgeries (O)] met the inclusion criteria. No difference was observed in age, gender, BMI, ASA, and procedure between groups. Tumors treated by L were smaller than O (p = 0.003). No difference was observed in morbidity, mortality, reoperation, or readmission between the groups. Length of hospital stay was shorter in L than O (6 vs. 9 days, p = 0.005). Conversion to open was necessary in 22% of all T4 tumors laparoscopic cases. However, when tumors were subdivided by pT4 classification, conversion was necessary for 4 of 34 (12%) pT4a patients vs. 5 of 7 (71%) pT4b patients (p = 0.003). In the pT4b cohort (n = 37), more tumors were treated by the open approach (30 vs. 7). For pT4b tumors, the R0 resection rate was 94% (86% in L vs. 97% in O, p = 0.249). The use of laparoscopy did not impact overall survival, disease-free survival, cancer-specific survival, or tumor recurrence overall in all T4 or T4a and T4b tumors.

CONCLUSIONS

Laparoscopic surgery can be safely performed in pT4 tumors with similar oncologic outcomes as compared to open surgery. However, for pT4b tumors, the conversion rate is very high. The open approach may be preferable.

Outcomes following open versus laparoscopic multi-visceral resection for locally advanced colorectal cancer: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to compare morbidity, mortality, oncological safety, and survival outcomes after laparoscopic multi-visceral resection (MVR) of the locally advanced primary colorectal cancer (CRC) compared with open surgery.

MATERIALS AND METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic and open surgery in patients with locally advanced CRC undergoing MVR were selected. The primary endpoints were peri-operative morbidity and mortality. Secondary endpoints were R0 and R1 resection, local and distant disease recurrence, disease-free survival (DFS), and overall survival (OS) rates. RevMan 5.3 was used for data analysis.

RESULTS

Ten comparative observational studies reporting a total of 936 patients undergoing laparoscopic MVR (n = 452) and open surgery (n = 484) were identified. Primary outcome analysis demonstrated a significantly longer operative time in laparoscopic surgery compared with open operations (P = 0.008). However, intra-operative blood loss (P<0.00001) and wound infection (P = 0.05) favoured laparoscopy. Anastomotic leak rate (P = 0.91), intra-abdominal abscess formation (P = 0.40), and mortality rates (P = 0.87) were comparable between the two groups. Moreover the total number of harvested lymph nodes, R0/R1 resections, local/distant disease recurrence, DFS, and OS rates were also comparable between the groups.

CONCLUSION

Although inherent limitations exist with observational studies, the available evidence demonstrates that laparoscopic MVR in locally advanced CRC seems to be a feasible and oncologically safe surgical option in carefully selected cohorts.

Laparoscopic and robotic multivisceral resection in colorectal cancer: A case series and systematic review

PURPOSE

Multivisceral resection (MVR) with open approach is the standard surgical treatment for locally advanced colorectal cancer. However, the medical literature concerning the practice of minimally invasive MVR in order to reduce postoperative complications and hospital stay has been growing exponentially over the last years. The present study aimed to examine our experience and to provide a systematic review about the results and complications of minimally invasive MVR.

METHODS

Data of patients that underwent minimally invasive MVR for locally advanced colorectal cancer from 2015 to 2021 were retrospectively reviewed. The literature was searched for studies concerning minimally invasive MVR for colorectal cancer.

RESULTS

A total of 39 laparoscopic MVR were performed in our department. Complications occurred in 14 patients (35.9%) with major complications in five patients (18.82%) according to Clavien-Dindo classification. Conversion was required in one case (2.56%) with subsequent mortality (2.56%). Pathologic adjacent organs or structures invasion was observed in 30 patients (76.9%) and positive resection margin occurred in two cases (5.2%). Twenty-two studies including 1055 patients were identified after literature search. In these studies, laparoscopic surgery and robotic surgery were performed in 90.15% and 9.85% of the patients, respectively. R0 resection was established in 95% of cases, conversion rate varied between 0% and 41.7%, and postoperative mortality ranged between 0% and 7.7% in the included articles.

CONCLUSION

Minimally invasive approach may be a safe option for patients requiring MVR for locally advanced colorectal cancer, with equivalent oncological results and could result in better early postoperative outcomes to open approach. However, further studies on this topic are needed to confirm the results of the current study.

Oncologic outcomes after laparoscopic versus open multivisceral resection for local advanced colorectal cancer: A meta-analysis

Laparoscopic (lap) colectomies for advanced colorectal cancer (CRC) often require resection of other organs. We systematically reviewed currently available literature on lap multi-visceral resection for CRC, with regard to short- and long-term oncological outcomes, and compared them with open procedures. We performed a systematic literature search in MEDLINE, EMBASE, Google Scholar and PubMed from inception to November 30, 2020. The aim of this study was to synthesize short-term and oncological outcomes associated with laparoscopic versus open surgery. Pooled proportions and risk ratios (RRs) were calculated using an inverse variance method. We included six observational cohort studies published between 2012 and 2020 (lap procedures: n = 262; open procedures: n = 273). Collectively, they indicated that postoperative complications were significantly more common after open surgeries than lap surgeries (RR: 0.53; 95% confidence interval [CI]: 0.39-0.72; P < 0.00001), but the two approaches did not significantly differ in positive resection margins (RR: 0.75; 95% CI: 0.38-1.50; P = 0.42), local recurrence (RR: 0.66; 95% CI: 0.28-1.62; P = 0.37), or (based on two evaluable studies) 5-year OS (RR: 0.70; 95% CI: 0.46-1.04; P = 0.08) or 5-year DFS (RR: 0.86; 95% CI: 0.67-1.11) for T4b disease. In conclusion, laparoscopic and open multi-visceral resections for advanced CRC have comparable oncologic outcomes. Although a randomized study would be ideal for further research, no such studies are currently available.

Robotic Approach is Associated With a Lower Conversion Rate Compared to Laparoscopic Approach for Patients Undergoing Colectomy for T4b Colon Cancer. An Analysis of the National Cancer Database

INTRODUCTION

We examined the perioperative outcomes of patients undergoing open, laparoscopic, or robotic colectomy for T4b colon cancer, as well as the clinical factors associated with conversion to an open approach and its consequences on perioperative and oncologic outcomes.

METHODS

The National Cancer Database was queried for patients undergoing colectomy for cT4b colon cancer (2010-2016). Patients undergoing laparoscopic or robotic colectomy were matched using Propensity-Score analysis. Factors associated with conversion to an open approach were assessed using Logistic-regression multivariable-analysis (MVA).

RESULTS

Colectomy for cT4b colon cancer was performed in 9030 patients (open: n = 6,543, robotic: n = 157, laparoscopic: n = 2330). In the propensity-matched groups, robotic approach had lower rate of conversion (12% vs 37%, P < .001), shorter hospital stays (5 vs 7-days, P = .02), and similar overall-survival (5-yr: 49% vs 39%, P = .16), compared to laparoscopic approach. Conversion to an open approach was noted in 801(32%) of the patients undergoing minimally invasive surgical colectomy (robotic n = 23(15%), laparoscopic n = 778(33%). Factors associated with lower rate of conversion on multivariable-analysis included recent year of surgery (95% CI: 0.88-.97), robotic approach (95% CI: 0.22-.56), and surgeries performed in Academic hospitals (95% CI: 0.65-.96). Conversion to an open approach was associated with higher rate of positive parenchymal margin (31% vs 25%, P = .001), higher rate of 30-day readmission (12% vs 9.5%, P = .04), and similar overall survival (5-yr: 32% vs 35%, P = .19), compared to those who had no conversion.

CONCLUSION

At the National level, patients undergoing colectomy for T4b colon cancer via a robotic approach had more favorable perioperative outcomes compared to laparoscopic approach. Conversion to an open approach did not compromise long term survival, despite being associated with higher rate of positive margins and readmissions rate.

Association of tumor size in pathological T4 colorectal cancer with desmoplastic reaction and prognosis

Background

Tumor size in pathological T4 (pT4) colorectal cancer (CRC) is associated with oncological prognosis; however, its relation to epithelial-mesenchymal transition (EMT)-associated histology is unclear. We aimed to investigate the association of tumor size with oncological prognosis and EMT.

Methods

We performed a retrospective analysis of 95 patients with primary CRC who underwent radical surgery and were consecutively diagnosed with pT4.

Results

Both 3-y disease-free survival (DFS) and cancer-specific survival (CSS) were significantly higher in patients with tumor size ≥50 mm than in those with tumor size <50 mm (P = .009 and P = .011, respectively). The independent factors identified in the multivariate analysis for DFS were pathological lymph node metastasis (hazard ratio [HR], 2.551; 95% confidence interval [CI], 1.031-6.315; P = .043), distant metastasis (HR, 2.511; 95% CI, 1.140-5.532; P = .022), tumor size (HR, 0.462; 95% CI, 0.234-0.913; P = .026), and adjuvant chemotherapy (HR, 0.357; 95% CI, 0.166-0.766; P = .008). The independent factors identified in multivariate analysis for CSS were tumor location (HR, 10.867; 95% CI, 2.539-45.518; P = .001) and tumor size (HR, 0.067; 95% CI, 0.014-0.321; P < .001). In pT4 CRC, smaller tumor size was associated with nonmature desmoplastic reaction and EMT-related histology.

Conclusions

Tumor size ≥50 mm was associated with a better DFS and CSS than that of <50 mm, in patients with pT4 CRC. Smaller tumor size with advanced invasion likely reflects a more biologically aggressive phenotype in pT4 CRC.

Laparoscopic versus open colectomy for locally advanced T4 colonic cancer: meta-analysis of clinical and oncological outcomes

BACKGROUND

The aim of this study was to review the early postoperative and oncological outcomes after laparoscopic colectomy for T4 cancer compared with open surgery.

METHOD

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for any relevant clinical study comparing laparoscopic and open colectomy as treatment for T4 colonic cancer. The risk ratio (RR) with 95 per cent c.i. was calculated for dichotomous variables, and the mean difference (m.d.) with 95 per cent confidence interval for continuous variables. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was implemented for assessing quality of evidence (QoE).

RESULTS

Twenty-four observational studies (21 retrospective and 3 prospective cohort studies) were included, analysing a total of 18 123 patients: 9024 received laparoscopic colectomy and 9099 underwent open surgery. Laparoscopic colectomy was associated with lower rates of mortality (RR 0.48, 95 per cent c.i. 0.41 to 0.56; P < 0.001; I2 = 0 per cent, fixed-effect model; QoE moderate) and complications (RR 0.61, 0.49 to 0.76; P < 0.001; I2 = 20 per cent, random-effects model; QoE very low) compared with an open procedure. No differences in R0 resection rate (RR 1.01, 1.00 to 1.03; P = 0.12; I2 = 37 per cent, random-effects model; QoE very low) and recurrence rate (RR 0.98, 0.84 to 1.14; P = 0.81; I2 = 0 per cent, fixed-effect model; QoE very low) were found.

CONCLUSION

Laparoscopic colectomy for T4 colonic cancer is safe, and is associated with better clinical outcomes than open surgery and similar oncological outcomes.

Therapeutic effects and limitations of chemoradiotherapy in advanced lower rectal cancer focusing on T4b

PURPOSE

This study aimed to elucidate the benefits and limitations of preoperative chemoradiotherapy (CRT) in rectal cancer treatment, specifically in T4b rectal cancer.

METHODS

This retrospective cohort study reviewed 1014 consecutive patients with clinical T3/4a/T4b adenocarcinomas of the lower rectum, who underwent total mesorectal excision at the Department of Surgical Oncology of the University of Tokyo Hospital and 22 referral institutions affiliated with the Japanese Study Group for Postoperative Follow-up of Colorectal Cancer. Patients were divided into two cohorts: cohort 1 comprised 298 consecutive patients who underwent CRT followed by radical surgery and cohort 2 comprised 716 consecutive patients who underwent curative surgery without preoperative therapy. We assessed the prognostic differences between the two cohorts, focusing particularly on T stages.

RESULTS

In T3/4a patients, cohort 1 showed a significantly lower local recurrence rate than cohort 2 (4.8% vs. 9.4%, p=0.024), but not in T4b patients (23.5% vs. 16.0%, p=0.383). In contrast, no significant differences in survival were observed between T3/4a and T4b patients. T4b classification was found to be an independent predictive factor of local recurrence in cohort 1, but not in cohort 2.

CONCLUSION

In T4b rectal cancer, preoperative CRT demonstrated a limited benefit for local control and survival. In cases of suspected T4b rectal tumors, additional therapies such as induction chemotherapy to conventional CRT may contribute to better outcomes.

Robotic Colorectal Cancer Surgery. How to Reach Expertise? A Single Surgeon-Experience

The complexity associated with laparoscopic colorectal surgery requires several skills to overcome the technical difficulties related to this procedure. To overcome the technical challenges of laparoscopic surgery, a robotic approach has been introduced. Our study reports the surgical outcomes obtained by the transition from laparoscopic to robotic approach in colorectal cancer surgery to establish in which type of approach the proficiency is easier to reach. Data about the first consecutive 15 laparoscopic and the first 15 consecutive robotic cases are extracted, adopting as a comparator of proficiency the last 15 laparoscopic colorectal resections for cancer. The variables studied are operative time, number of harvested nodes, conversion rate, postoperative complications, recovery outcomes. Our analysis includes 15 patients per group. Our results show that operative time is significantly longer in the first 15 laparoscopic cases (p = 0.001). A significantly lower number of harvested nodes was retrieved in the first 15 laparoscopic cases (p = 0.003). Clavien Dindo I complication rate was higher in the first laparoscopic group, but without a significant difference among the three groups (p = 0.09). Our results show that the surgeon needed no apparent learning curve to reach their laparoscopic standards. However, further multicentric prospective studies are needed to confirm this conclusion.

Feasibility and Safety of Laparoscopic Radical Colectomy for T4b Colon Cancer at a University Hospital in Vietnam

BACKGROUND

The choice of optimal treatment strategies for T4b colon cancers has still been discussed, particularly the initiation of neoadjuvant therapy or surgery. We conducted this study to evaluate the safety and feasibility of laparoscopic multivisceral resection for T4b colon cancers.

METHODS

We used the retrospective design to include all 43 patients with T4b colon cancer at a university hospital in Vietnam from March 2017 to March 2019. All patients were followed 30 days after the surgery, and information about the day of the first flatus, length of hospital stay, iatrogenic complications, postoperative morbidity, mortality, and adjuvant chemotherapy was collected.

RESULTS

The mean operating time was 187 minutes (ranging from 80 to 310), the mean blood loss was 64.3 ml (5-200), and the conversion rate was 2.3%. The mean number of lymph nodes harvested was 15.5 (SD = 8.06), and 33 patients (76.7%) had at least 12 lymph nodes harvested. A total of 21 patients (48.8%) had lymph node metastases with a mean number of lymph node metastases of 1.89 (SD = 3.4). The radial resection margin was R0 in all 43 patients (100%). The median time until the first flatus and hospital stay were 3 days (2-5) and 7.1 (6-11) days, respectively. There was no mortality at 30 days postoperatively, and one patient had iatrogenic complication (2.3%).

CONCLUSION

Laparoscopic radical colectomy was feasible and safe for patients with T4b colon cancer except those requiring major and complicated reconstruction.