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

Sprayed hyaluronic acid based multidrug composite hydrogel for postoperative colorectal cancer ultra-efficient long-lasting multi-stage immuno-chemo synergistic therapy

To enhance the therapeutic efficacy of postoperative colorectal cancer treatment and prevent peritoneal metastasis, we propose a strategy utilizing the photothermal-induced ultra-efficient and long-lasting multi-stage immuno-chemo synergistic therapy. To implement this strategy, oxaliplatin (OXA), curcumin (Cur), and Mn2+ were coordinated to form infinite coordination polymer nanoparticles (OXA-Mn(II)-Cur ICP NPs). These nanoparticles are encapsulated with polydopamine (PDA) to create OXA-Mn(II)-Cur ICP@PDA NPs, which are subsequently embedded in a sprayable hyaluronic acid-based hydrogel. The resulting ICP@PDA NPs@composite hydrogel exhibits strong tissue adhesion and segmented pH-responsive drug release properties. Notably, the hydrogel can sustainably release drugs for over 20 days in vivo, maximizing local drug concentration while minimizing systemic toxic side effects. Each component of the composite hydrogel serves multiple functions, and its application to postoperative tumor sites enables long-term, dual-pathway, multi-stage immune activation. This immune response synergizes with chemotherapy to achieve a highly effective therapeutic outcome. In vivo experiments demonstrated that the composite hydrogel effectively eliminates residual tumors, ensuring a 100% survival rate without recurrence for 80 days in treated mice. Furthermore, it inhibits peritoneal metastasis and completely eradicates intraperitoneal tumors within 20 days. The ICP@PDA NPs@composite hydrogel represents a promising therapeutic platform for postoperative colorectal cancer treatment and metastasis prevention.

Design and validation of a simulation-based training module for ileo-transverse intracorporeal anastomosis

BACKGROUND

The benefits of the totally laparoscopic right hemicolectomy have been established, but its adoption has been limited by the challenges of intracorporeal suturing. While simulation is effective for training advanced surgical skills, no dedicated simulation-based course exists for intracorporeal ileo-transverse anastomosis (ICA). This study aimed to develop and validate a simulation module for training in ICA.

METHODS

This study employed a proof-of-concept design for an educational tool. Key aspects of the anastomosis were identified using the team's surgical experience, surgical videos, and existing evidence. Surgeons were recruited to test and refine successive simulation models through an iterative process until a functional prototype was achieved and assessed. Subsequently, surgeons with varying experience levels were invited to perform an ICA in the model. Performance was evaluated by two blinded surgeons through video recordings, utilizing a modified Objective Structured Assessment of Technical Skills (OSATS), a Specific Rating Score (SRS), and operative time measurements. Non-parametric descriptive and analytical methods were applied, with results presented as median [IQR].

RESULTS

An ex vivo based model was developed. Seventeen participants evaluated the model. Eighty-three percent declared acceptable or maximum fidelity regarding the colon. Resemblance to the surgical scenario in terms of ergonomic and anatomical similarity was highlighted. All participants found the model useful to train intracorporeal suturing. Thirteen subjects performed the ICA. Experts achieved significantly higher OSATS scores (22.3 [22-22.5] vs 18 [16-19.5]; p = .013), exhibited a trend toward higher SRS, and obtained shorter operative times (21.5 vs 36 min; p = .039).

CONCLUSION

An ex vivo simulation module for ICA was developed, demonstrating acceptable fidelity in replicating the surgical environment. The simulated scenario could successfully distinguish between levels of surgical experience, as evidenced by significant differences in OSATS scores and operative times, thereby confirming its construct validity.

Risk Factors for Anastomotic Leak in Patients Undergoing Surgery for Rectal Cancer Resection: A Retrospective Analysis

Introduction Anastomotic leakage (AL) is one of the most severe complications following rectal cancer (RC) surgery, with significant implications for morbidity, mortality, and oncological outcomes. Identifying risk factors associated with AL may enhance surgical decision-making and improve patient prognosis. Methods A retrospective cohort study was conducted, including 42 adult patients who underwent RC resection at a hospital in Mexico City between January 2015 and December 2022. Demographic, clinical, pathological, and surgical variables were analyzed to assess their association with AL. Univariate and multivariate statistical analyses were performed to identify independent risk factors. Results The overall incidence of AL was 11.9%, consistent with previous literature. Univariate analysis revealed no significant differences in patient-related factors such as age, BMI, ASA classification, diabetes mellitus, smoking, or biochemical markers (p>0.05). Treatment-related factors such as neoadjuvant therapy and diverting stoma (DS) placement did not show a significant association with AL. However, surgical factors played a crucial role: operative time was significantly longer in patients with AL (349.0 vs. 232.9 minutes, p=0.024), intraoperative blood loss was markedly higher (800.0 vs. 198.6 mL, p<0.001), and transfusion rates were elevated (60.0% vs. 13.5%, p=0.040). Tumor location in the middle rectum was more frequent among AL cases (60.0% vs. 18.9%, p=0.090). Postoperative complications were significantly more severe in patients with AL, with prolonged hospital stays (20.0 vs. 10.2 days, p=0.043) and increased reintervention rates (80.0% vs. 5.6%, p<0.001). In the logistic regression model, none of the analyzed variables reached statistical significance (p>0.99). However, operative time showed an odds ratio (OR) of 1.736 (p=0.997), suggesting that for each additional minute of surgery, the risk of AL could increase by 73.6%. Despite this trend, the wide confidence interval limits its precision and clinical applicability. Age showed an OR of 0.023 (p=0.998), potentially suggesting a 97.7% reduction in leakage risk for each additional year, although this result was not statistically significant and should be interpreted with caution. Conclusion Although no statistically significant risk factors were identified in the multivariate analysis, intraoperative variables such as prolonged surgical time, high blood loss, and transfusion requirement emerged as clinically relevant trends. These findings emphasize the need for optimizing surgical techniques and perioperative management to mitigate AL risk. Further studies with larger sample sizes are necessary to validate these associations and improve risk stratification models.

Comparative effectiveness of laparoscopic versus open colectomy in colon cancer patients: a study protocol for emulating a target trial using cancer registry data

INTRODUCTION

The objective of this study is to compare the 5 year overall survival of patients with stage I-III colon cancer treated by laparoscopic colectomy versus open colectomy.

METHODS

Using Mecklenburg-Western Pomerania Cancer Registry data from 2008 to 2018, we will emulate a phase III, multicenter, open-label, two-parallel-arm hypothetical target trial in adult patients with stage I-III colon cancer who received laparoscopic or open colectomy as an elective treatment. An inverse-probability weighted Royston‒Parmar parametric survival model (RPpsm) will be used to estimate the hazard ratio of laparoscopic versus open surgery after confounding factors are balanced between the two treatment arms. Further to the hazard ratio, we will also compute differences in the absolute risk (at 1, 3, and 5 years) and restricted mean survival time (up to 1, 3, and 5 years). A weighted Kaplan‒Meier curve will be used to compare five-year overall survival in both treatment arms. Various comparator and sensitivity analyses will be performed to check the robustness of the results that will be estimated by the RPpsm main model. Treatment period- and stage-specific results will also be provided.

DISCUSSION

This study aims to causally model the effect of laparoscopic versus open colectomy on 5 year overall survival using a target trial emulation approach. As the cancer registry data do not cover BMI, comorbidity, and previous abdominal surgery for non-malignant indications, the potential for residual confounding arising from these factors is a limitation of this study. This will be approached in a quantitative bias analysis using the E-method. The results will substantiate existing evidence on the comparative effectiveness of laparoscopic versus open colectomy in patients with stage I-III colon cancer and may guide clinical decisions as to whether a laparoscopic approach is as safe as an open approach in terms of improving 5-year overall survival in these patient groups.

Pushing boundaries: simultaneous minimal-invasive resection of complex colorectal liver metastases and its primary tumor

INTRODUCTION

Synchronous liver metastases occur in approximately 15-20% of patients with colorectal cancer. Optimal oncological treatment of oligometastatic disease combines surgical resection and systemic therapy. Open simultaneous resection of the primary and liver metastases is well described, but there is not much evidence for the increasing use of the minimally invasive approach. We here report the results of our experience of simultaneous minimally invasive resections.

METHODS

A prospective database of patients with resection of colorectal liver metastases (CRLM) at the Charité - Universitätsmedizin Berlin was used for retrospective data analysis. We report all patients undergoing simultaneous minimal invasive resection of colorectal cancer and its synchronous liver metastases between May 2015 and December 2021.

RESULTS

Out of 281 patients undergoing resection of CRLM, 33 (11.7%) patients had simultaneous minimal invasive resection of the colorectal primary. The primary tumor was located mostly within the rectum (n = 17; 48.6%), followed by the descending colon (n = 6; 17.1%). CRLM were localized in both liver lobes in 69.7% (n = 23) of cases. Following resection of the colorectal tumor, an anastomosis was performed in 31 of 33 patients (93.9%), with no anastomotic leakage observed in the follow up. Simultaneous liver resections were performed mostly as subsegment (n = 20) or bisegment resections (n = 11). Mean IWATE-Score of all hepatic resections was 5.5 (± 2.4). Complication rates (Clavien-Dindo ≥ 3) were similar compared between low/intermediate and advanced/expert difficulty for liver resection (n = 4, 17.4% vs. n = 2, 20.0%; p = 1.0). In one case conversion to open resection was required.

CONCLUSION

Our data indicate that simultaneous minimal invasive resection of CRLM and the primary tumor is a safe and feasible procedure. Complication rates were consistent across different levels of difficulty (low to expert) in liver resections. Therefore, indications for simultaneous resection may be expanded.

Comparative analysis of the oncologic outcomes and risk factors for open conversion in laparoscopic surgery for non-metastatic colorectal cancer: A retrospective multicenter study

PURPOSE

Laparoscopic colon surgery is now commonly used for colorectal cancer (CRC) resection. The objective of this study was to compare the oncologic outcomes between open conversion and laparoscopic surgery, and to identify risk factors for open conversion.

METHODS

We retrospectively reviewed the medical records of patients who underwent curative resection for stage 0-III CRC at five Hallym University-affiliated hospitals between January 2011 and June 2021. The patients were divided into the conversion and laparoscopic groups according to whether laparoscopic surgery was completed.

RESULTS

Out of 2231 patients, laparoscopic surgery was completed in 2131 patients and 100 (4.5 %) converted to open surgery. The operation time (P = 0.028) and postoperative hospital stay (P = 0.036) were longer in the conversion group than in the laparoscopic group. Overall (P = 0.022) and severe (Clavien-Dindo classification grade ≥3) (P = 0.048) complications were more frequent in the conversion group than in the laparoscopic group. The 5-year recurrence-free survival (RFS) rate was worse in the conversion group than in the laparoscopic group (P = 0.002). In the multivariable analysis, open conversion was not a prognostic factor for RFS (P = 0.082). Abdominal surgery history (P = 0.021), obstruction (P < 0.001), and T4 stage (P < 0.001) were independently associated with open conversion.

CONCLUSION

The conversion group had worse perioperative and oncologic outcomes. History of abdominal surgery, obstruction, and T4 stage were associated with open conversion. However, conversion itself was not associated with RFS.

Assessing the performance of non-specialised private hospitals in Malaysia - an upper-middle-income medical tourism destination country using the Pabón-Lasso model

BACKGROUND

The government has rapidly promoted the privatisation of healthcare to improve systemic performance, based on the theory that markets improve efficiency. This study aims to measure the efficiency of private hospitals following their expansion and venture into the medical tourism industry through extensive governmental support.

METHODS

Inpatient utilisation of 101 private, non-specialised hospitals in Malaysia in 2014 and 2018 from the Health Informatics Centre, Ministry of Health Malaysia database was studied using paired samples t-test, analysis of variance (ANOVA), and the Pabón-Lasso model.

RESULTS

Better quantitative performance was found among larger hospitals, those with hospital accreditation, and those participating in medical tourism activities. There is a scale effect of efficiency between smaller and larger hospitals. However, when compared within respective size categories, Category 1 (small hospitals with less than 100 beds) has the highest percentage of efficient hospitals (39.3 per cent in 2014 and 35.7 per cent in 2018 in Sector 3 of the Pabón Lasso graphs).

CONCLUSION

This study has found that a higher bed occupancy rate (BOR) and longer average length of stay (ALoS) are associated with larger private hospitals, hospital accreditation, and participation in medical tourism activities in Malaysia. There is a need to expedite strategic hospitals partnership for resource optimisation and capacity pooling towards producing better performance.

Trends and outcomes in colorectal cancer surgery: a multicenter cross-sectional study of minimally invasive versus open techniques in Germany

BACKGROUND

The objective of this study was to assess the trend from open to modern minimally invasive (laparoscopic and robot-assisted) surgical techniques for colorectal cancer (CRC) in Germany, with a particular focus on hospital mortality, postoperative complications, and length of hospital stay.

METHODS

A multicenter cross-sectional study was conducted using data from 36 German hospitals, encompassing 1,250,029 cases from January 2019 to December 2023. The study included all hospitalized patients aged ≥ 18 with CRC who underwent surgery. Surgical cases were categorized as open or minimally invasive. Outcomes assessed included in-hospital mortality, morbidity, and hospital length of stay. Statistical analyses involved multivariable logistic and linear regression models adjusted for main diagnosis, metastasis presence, age, sex, and comorbidities.

RESULTS

The study included 4525 CRC cases: 2767 underwent open surgery and 1758 underwent minimally invasive surgery (173 robotic). In-hospital mortality was significantly higher in open surgery (6.1% vs. 1.7%). Open surgery was also significantly associated with higher rates of acute post-hemorrhagic anemia (OR: 2.38; 95% CI: 1.87-3.02), respiratory failure (OR: 1.71; 95% CI: 1.34-2.18), and intraoperative and postprocedural complications (OR: 3.64; 95% CI: 2.83-4.70). Average hospital stay was longer for open surgery (19.5 days vs. 11.0 days).

CONCLUSION

Despite the advantages of minimally invasive surgery, including reduced mortality, morbidity, and shorter hospital stays, open surgery remains the predominant approach for CRC in Germany. These findings underscore the need for increased adoption of minimally invasive techniques and highlight the potential benefits of shifting toward minimally invasive methods to enhance the overall quality of CRC care.

Short- and long-term outcomes of laparoscopic right hemicolectomy with D3 resection for right colon cancer in elderly patients

BACKGROUND

Laparoscopic right hemicolectomy (RHC) with D3 resection, similar to complete mesocolic excision, is an oncologically satisfying procedure; however, it remains controversial in elderly patients. There are no reports of the procedure for tumors fed by middle colic vessels because it is a difficult procedure. We evaluated the feasibility and oncological outcomes of the procedure in elderly patients.

METHODS

We retrospectively evaluated 336 consecutive patients undergoing laparoscopic right hemicolectomy with D3 resection for Stage I-III ascending and transverse colon cancer between 2010 and 2021. Patients were divided into the EP (age ≥ 75 years) and nEP (age < 75 years) groups, and short- and long-term outcomes were analyzed using propensity score matching.

RESULTS

The median follow-up period was 60.7 months. After matching, we enrolled 129 patients. The surgery time, estimated blood loss, postoperative complication rate, number of harvested lymph nodes, and recurrence rate did not differ significantly between the groups; however, the adjuvant chemotherapy rate was significantly lower in the EP group. The EP group had significantly shorter overall survival (OS) (p < 0.01) than the nEP group; however, the cancer-specific (p = 0.15) and recurrence-free (p = 0.36) survivals did not differ significantly from those in the nEP group. In multivariate analyses, age ≥ 75 years, ASA ≥ 3, and pT4 were independent prognostic factors for OS (p = 0.02, < 0.01, < 0.01, respectively); however, only pT4 was an independent prognostic factor for CSS and RFS (p < 0.01 for both).

CONCLUSIONS

This procedure offers safe, feasible, and satisfactory oncological outcomes for elderly patients.

Robotic surgery is associated with a decreased risk of circumferential resection margin positivity compared with conventional laparoscopic surgery in patients with rectal cancer undergoing mesorectal excision: A systematic review and meta-analysis

OBJECTIVE

To investigate whether robotic surgery (RS) decreases the risk of circumferential resection margin (CRM) positivity compared with conventional laparoscopic surgery (LS) in patients with rectal cancer (RC) undergoing mesorectal excision (ME).

BACKGROUND

Although it is well known that CRM positivity affects postoperative outcomes in patients with RC undergoing ME, few studies have investigated whether RS is superior to conventional LS for the risk of CRM positivity.

METHODS

We performed a comprehensive electronic search of the literature up to December 2022 to identify studies that compared the risk of CRM positivity between patients with RC undergoing robotic and conventional laparoscopic surgery. A meta-analysis was performed using random-effects models to calculate risk ratios (RRs) and 95 % confidence intervals (CIs), and heterogeneity was analyzed using I2 statistics.

RESULTS

Eighteen studies, consisting of 4 randomized controlled trials (RCTs) and 14 propensity score matching (PSM) studies, involved a total of 9203 patients with RC who underwent ME were included in this meta-analysis. The results demonstrated that RS decreased the overall risk of CRM positivity (RR, 0.82; 95 % CI, 0.73-0.92; P = 0.001; I2 = 0 %) compared with conventional LS. Results of a meta-analysis of the 4 selected RCTs also showed that RS decreased the risk of CRM positivity (RR, 0.62; 95 % CI, 0.43-0.91; P = 0.01; I2 = 0 %) compared with conventional LS.

CONCLUSIONS

This meta-analysis revealed that RS is associated with a decreased risk of CRM positivity compared with conventional LS in patients with RC undergoing ME.

Assessing Surgeons' Attitude to Teaching Intra-Corporeal Anastomosis

Introduction: There is a controversy in minimally invasive colorectal procedures regarding choosing optimal technique between intra-corporeal (ICA) and extra-corporeal anastomosis (ECA). Previous studies recognize the short-term benefits in right hemicolectomy with intra-corporeal approach; however, ICA can result in increased operative difficulty. The aim of this study is to understand attitudes towards teaching ICA in colorectal procedures and how this varies between subspeciality training. Methods: Active members of General Surgeons Australia were contacted through email to participate in a voluntary, unincentivized survey. Demographic details were collected and participants were asked to rate agreement for simulation-based training for increasing adoption of ICA through a Likert scale and when preferences for teaching ICA. Descriptive statistics were completed to describe frequencies and ordinal regression was completed to determine factors for Likert scale question. Results: There were 43 respondents and most participants recognized that ECA was easier to teach trainees and should be taught first. 53.5% of respondents recognized that simulation-based training would assist the adoption of ICA. Surgeons who routinely close bowel or enteric defects intra-corporeally are 354% more likely to show an interest in simulation-based training for adopting ICA, however, surgeons who are not involved in teaching trainees did not show an interest in simulation-based training. Conclusion: There is significant agreement that ECA forms the basis to learn ICA and simulation-based training would assist with the uptake of ICA. However, a multimodal approach, including expanding training avenues and providing financial incentives, would be necessary to enhance the adoption of ICA in colorectal surgery.

Functional outcomes and quality of life following open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: a systematic review and meta-analysis

BACKGROUND

The standard surgical treatment for rectal cancer is total mesorectal excision (TME), which may negatively affect patients' functional outcomes and quality of life (QoL). However, it is unclear how different TME techniques may impact patients' functional outcomes and QoL. This systematic review and meta-analysis evaluated functional outcomes of urinary, sexual, and fecal functioning as well as QoL after open, laparoscopic (L-TME), robot-assisted (R-TME), and transanal total mesorectal excision (TaTME).

METHODS

A systematic review and meta-analysis, based on the preferred reporting items for systematic reviews and meta-analysis statement, were conducted (PROSPERO: CRD42021240851). A literature review was performed (sources: PubMed, Medline, Embase, Scopus, Web of Science, and Cochrane Library databases; end-of-search date: September 1, 2023), and a quality assessment was performed using the Methodological index for non-randomized studies. A random-effects model was used to pool the data for the meta-analyses.

RESULTS

Nineteen studies were included, reporting on 2495 patients (88 open, 1171 L-TME, 995 R-TME, and 241 TaTME). Quantitative analyses comparing L-TME vs. R-TME showed no significant differences regarding urinary and sexual functioning, except for urinary function at three months post-surgery, which favoured R-TME (SMD [CI] -0 .15 [- 0.24 to - 0.06], p = 0.02; n = 401). Qualitative analyses identified most studies did not find significant differences in urinary, sexual, and fecal functioning and QoL between different techniques.

CONCLUSIONS

This systematic review and meta-analysis highlight a significant gap in the literature concerning the evaluation of functional outcomes and QoL after TME for rectal cancer treatment. This study emphasizes the need for high-quality, randomized-controlled, and prospective cohort studies evaluating these outcomes. Based on the limited available evidence, this systematic review and meta-analysis suggests no significant differences in patients' urinary, sexual, and fecal functioning and their QoL across various TME techniques.

Robotic versus laparoscopic right colectomy for nonmetastatic pT4 colon cancer: A European multicentre propensity score-matched analysis

AIM

Minimally invasive surgery has been increasingly adopted for locally advanced colon cancer. However, evidence comparing robotic (RRC) versus laparoscopic right colectomy (LRC) for nonmetastatic pT4 cancers is lacking.

METHODS

This was a multicentre propensity score-matched (PSM) study of a cohort of consecutive patients with pT4 right colon cancer treated with RRC or LRC. The two surgical approaches were compared in terms of R0, number of lymph nodes harvested, intra- and postoperative complication rates, overall (OS), and disease-free survival (DFS).

RESULTS

Among a total of 200 patients, 39 RRC were compared with 78 PS-matched LRC patients. The R0 rate was similar between RRC and LRC (92.3% vs. 96.2%, respectively; p = 0.399), as was the odds of retrieving 12 or more lymph nodes (97.4% vs. 96.2%; p = 1). No significant difference was noted for the mean operating time (192.9 min vs. 198.3 min; p = 0.750). However, RRC was associated with fewer conversions to laparotomy (5.1% vs. 20.5%; p = 0.032), less blood loss (36.9 vs. 95.2 mL; p < 0.0001), fewer postoperative complications (17.9% vs. 41%; p = 0.013), a shorter time to flatus (2 vs. 2.8 days; p = 0.009), and a shorter hospital stay (6.4 vs. 9.5 days; p < 0.0001) compared with LRC. These results were confirmed even when converted procedures were excluded from the analysis. The 1-, 3- and 5-year OS (p = 0.757) and DFS (p = 0.321) did not significantly differ between RRC and LRC.

CONCLUSION

Adequate oncological outcomes are observed for RRC and LRC performed for pT4 right colon cancer. However, RRC is associated with lower conversion rates and improved short-term postoperative outcomes.

Evaluation of the tumor-targeting specific imaging and killing effect of a CEA-targeting nanoparticle in colorectal cancer

INTRODUCTION

Colorectal cancer (CRC) is a prevalent digestive malignancy with significant global mortality and morbidity rates. Improving diagnostic capabilities for CRC and investigating novel therapeutic approaches are pressing clinical imperatives. Additionally, carcinoembryonic antigen (CEA) has emerged as a highly promising candidate for both colorectal tumor imaging and treatment.

METHODS

A novel active CEA-targeting nanoparticle, CEA(Ab)-MSNs-ICG-Pt, was designed and synthesized, which served as a tumor-specific fluorescence agent to help in CRC near-infrared (NIR) fluorescence imaging. In cell studies, CEA(Ab)-MSNs-ICG-Pt exhibited specific targeting to RKO cells through specific antibody-antigen binding of CEA, resulting in distribution both within and around these cells. The tumor-targeting-specific imaging capabilities of the nanoparticle were determined through in vivo fluorescence imaging experiments. Furthermore, the efficacy of the nanoparticle in delivering chemotherapeutics and its killing effect were evaluated both in vitro and in vivo.

RESULTS

The CEA(Ab)-MSNs-ICG-Pt nanoparticle, designed as a novel targeting agent for carcinoembryonic antigen (CEA), exhibited dual functionality as a targeting fluorescent agent. This CEA-targeting nanoparticle showed exceptional efficacy in eradicating CRC cells in comparison to individual treatment modalities. Furthermore, it exhibits exceptional biosafety and biocompatibility properties. CEA(Ab)-MSNs-ICG-Pt exhibits significant promise due to its ability to selectively target tumors through NIR fluorescence imaging and effectively eradicate CRC cells with minimal adverse effects in both laboratory and in vivo environments.

CONCLUSION

The favorable characteristics of CEA(Ab)-MSNs-ICG-Pt offer opportunities for its application in chemotherapeutic interventions, tumor-specific NIR fluorescence imaging, and fluorescence-guided surgical procedures.

Surgical Site Infections in Colorectal Cancer Surgeries: A Systematic Review and Meta-Analysis of the Impact of Surgical Approach and Associated Risk Factors

BACKGROUND

Surgical site infections (SSIs) represent a noteworthy contributor to both morbidity and mortality in the context of patients who undergo colorectal surgery. Several risk factors have been identified; however, their relative significance remains uncertain.

METHODS

We conducted a meta-analysis of observational studies from their inception up until 2023 that investigated risk factors for SSIs in colorectal surgery. A random-effects model was used to pool the data and calculate the odds ratio (OR) and 95% confidence interval (CI) for each risk factor.

RESULTS

Our analysis included 26 studies with a total of 61,426 patients. The pooled results showed that male sex (OR = 1.45), body mass index (BMI) ≥ 25 kg/m2 (OR = 1.09), American Society of Anesthesiologists (ASA) score ≥ 3 (OR = 1.69), were all independent risk factors for SSIs in colorectal surgery. Conversely, laparoscopic surgery (OR = 0.70) was found to be a protective factor.

CONCLUSIONS

The meta-analysis conducted revealed various risk factors, both modifiable and non-modifiable, associated with surgical site infections (SSIs) in colorectal surgery. These findings emphasize the significance of targeted interventions, including optimizing glycemic control, minimizing blood loss, and using laparoscopic techniques whenever feasible in order to decrease the occurrence of surgical site infections in this particular group of patients.

Laparoscopic versus open pancreaticoduodenectomy for ampullary cancer: A retrospective study

INTRODUCTION

Studies comparing laparoscopic pancreaticoduodenectomy (LPD) with open pancreaticoduodenectomy (OPD) for ampullary carcinoma (AC) are limited. This study aimed to compare short- and long-term outcomes between LPD and OPD for AC.

METHODS

This study included patients with AC who underwent pancreaticoduodenectomy (PD) with curative intention at Ogaki Municipal Hospital from April 2008 to March 2023.

RESULTS

Fifty-five patients underwent LPD (n = 26) or OPD (n = 29). There were no significant differences in the demographics between the two groups. The LPD group had a significantly longer operative time (268 vs. 225 min), less blood loss (125 vs. 450 mL), and shorter postoperative hospital stay (18 vs. 23 days) than the OPD group. There was no significant difference in the morbidity ratio. Fewer lymph nodes were harvested in the LPD group than OPD group (9.5 vs. 16.0), but there were no significant differences in lymph node metastasis or pathological stages. There were no significant differences in overall survival (OS) or recurrence-free survival (RFS). The 3- and 5-year OS rates in the LPD group and the OPD group were 63.0% and 54%, 64.8%, and 61.2%, respectively. The 3- and 5-year RFS rates were 57.4% and 57.4%, 58.1%, and 54.4%, respectively.

CONCLUSIONS

LPD for AC had short- and long-term outcomes comparable with those of OPD. LPD could be considered the standard treatments for AC because of less blood loss and a shorter hospital stay.

[Robotic rectal surgery]

Colorectal cancer is one of the most frequent cancerous diseases in industrial nations, whereby tumors of the rectum constitute approximately 30-40% of all colorectal cancers. In addition to the implementation and establishment of novel neoadjuvant concepts for the treatment of rectal cancer, there has been a continuous evolution of surgical techniques in recent years towards minimally invasive surgery. In this respect robot-assisted surgery has become more and more popular despite seemingly weak evidence regarding clinical benefits and the not to be ignored economic aspects; however, recently published high-quality studies provide new evidence showing advantages for a robotic resection in patients suffering from rectal cancer. Thus, the progressive implementation of robotic surgical systems is increasingly attaining a scientific foundation.

[Robotic Colorectal Surgery: Analysis of the First Three Years of Activity in a Hospital of the Portuguese National Health Service]

INTRODUCTION

Minimally invasive surgery has been increasingly accepted and used in colorectal surgery. Several studies report that robotic surgery may provide advantages over 'conventional' laparoscopy, namely in rectal surgery. This paper provides an account of the first three years of experience with robotic surgery in the Unidade de Patologia Colorretal of the Unidade Local de Saúde S. José.

METHODS

Variables were defined to develop a prospective database containing the data of consecutive patients operated by three internationally certified colorectal surgeons using the Da Vinci Xi® system between November 2019 and October 2022. The database was converted into an anonymized version that was used for this study. The analysis was performed on the data of all the patients operated during this period.

RESULTS

Eighty patients were included, 47 male, median age 70 years, and median BMI 26 kg/m2 . ASA score was II in 53.7% and III in 41.3% of pa- tients. Of the total, 97.6% had malignant or potentially malignant disease. Operative procedures consisted of 34 colectomies proximal to the splenic flexure, 20 distal colectomies and 26 anterior resections. There were two synchronous resections of liver metastases. Early perioperative outcomes and histopathological results were analyzed: median operative time: 300 minutes; median estimated blood loss: 50 mL; conversion rate: 2.5%; median days until first bowel movement: three days; median length of hospital stay: six days; complication rate: 20%, of which 5% were Clavien III and 0% Clavien IV/V; anastomotic leak rate: 2.5%; 30-day readmission rate: 1.3%; median lymph nodes resected: 20; R0 resection rate: 100%; mesorectal integrity rate: 95,8% complete/near complete.

CONCLUSION

Our results show that the adoption of robotic colorectal surgery in our center was safe and resulted in similar or improved short-term clinical outcomes and histopathological results when compared to those described in the literature.

Evaluating Surgical Outcomes and Survival in Colon Cancer Patients Over 80 Years Old

BACKGROUND AND AIMS

In the context of an increasing older population, knowing the surgical outcomes of older patients is of paramount importance to define a comprehensive strategy for colon cancer treatment in these patients. This study aimed to analyze the surgical outcomes and survival of patients over 80 years old undergoing surgery for colon cancer.

MATERIALS AND METHODS

This is an observational retrospective longitudinal study of patients over 80 years old with colon cancer diagnosis who underwent surgery for this condition, between 2018 and 2021, in a Portuguese hospital. Demographic and clinical features were characterized. Kaplan-Meier method was used for survival analysis.

RESULTS

Out of 90 patients in the study, 41.1% were female. The majority (56.7%) had an Eastern Cooperative Oncology Group (ECOG) performance status of 1 or 0, with a median Charlson Comorbidity Index of 7.0. Tumors were primarily located in the right colon (52.2%) and sigmoid colon (25.6%), with most patients having stage II (35.6%) or stage III (25.5%) disease. Elective surgeries accounted for 73% of procedures, and 80.0% had curative intent, with laparoscopic surgery performed in 66.7% of cases. Only 8.3% of those undergoing curative-intent procedures received adjuvant chemotherapy. Emergent admissions were associated with more advanced cancer stages, higher rates of palliative intent procedures (45.8% versus 10.6%, p < 0.001), and more open surgeries (75.0% versus 9.1%, p < 0.001) when compared to elective procedures. Postoperative mortality was higher in the emergent group (20.8% versus 10.6%), though there was no association between the type of admission and postoperative complications. Median overall survival for all patients was 36.7 (95% CI 28.1 to 45.3) months, with significant differences between curative-intent and palliative surgeries (median of 39.8 (95% CI 32.6 to 47.0) versus 10.6 (95% CI 0.67 to 20.5) months, p = 0.015). The elective group of patients had significantly better overall survival compared to the emergent group (median of 36.7 (95% CI 30.7 to 42.7) versus 11.9 (95% CI 6.0 to 17.8) months, p = 0.01). Among the patients who underwent curative-intent procedures, there were no significant differences in overall or disease-free survival between elective and emergent groups.

CONCLUSIONS

Despite the increased complexity of managing older patients, particularly in emergent cases, these findings emphasize the importance of elective, curative-intent surgeries to optimize overall survival. Effective treatment strategies and perioperative management tailored to this age group are essential for improving surgical outcomes and extending survival in elderly colon cancer patients.

Laparoscopy is non-inferior to open surgery for rectal cancer: A systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery has been endorsed by clinical guidelines for colon cancer, but not for rectal cancer on account of unapproved oncologic equivalence with open surgery.

AIMS

We started this largest-to-date meta-analysis to comprehensively evaluate the safety and efficacy of laparoscopy in the treatment of rectal cancer compared with open surgery.

MATERIALS & METHODS

Both randomized and nonrandomized controlled trials comparing laparoscopic proctectomy and open surgery between January 1990 and March 2020 were searched in PubMed, Cochrane Library and Embase Databases (PROSPERO registration number CRD42020211718). The data of intraoperative, pathological, postoperative and survival outcomes were compared between two groups.

RESULTS

Twenty RCTs and 93 NRCTs including 216,615 patients fulfilled the inclusion criteria, with 48,888 patients received laparoscopic surgery and 167,727 patients underwent open surgery. Compared with open surgery, laparoscopic surgery group showed faster recovery, less complications and decreased mortality within 30 days. The positive rate of circumferential margin (RR = 0.79, 95% CI: 0.72 to 0.85, p < 0.0001) and distal margin (RR = 0.75, 95% CI: 0.66 to 0.85 p < 0.0001) was significantly reduced in the laparoscopic surgery group, but the completeness of total mesorectal excision showed no significant difference. The 3-year and 5-year local recurrence, disease-free survival and overall survival were all improved in the laparoscopic surgery group, while the distal recurrence did not differ significantly between the two approaches.

CONCLUSION

Laparoscopy is non-inferior to open surgery for rectal cancer with respect to oncological outcomes and long-term survival. Moreover, laparoscopic surgery provides short-term advantages, including faster recovery and less complications.

Has the open surgical approach in colorectal cancer really become uncommon?

Colorectal cancer is the third most common cancer in the world. Surgery is mandatory to treat patients with colorectal cancer. Can colorectal cancer be treated in laparoscopy? Scientific literature has validated the oncological quality of laparoscopic approach for the treatment of patients with colorectal cancer. Randomized non-inferiority trials with good remote control have answered positively to this long-debated question. Early as 1994, first publications demonstrated technical feasibility and compliance with oncological imperatives and, as far as short-term outcomes are concerned, there is no difference in terms of mortality and post-operative morbidity between open and minimally invasive surgical approaches, but only longer operating times at the beginning of the experience. Subsequently, from 2007 onwards, long-term results were published that demonstrated the absence of a significant difference regarding overall survival, disease-free survival, quality of life, local and distant recurrence rates between open and minimally invasive surgery. In this editorial, we aim to summarize the clinical and technical aspects which, even today, make the use of open surgery relevant and necessary in the treatment of patients with colorectal cancer.

Robotic-assisted low anterior resection for rectal cancer shows similar clinical efficacy to laparoscopic surgery: A propensity score matched study

BACKGROUND

Rectal cancer ranks as the second leading cause of cancer-related mortality worldwide, necessitating surgical resection as the sole treatment option. Over the years, there has been a growing adoption of minimally invasive surgical techniques such as robotic and laparoscopic approaches. Robotic surgery represents an innovative modality that effectively addresses the limitations associated with traditional laparoscopic techniques. While previous studies have reported favorable perioperative outcomes for robot-assisted radical resection in rectal cancer patients, further evidence regarding its oncological safety is still warranted.

AIM

To conduct a comparative analysis of perioperative and oncological outcomes between robot-assisted and laparoscopic-assisted low anterior resection (LALAR) procedures.

METHODS

The clinical data of 125 patients who underwent robot-assisted low anterior resection (RALAR) and 279 patients who underwent LALAR resection at Shandong Provincial Hospital Affiliated to Shandong First Medical University from December 2019 to November 2022 were retrospectively analyzed. After performing a 1:1 propensity score matching, the patients were divided into two groups: The RALAR group and the LALAR group (111 cases in each group). Subsequently, a comparison was made between the short-term outcomes within 30 d after surgery and the 3-year survival outcomes of these two groups.

RESULTS

Compared to the LALAR group, the RALAR group exhibited a significantly earlier time to first flatus [2 (2-2) d vs 3 (3-3) d, P = 0.000], as well as a shorter time to first fluid diet [4 (3-4) d vs 5 (4-6) d, P = 0.001]. Additionally, the RALAR group demonstrated reduced postoperative indwelling catheter time [2 (1-3) d vs 4 (3-5) d, P = 0.000] and decreased length of hospital stay after surgery [5 (5-7) d vs 7(6-8) d, P = 0.009]. Moreover, there was an observed increase in total cost of hospitalization for the RALAR group compared to the LALAR group [10777 (10780-11850) dollars vs 10550 (8766-11715) dollars, P = 0.012]. No significant differences were found in terms of conversion rate to laparotomy or incidence of postoperative complications between both groups. Furthermore, no significant disparities were noted regarding the 3-year overall survival rate and 3-year disease-free survival rate between both groups.

CONCLUSION

Robotic surgery offers potential advantages in terms of accelerated recovery of gastrointestinal and urologic function compared to LALAR resection, while maintaining similar perioperative and 3-year oncological outcomes.

[Treatment strategies for recurrent rectal cancer]

Multimodal treatment approaches with neoadjuvant radiotherapy and chemotherapy followed by oncological and total mesorectal excision (TME) have significantly reduced the recurrence rate even in locally advanced rectal cancer. Nevertheless, up to 10% of patients develop a local relapse. Surgical R0 resection is the only chance of a cure in the treatment of locally recurrent rectal cancer (LRRC). Due to the altered anatomy and physiology of the true pelvis as a result of the pretreatment and operations as well as the localization and extent of the recurrence, the treatment decision is individualized and remains a challenge for the interdisciplinary team. Even locally advanced tumors with involvement of adjacent structures can be treated in designated centers using multimodal treatment concepts with potentially curative intent.

Conversion rate to open surgery during transanal total mesorectal excision (TaTME) for rectal cancer: a single-center experience

Minimally invasive techniques for rectal cancer have demonstrated considerable advantages in terms of faster recovery and less post-operative complications. However, due to the complex anatomy and a limited surgical field, conversion to open surgery is still sometimes required, with a negative impact on the short-and long-term outcomes. The purpose of this study was to analyse the conversion rate to open abdominal surgery during laparoscopic transanal total mesorectal excision (TaTME) procedures performed at a high-volume Italian referral center. All consecutive TaTME performed for mid-to-low rectal cancer between 2015 and 2023 were reviewed, independently if treated with a primary anastomosis (with/without a diverting ostomy) or an end stoma. All procedures were performed using a standardized approach by the same surgical team. Patients with benign diagnosis that underwent different-from rectal resection procedures and cases pre-operatively scheduled for open surgery were excluded. The primary outcome of interest was the rate of conversion, defined as an un-planned intraoperative switch to open surgery using a midline laparotomy. Secondary aims included the comparison of patients who had a longer vs shorter operative time. Out of 220 patients, 210 were selected. In 187 cases, a primary anastomosis was performed, while 23 patients received a terminal colostomy (1 in the converted group; 22 in the full MIS- TaTME group, 10.6%). A surgical approach modification occurred in two cases, with a conversion rate of 0.95%. Median operative time was 281 min. Reasons for conversions included intra-operative difficulties impairing the mini-invasive procedure without intra-operative complications in one case, and difficulties in the laparoscopic control of an intraoperative bleeding due to a splenic lesion in another patient. Male sex and a higher BMI were found to be statistically significantly associated to longer operative time (respectively: p = 0.001 and p = 0.0025). In a high-volume center, a standardized TaTME is associated to a low conversion rate to open abdominal surgery.

Port-Site Metastasis After Laparoscopic Gastrectomy Extending to the Thigh: A Case Report

Port-site metastasis (PSM) is rare following laparoscopic gastrectomy for gastric cancer. Previous reports focused on localized lesions treated with excision; contrastingly, case reports describing extensive invasion into the lower extremity skeletal muscles causing deterioration in activities of daily living are nonexistent. A 55-year-old male underwent a laparoscopic distal gastrectomy for gastric cancer. The pathological findings revealed a stage IIIA tumor. Two years later, skin hardening was observed on the left upper abdominal wall. Computed tomography displayed a 13-cm-long, flat tumor along the skeletal muscle around the left upper 12 mm port site and right hydronephrosis. The patient was diagnosed with PSM and retroperitoneal recurrence. Despite chemotherapy, three years postoperatively, PSM widely spread from the left upper abdomen to the left thigh, eventually inducing opioid-resistant leg pain and subsequent walking difficulties. Palliative radiotherapy could not improve these symptoms. The patient died three years and five months postoperatively. Extensively invasive PSM can induce refractory cancer pain and physical disorders. Therefore, early detection and palliative resection of PSM may help maintain the quality of life of patients with gastric cancer.

The Impact of Enhanced Recovery on Long-Term Survival in Rectal Cancer

INTRODUCTION

Implementing perioperative interventions such as enhanced recovery pathways (ERPs) has improved short-term outcomes and minimized length of stay. Preliminary evidence suggests that adherence to the enhanced recovery after surgery protocol may also enhance 5-year cancer-specific survival (CSS) in colorectal cancer surgery. This retrospective study presents long-term survival outcomes and disease recurrence from a high-volume, single-center practice.

METHODS

All patients over 18 years of age diagnosed with rectal adenocarcinoma and undergoing elective minimally invasive surgery (MIS) were retrospectively reviewed between February 2005 and April 2018. Relevant data were extracted from Mayo electronic records and securely stored in a database. Short-term morbidity and long-term oncological outcomes were compared between patients enrolled in ERP and those who received non-enhanced care.

RESULTS

Overall, 600 rectal cancer patients underwent MIS, of whom 320 (53.3%) were treated according to the ERP and 280 (46.7%) received non-enhanced care. ERP was associated with a decrease in length of stay (3 vs. 5 days; p < 0.001) and less overall complications (34.7 vs. 54.3%; p < 0.001). The ERP group did not show an improvement in overall survival (OS) or disease-free survival (DFS) compared with non-enhanced care on multivariable (non-ERP vs. ERP OS: hazard ratio [HR] 1.268, 95% confidence interval [CI] 0.852-1.887; DFS: HR 1.050, 95% CI 0.674-1.635) analysis.

CONCLUSION

ERP was found to be associated with a reduction in short-term morbidity, with no impact on long-term oncological outcomes, such as OS, CSS, and DFS.

The urinary and sexual outcomes of robot-assisted versus laparoscopic rectal cancer surgery: a systematic review and meta-analysis

To compare the urinary and sexual outcomes between robot-assisted rectal cancer (RC) surgery (RRCS) and laparoscopic RC surgery (LRCS) using a meta-analysis, searches were conducted of the Embase, PubMed, Cochrane Library, CNKI, and Wanfang databases. The International Prostate Symptom Score (IPSS) was the primary outcome. Eleven studies (790 patients with RRCS and 888 with LRCS) were included. The IPSS scores were significantly lower for RRCS than LRCS from baseline to 3 months (weighted mean difference [WMD] =  - 1.21, 95% confidence interval [CI]: - 1.8,-0.62, I2 = 89.9%), to 6 months (WMD =  - 1.13, 95% CI: - 1.74, - 0.52, I2 = 93.3%), and to 12 months (WMD =  - 0.93, 95% CI: - 1.59, - 0.26, I2 = 93.8%). The International Index of Erectile Function (IIEF) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 3.36, 95% CI: 1.28, 5.44, I2 = 92.7%). The female sexual function index (FSFI) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 1.31, 95% CI: 0.87, 1.76, I2 = 0), to 6 months (WMD = 2.36, 95% CI: 1.93, 2.79, I2 = 24.3%), and to 12 months (WMD = 1.67, 95% CI: 0.41, 2.93, I2 = 90.9%). RRCS also achieved a better recovery of the urological and sexual function than LRCS for patients with RC. Larger-scale prospective randomized control trials are needed to verify these results.

Outcome of Colorectal Robotic Surgery in Newly Established Robotic Surgery Center: A Case Series

INTRODUCTION

The robotic platform compared to laparoscopy has proven to have similar postoperative outcomes, however its adoption in the Middle East has been slow and there is limited data regarding outcomes with its use in small newly established robotic colorectal programs. Our aim was to report our experience and outcomes of robotic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare them to larger, more experienced centers.

METHODS

This is retrospective review of data collected between November 2021 and March 2023 from a tertiary health care referral center. The series included 51 patients who had elective or urgent robotic colorectal surgery. Patients who had emergency surgery were excluded. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and quality of oncological specimen.

RESULTS

The overall morbidity was 31.4% (n = 16 patients). Only 9.8% (n = 5) had serious morbidity of which three required interventions under general anesthesia. The median length of hospital stay was 6 days (IQR = 4), and there was no mortality. Of 17 rectal cancer resections, 88% had complete mesorectal excision, 15 of them were R0 resections, median lymph node harvested was 14 (IQR = 7) and two cases were converted to open. All the colon cancer resections had R0 resection, median lymph nodes harvested was 21 (IQR = 4) and none were converted to open.

CONCLUSIONS

The implementation and integration of robotic colorectal surgery at a newly established center in a small country, when led by fellowship trained robotic colorectal surgeons, is safe and effective in terms of morbidity, mortality, conversion to open and specimen pathological quality.

Outcomes in robotic-assisted compared to laparoscopic-assisted colorectal surgery in a newly established colorectal tertiary center: a retrospective comparative cohort study

The robotic platform matches or surpasses laparoscopic surgery in postoperative results. However, limited date and slow adoption are noticed in the middle east. We aimed to report outcomes of robotic and laparoscopic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare it to larger more experienced centers. Retrospective review of prospectively collected data between 2021 and 2023 of 107 patients who had robotic-assisted or laparoscopic-assisted colorectal surgery was included in the study. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and the quality of oncological specimen. Of 107 patients, 57 were in the robotic and 50 were in the laparoscopic surgery groups. Overall, there were no significant differences in overall morbidity (46.8 vs. 53.2%, p = 0.9), serious morbidity (10.5 vs. 8%, p = 0.7), or mortality (0 vs. 4%, p = 0.2). Regarding oncological outcomes, there were no significant difference between the two groups regarding the number of lymph node harvested (17.7 ± 6.9 vs 19.0 ± 9.7, p = 0.5), R0 resections (92.7 vs. 87.1%, p = 0.5), and the rate of complete mesorectal excision (92.7 vs. 71.4%, p = 0.19). The study found that the robotic group had an 86% reduction in conversion rate to open surgery compared to the laparoscopic group, despite including more obese and physically dependent patients (OR = 0.14, 95% CI 0.03-0.7, p = 0.01). Robotic surgery appears to be a safe and effective as laparoscopic surgery in smaller colorectal surgery programs led by fellowship-trained robotic surgeons, with outcomes comparable to those of larger programs.

Surgical and Oncological Outcome of Laparoscopic Resection of Colorectal Cancers: A Single-Center Experience

BACKGROUND

Laparoscopy is one of the major advances in surgery in the last 30 years and has many benefits. Although laparoscopy was initially used for resection of benign colon lesions, it is now widely used for colorectal cancer resections after strong evidence has confirmed its safety and efficacy. We aim to report both the surgical and oncological outcomes of our first series of laparoscopic colorectal cancer resections.

METHODS

In 2013, a laparoscopic colorectal resection service was established in northern Iraq at Zheen Hospital, Erbil. Data from all consecutive colorectal cancers were collected. Patients with locally advanced diseases and those who required emergency operations for bowel obstruction or perforation were excluded. We analyzed demographic, operative, postoperative, and histopathological data for all patients who were included in the study.

RESULTS

A total of 124 patients with colorectal cancers presented to our unit between January 2013 and January 2023. Only 112 patients fulfilled the inclusion criteria and underwent laparoscopic resections. The median age of the patients was 54.5 years. The majority of patients were men (n=62; 55.4%). In 39 patients (35%), the cancer was located in the sigmoid; in 33 patients (29.5%) the cancer was in the rectum. Laparoscopic anterior resection was the most common procedure (n=50; 45%), followed by right hemicolectomy in 17 cases (15.1%). The conversion rate to open surgery was 8% (nine cases). The most common causes of conversion to open surgery were dilated bowel loops and tumour adherence to other structures. The mean operative time was 190 minutes and the mean hospital stay was three days. No complications were reported in 94 patients (84%). Among the complications, wound infection was seen in seven patients (7.8%). There were six anastomotic leaks (6.7%). The mean number of lymph nodes harvested was 13. In 70 patients (62.5%), the lymph node count was ≥12 with a median of 13. The mean distal resection margin was 6 cm and 2.5 cm for colon and rectal resections, respectively.

CONCLUSION

This study reveals that laparoscopic resection for colorectal cancers is surgically practicable and safe with the benefits of a short hospital stay, adequate resection margins, and adequate lymph node yield.

Influence of neoadjuvant treatment strategy on perioperative outcomes in locally advanced rectal cancer

AIM

Neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer facilitates tumour downstaging and complete pathological response (pCR). The goal of neoadjuvant systemic chemotherapy (total neoadjuvant chemotherapy, TNT) is to further improve local and systemic control. While some patients forgo surgery, total mesorectal excision (TME) remains the standard of care. While TNT appears to be noninferior to nCRT with respect to short-term oncological outcomes few data exist on perioperative outcomes. Perioperative morbidity including anastomotic leaks is associated with a negative effect on oncological outcomes, probably due to a delay in proceeding to adjuvant therapy. Thus, we aimed to compare conversion rates, rates of sphincter-preserving surgery and anastomosis formation rates in patients undergoing rectal resection after either TNT or standard nCRT.

METHODS

An institutional colorectal oncology database was searched from January 2018 to July 2023. Inclusion criteria comprised patients with histologically confirmed rectal cancer who had undergone neoadjuvant therapy and TME. Exclusion criteria comprised patients with a noncolorectal primary, those operated on emergently or who had local excision only. Outcomes evaluated included rates of conversion to open, sphincter-preserving surgery, anastomosis formation and anastomotic leak.

RESULTS

A total of 119 patients were eligible for inclusion (60 with standard nCRT, 59 with TNT). There were no differences in rates of sphincter preservation or primary anastomosis formation between the groups. However, a significant increase in conversion to open (p = 0.03) and anastomotic leak (p = 0.03) was observed in the TNT cohort.

CONCLUSION

In this series TNT appears to be associated with higher rates of conversion to open surgery and higher anastomotic leak rates. While larger studies will be required to confirm these findings, these factors should be considered alongside oncological benefits when selecting treatment strategies.

A sutureless overlapped anastomosis technique using linear staplers with reinforced bioabsorbable material in robotic right colectomy with intracorporeal anastomosis

AIM

Creation of an overlapped anastomosis using handsewn sutures for common enterotomy is very popular in robotic right colectomy (RRC) with intracorpareal anastomosis (IA). The aim of this study is to present a simple method for constructing a sutureless overlapped anastomosis using a 60 mm linear stapler with a reinforced bioabsorbable material in RRC with IA.

METHOD

The distal ileum and proximal colon were put in overlapping positions. Enterotomies were created 2 cm proximal to the ileal stump and 8 cm distal to the colonic stump on the antimesenteric side. Subsequently, a 60 mm linear stapler with a reinforced bioabsorbable material was inserted into each lumen and fired. Finally, the bowel was elevated while holding the bioabsorbable material, and the common enterotomy was grasped with the robotic instrument in the middle and closed using a linear stapler with a reinforced bioabsorbable material.

RESULTS

This technique was applied to 10 patients with tumours of the caecum, ascending colon, or transverse colon. The median operating time, anastomosis construction time, blood loss, and postoperative stay were 281 min (range 228-459 min), 12 min (range 11-17 min), 10 mL (range 0-110 mL), and 10 days (range 8-15 days), respectively. No adverse intraoperative events were observed. Postoperatively, one patient developed chylous ascites, but there were no other complications.

CONCLUSION

The simple technique for constructing a sutureless overlapped anastomosis using a 60 mm linear stapler with a reinforced bioabsorbable material in robotic right colectomy with intracorporeal anastomosis appears to be safe and feasible.

Robotic-Assisted versus Laparoscopic Surgery for Rectal Cancer: An Analysis of Clinical and Financial Outcomes from a Tertiary Referral Center

Background: The popularity of robotic-assisted surgery for rectal cancer is increasing, but its superiority over the laparoscopic approach regarding safety, efficacy, and costs has not been well established. Methods: A retrospective single-center study was conducted comparing consecutively performed robotic-assisted and laparoscopic surgeries for rectal cancer between 1 January 2016 and 31 September 2021. In total, 125 adult patients with sporadic rectal adenocarcinoma (distal extent ≤ 15 cm from the anal verge) underwent surgery where 66 were operated on robotically and 59 laparoscopically. Results: Severe postoperative complications occurred less frequently with robotic-assisted compared with laparoscopic surgery, as indicated by Clavien-Dindo classification grades 3b-5 (13.6% vs. 30.5%, p = 0.029). Multiple logistic regression analyses after backward selection revealed that robotic-assisted surgery was associated with a lower rate of total (Clavien-Dindo grades 1-5) (OR = 0.355; 95% CI 0.156-0.808; p = 0.014) and severe postoperative complications (Clavien-Dindo grades 3b-5) (OR = 0.243; 95% CI 0.088-0.643; p = 0.005). Total inpatient costs (median EUR 17.663 [IQR EUR 10.151] vs. median EUR 14.089 [IQR EUR 12.629]; p = 0.018) and surgery costs (median EUR 10.156 [IQR EUR 3.551] vs. median EUR 7.468 [IQR EUR 4.074]; p < 0.0001) were higher for robotic-assisted surgery, resulting in reduced total inpatient profits (median EUR -3.196 [IQR EUR 9.101] vs. median EUR 232 [IQR EUR 6.304]; p = 0.004). Conclusions: In our study, robotic-assisted surgery for rectal cancer resulted in less severe and fewer total postoperative complications. Still, it was associated with higher surgery and inpatient costs. With increasing experience, the operative time may be reduced, and the postoperative recovery may be further accelerated, leading to reduced surgery and total inpatient costs.

Long-term oncological outcomes of transanal versus laparoscopic total mesorectal excision for mid-low rectal cancer: a retrospective analysis of 2502 patients

BACKGROUND

Transanal total mesorectal resection (taTME) has recently emerged as a promising surgical approach for the treatment of mid-low rectal cancer. However, there is limited evidence on the long-term survival outcomes associated with taTME. This retrospective study aimed to compare the overall survival (OS), disease-free survival (DFS), and cancer-specific survival of taTME and laparoscopic TME (laTME) in patients with mid-low rectal cancer.

MATERIALS AND METHODS

From July 2014 to June 2022, a total of 3627 patients were identified from two prospective cohorts: the laparoscopic rectal surgery cohort and the CNTAES cohort. To balance the baseline characteristics between the taTME and laTME groups, propensity score matching (PSM) was performed.

RESULTS

A total of 2502 patients were included in the study. Prior to PSM, the laTME group comprised 1853 patients, while the taTME group comprised 649 patients. The 5-year OS (82.9% vs. 80.4%, P =0.202) and 5-year DFS (74.4% vs. 72.5%, P =0.167) were comparable between the taTME and laTME groups. After PSM, the taTME group showed no statistically significant difference in the 5-year OS (83.1% vs. 79.2%, P =0.101) and 5-year DFS (74.8% vs. 72.1%, P =0.135) compared to the laTME group. Subgroup analysis further suggested that taTME may potentially reduce the risk of death [hazard ratio 0.652; (95% CI, 0.452-0.939)] and disease recurrence [hazard ratio 0.736; (95% CI, 0.562-0.965)] specifically in patients with low rectal cancer.

CONCLUSION

In this study, taTME demonstrated comparable oncologic safety to laTME in patients with mid-low rectal cancer. Moreover, the results indicate that taTME may confer potential survival benefits for patients with low rectal cancer.

Perioperative outcomes for single-port robotic versus single-incision laparoscopic surgery: a comparative analysis in colorectal cancer surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) may offer improved cosmesis, reduced postoperative pain and faster recovery than conventional platforms, but widespread implementation was limited by technical demands. A single-port robotic platform was recently introduced, with components that further enhance SILS benefits without the technical challenges. No study to date has compared the two platforms to validate benefits. Our goal was to compare outcomes of SP robotics and SILS in colorectal cancer (CRC).

METHODS

A prospective cancer registry was reviewed for CRC patients undergoing curative resection through a SILS or SP robotic approach from 2010 to 2022. Patient and cancer demographics, intraoperative, and postoperative outcomes were compared in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. The main outcome measures were complications, operative time, and oncologic quality measures.

RESULTS

Matching resulted 50 SP robotic and 50 SILS patients. Cohorts were well matched in all demographics, but SP robotic rectal cancer cases were significantly closer to the anorectal ring than SILS (1.8 cm vs. 3.4 cm, p = 0.018). SP robotic and SILS platforms had similar operative times. Intraoperative conversions was comparable, but more SILS cases required additional ports to be placed (p = 0.040). The intraoperative complications rate, complete total mesorectal excision rates, and lymph node yield were not statistically significantly different. There were no positive margins in either group. Postoperatively, groups had analogous day of return of bowel function, comparable morbidity, and discharge destination. There was no mortality in either group. The length of stay was significantly shorter with SP robotics than SILS (mean 4.135 vs. 5.282 days, median 4 (2-8) vs. 5 (2-14) days; p = 0.045).

CONCLUSIONS

Single-port robotics provided high quality oncologic surgery, adding the technical benefits of robotics to clinical and cosmetic benefits of single-port surgery. There were comparable operative time, complication rates, and oncologic outcomes in CRC cases, with shorter hospital stays with SP robotics. This early data is encouraging for expansion SP robotic technology.

Optimization of treatment strategies based on preoperative imaging features and local recurrence areas for locally advanced lower rectal cancer after lateral pelvic lymph node dissection

Purpose

Local recurrence (LR) is the main cause of treatment failure in locally advanced lower rectal cancer (LALRC). This study evaluated the preoperative risk factors for LR in patients with LALRC to improve the therapeutic strategies.

Patients and Methods

LALRC patients who underwent total mesorectal excision (TME) with lateral pelvic lymph node (LPN) dissection (LPND) from January 2012 to December 2019 were reviewed. The log-rank test was used to assess local recurrence-free survival (LRFS), and multivariate Cox regression was used to identify the prognostic risk factors for LRFS. Follow-up imaging data were used to classify LR according to the location.

Results

Overall, 376 patients were enrolled, and 8.8% (n=33) of these patients developed LR after surgery. Multivariate analysis identified positive clinical circumferential resection margin (cCRM) as an independent prognostic factor for LRFS (HR: 4.94; 95% CI, 1.75-13.94; P=0.003). The most common sites for LR were the pelvic plexus and internal iliac area (PIA) (54.5%), followed by the central pelvic area (CPA) (39.4%) and obturator area (OA) (6.1%). Following a subgroup analysis, LR in the OA was not associated with positive cCRM. Patients treated with upfront surgery (n=35, 14.1%) had a lower cCRM positive rate when compared with patients treated with neoadjuvant chemoradiotherapy (nCRT) (n=12, 23.5%). However, the LR rate in the nCRT group was still lower (n=28, 36.4%) than that in the upfront surgery group (n=35, 14.%). Among patients with positive cCRM, the LR rate in patients with nCRT remained low (n=3, 10.7%).

Conclusion

Positive cCRM is an independent risk factor for LR after TME plus LPND in LALRC patients. LPND is effective and adequate for local control within the OA regardless of cCRM status. However, for LALRC patients with positive cCRM, nCRT should be considered before LPND to further reduce LR in the PIA and CPA.

Impact of laparoscopic versus open surgery on humoral immunity in patients with colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery (LS) is hypothesized to result in milder proinflammatory reactions due to less severe operative trauma, which may contribute to the observed clinical benefits after LS. However, previous systematic reviews and meta-analyses on the impact of LS on immunocompetence are outdated, limited and heterogeneous. Therefore, the humoral response after laparoscopic and open colorectal cancer (CRC) resections was evaluated in a comprehensive systematic review and meta-analysis.

METHODS

Included were randomized controlled trials (RCTs) measuring parameters of humoral immunity after LS compared to open surgery (OS) in adult patients with CRC of any stage. MEDLINE, Embase, Web of Science (SCI-EXPANDED), Cochrane Library, Google Scholar, ClinicalTrials.gov and ICTRP (World Health Organization) were systematically searched. Risk of bias (RoB) was assessed using the Cochrane RoB2 tool. Weighted inverse variance meta-analysis of mean differences was performed for C-reactive protein (CRP), interleukin (IL)-6, IL-8, tumour necrosis factor (TNF)α and vascular endothelial growth factor (VEGF) using the random-effects method. Methods were prospectively registered in PROSPERO (CRD42021264324).

RESULTS

Twenty RCTs with 1131 participants were included. Narrative synthesis and meta-analysis up to 8 days after surgery was performed. Quantitative synthesis found concentrations to be significantly lower after LS at 0-2 h after surgery (IL-8), at 3-9 h (CRP, IL-6, IL-8, TNFα) and at postoperative day 1 (CRP, IL-6, IL-8, VEGF). At 3-9 h, IL-6 was notably lower in the LS group by 86.71 pg/ml (mean difference [MD] - 86.71 pg/ml [- 125.05, - 48.37], p < 0.00001). Combined narratively, 13 studies reported significantly lower concentrations of considered parameters in LS patients, whereas only one study reported lower inflammatory markers (for CRP and IL-6) after OS.

CONCLUSION

The increase in postoperative concentrations of several proinflammatory parameters was significantly less pronounced after LS than after OS in this meta-analysis. Overall, the summarized evidence reinforces the view of a lower induction of inflammation due to LS.

Oncological right hemicolectomy in a trimodal comparison: open surgery versus laparoscopic procedures with extra- and intracorporeal anastomosis technique

PURPOSE

This study aimed to investigate the surgical short- and mid-term outcomes, as well as the impact on quality of life and recovery, following oncological right hemicolectomy. To accomplish this, three patient cohorts were examined, which included laparotomy OA), laparoscopy with intracorporeal anastomosis (LIA), and laparoscopy with extracorporeal anastomosis (LEA). Our hypothesis was that the group undergoing intracorporeal anastomosis would demonstrate superior outcomes compared to the other cohorts.

METHODS

The analysis included a total of 135 patients who were enrolled between 2015 and 2020. In addition to retrospectively collected data, we conducted follow-up surveys using a validated Gastrointestinal Quality of Life Index (GIQLI) questionnaire and semi-structured interviews. These surveys were conducted between July and September 2021 to gather comprehensive information regarding the patients' quality of life.

RESULTS

The study cohort was divided into OA (n = 67), LEA (n = 14), and LIA (n = 54). The duration of surgery was significantly longer in the laparoscopic groups (median = 200.5 (LEA) and 184.0 (LIA) min vs 170.0 min (OA); p = 0.007), while the length of hospital stay was significantly shorter (median = 6.0 and 7.0 days vs 9.0 days; p = 0.005). The overall postoperative complication rate was significantly higher in the laparotomy group compared to the intracorporeal group (64.2% vs 35.2%; p = 0.006), with the extracorporeal group having a rate of 42.9%. Reoperation within 30 days occurred exclusively in the open surgery group (n = 9; 13.43%; p = 0.007). The overall response rate to the survey was 75%. Overall, the GIQLI score was comparable among the three groups, and there were no significant differences in the questions related to recovery, regained function, and contentment.

CONCLUSION

The laparoscopic approaches demonstrated significantly lower complication rates compared to laparotomy, while no significant differences were observed between the two laparoscopic techniques.

Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England

BACKGROUND

Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity.

METHODS

Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis.

RESULTS

A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS.

CONCLUSIONS

MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.

Laparoscopic radical surgery for locally advanced T4 transverse colon cancer and prognostic factors analysis: Evidence from multi-center databases

The safety and efficacies of laparoscopic radical procedures are still controversial for locally advanced pathological T4 (pT4) TCC (transverse colon cancer). Therefore, the aim of this study is to evaluate the oncologic and perioperative outcomes and to recognize the prognostic factors in radical resection for pT4 TCC derived from multi-center databases. 314 patients with TCC who underwent radical resection between January 2004 and May 2017, including 139 laparoscopic resections and 175 open resections, were extracted from multicenter databases. Oncological as well as perioperative outcomes were investigated. The baseline characteristics of the 2 groups did not differ significantly. Nevertheless, the laparoscopic technique was found to be linked with a significantly longer duration of surgery (208.96 vs 172.89 minutes, P = .044) and a significantly shorter postoperative hospital stay (12.23 vs 14.48 days, P = .014) when compared to the conventional open approach. In terms of oncological outcomes, lymph node resection (16.10 vs 13.66, P = .886), 5-year overall survival (84.7% vs 82.7%, P = .393), and disease-free survival (82.7% vs 83.9%, P = .803) were similar between the 2 approaches. Based on multivariate analysis, it was determined that differentiation and N classification were both independent prognostic factors for overall survival. However, it was found that only N classification was an independent prognostic factor for disease-free survival. These findings underscore the significance of differentiation and N classification as key determinants of patient outcomes in this context. Overall, the laparoscopic approach may offer advantages in terms of shorter hospital stays, while maintaining comparable oncological outcomes. Laparoscopic radical procedure can gain a couple of short-term benefits without reducing long-term oncological survival for patients with pT4 TCC.

Robotic and laparoscopic sphincter-saving resections have similar peri-operative, oncological and functional outcomes in female patients with rectal cancer

BACKGROUND

This study aimed to compare perioperative, long-term oncological, and anorectal functional outcomes of robotic total mesorectal excision (R-TME) and laparoscopic total mesorectal excision (L-TME) sphincter-saving total mesorectal excision in female patients with rectal cancer.

METHODS

Retrospective analysis of prospectively maintained database was performed. Sixty-eight cases (L-TME, n = 34; R-TME, n = 34) were performed by a single surgeon (January 2014-January 2019). Patient characteristics, perioperative recovery, postoperative complications, pathology results, and oncological outcomes were compared between the two groups.

RESULTS

Clinical characteristics did not differ between the groups. Mean operating time was longer in R-TME (165.50 ± 95.50 vs. 124.50 ± 82.60 min, p < 0.001). There was no conversion to open surgery in both groups. Mesorectal integrity was complete in both groups (100%). Length of distal and circumferential resection margins (CRM) did not differ between groups. CRM involvement was observed in 1 (2.8%) and 1 (2.8%) in L-TME and R-TME patients, respectively. Incidence of anastomotic leakage was 5.8% (n = 2) in L-TME and 8.8% (n = 3) in R-TME, respectively. Mean length of follow-up was 62.5 (36-102) months for R-TME and 63 (36-103) months for L-TME. Five-year overall survival rates were 92.8% in L-TME and 89.6% in R-TME. Disease-free survival rates were 87.5% in L-TME and 89.6% in R-TME. Local recurrence rates were 3.0% for both groups. Mean Wexner score for L-TME and R-TME patients was: 9.42 ± 8.23 and 9.22 ± 3.64 (p = 0.685), respectively. Daily stool frequency was similar between groups.

CONCLUSION

Robotic total mesorectal excision (R-TME) and laparoscopic TME (L-TME) have similar perioperative, oncological, and anorectal functional results in female patients with rectal cancer. The robotic approach for rectal cancers in female patients could be not as critical as for male patients.

Robotic natural orifice specimen extraction surgery (NOSES) for anterior resection

Minimally invasive colorectal surgery is currently well-accepted, with open techniques being reserved for very difficult cases. Laparoscopic colectomy has been proven to have lower mortality, complication, and ostomy rates; a shorter median length of stay; and lower overall costs when compared to its open counterpart. This trend is seen in both benign and malignant indications. Natural orifice specimen extraction surgery (NOSES) in colorectal surgery was first described in the early 1990s. Three recent meta-analyses comparing transabdominal extraction against NOSES concluded that NOSES was superior in terms of overall postoperative complications, recovery of gastrointestinal function, postoperative pain, aesthetics, and hospital stay. However, NOSES was associated with a longer operative time. Herein, we present our technique of robotic NOSES anterior resection using the da Vinci Xi platform in diverticular disease and sigmoid colon cancers.

A prospective phase II clinical trial/IDEAL Stage 2a series of single-port robotic colorectal surgery for abdominal and transanal cases

AIM

Slow laparoscopy adoption accelerated the uptake of robotic surgery. However, the current robotic platforms have limitations in transanal applications and multiple port sites. The da Vinci single-port (SP) robot is currently used on trial for colorectal surgery, and broad assessment of outcomes is needed. We aimed to report findings of a phase II clinical trial of SP robotic colorectal surgery.

METHODS

A sequentially reported prospective case series was performed on patients using SP robotics at a tertiary referral centre from 1 October 2018 to 31 August 2021. Cases were stratified into abdominal and transanal cohorts. Demographics, intra-operative variables and 30-day postoperative outcomes were evaluated. Univariate analysis was performed, with statistical process control for the docking process. Main outcomes were conversion rates, morbidity, mortality and point of standardization of docking.

RESULTS

In all, 133 patients were included: 93 (69.92%) abdominal and 40 (30.08%) transanal. The main diagnosis was rectal cancer (n = 59) and the procedure performed a robotic transanal abdominal transanal radical proctosigmoidectomy (n = 30). There were no conversions to open surgery. Two abdominal (2.15%) and three transanal cases (7.50%) were converted to laparoscopy. All colorectal adenocarcinomas had negative margins, proper lymph node harvest and complete mesorectal excision, as appropriate. Docking became a standardized process at cases 34 (abdominal) and 23 (anorectal). After surgery, bowel function returned on mean day 2 (abdominal) and 1 (transanal). The morbidity rate was 15.05% (abdominal) and 27.50% (transanal). There were two major morbidities in each cohort. Overall, there were three (2.65%) readmissions, one reoperation and no mortality.

CONCLUSIONS

Single-port robotics is feasible for all types of colorectal procedures, with good clinical and oncological outcomes. With this development in colorectal surgery, further studies can develop best practices with this novel technology.

Intracorporeal Versus Extracorporeal Colo-colic Anastomosis in Minimally-invasive Left Colectomy: a Systematic Review and Meta-analysis

PURPOSE

The primary aim was to investigate the operative outcomes of intracorporeal (IA) and extracorporeal (EA) anastomosis in left-sided minimally-invasive colectomy.

METHODS

A comprehensive literature search was conducted for studies comparing operative outcomes and follow-up data of IA versus EA in minimally-invasive left colectomy. Studies that investigated recto-sigmoid resections using transanal circular staplers were excluded. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios (ORs) and mean differences with 95 per cent confidence intervals were calculated.

RESULTS

Eight studies with a total of 750 patients were included (IA n = 335 versus EA n = 415). IA was associated with significantly lower overall morbidity (OR 0.40, 95% CI 0.26-0.61, p < 0.0001) and less frequent surgical site infection (SSI) (OR 0.27, 95% CI 0.12-0.61, p = 0.002) as primary outcomes compared to EA. Of the secondary outcomes, length of incision (SMD -2.51, 95% CI -4.21 to -0.81, p = 0.004), time to first oral diet intake (SMD -0.49, 95% CI -0.76 to -0.22, p = 0. 0004) and time to first bowel movement (SMD -0.40, 95% CI -0.71 to -0.09, p = 0.01) were significantly in favor of IA, while operative time was significantly shorter in the EA group (SMD 0.36, 95% CI 0.14-0.59, p = 0.001).

CONCLUSIONS

IA proves to be a safe and feasible option as it demonstrates benefits in terms of lower overall morbidity, fewer rates of SSI, smaller incision length, and faster postoperative gastrointestinal recovery despite a longer operative time compared to EA.

Short-term and long-term outcomes of single-incision plus one-port laparoscopic surgery for colorectal cancer: a propensity-matched cohort study with conventional laparoscopic surgery

BACKGROUND

Single-incision plus one-port laparoscopic surgery (SILS + 1) has been demonstrated to be minimally invasive while possessing better cosmesis and less pain compared with conventional laparoscopic surgery (CLS). However, SILS + 1 as an alternative to CLS for colorectal cancer is still controversial.

METHODS

A total of 1071 patients who underwent curative laparoscopic surgery for colon cancer between 2015 and 2018 were included. Of these patients, 258 SILS + 1 cases and 516 CLS cases were analyzed using propensity score matching. The baseline characteristics, surgical outcomes, pathologic findings and recovery course, morbidity and mortality within postoperative 30 days and 3-year disease-free and overall survival were compared.

RESULTS

Baseline characteristics were balanced between the groups. The mean operating time was significantly shorter in SILS + 1 group, with less estimated blood loss. Tumor size, tumor differentiation, number of harvested lymph nodes, resection margin and pathologic T, N, TNM stage was similar between the groups. There was no significant difference in overall perioperative complications. Uni- and multivariate analyses revealed that SILS + 1 was not a risk factor for complications. Postoperatively, SILS + 1 group showed faster recovery than CLS group in terms of ambulation, bowel function, oral intake and discharge. The 3-year disease-free survival rates of SILS + 1 and CLS groups were 90.1% and 87.3%(p = 0.59), respectively and the 3-year overall survival rates were 93.3% vs. 89.8%(p = 0.172).

DISCUSSION

Our study revealed that SILS + 1 is safe, feasible, oncologically efficient, and may be considered as a surgical option for selected patients with colorectal cancer.

Comparison of robotic-assisted versus conventional laparoscopic surgery in colorectal cancer resection: a systemic review and meta-analysis of randomized controlled trials

Introduction

There is still controversy on whether or not robot-assisted colorectal surgery (RACS) have advantages over laparoscopic-assisted colorectal surgery(LACS).

Materials and methods

The four databases (PubMed, Embase, Web of Science and Cochrane Library)were comprehensively searched for randomized controlled trials (RCTs) comparing the outcomes of RACS and LACS in the treatment of colorectal cancer from inception to 22 July 2023.

Results

Eleven RCTs were considered eligible for the meta-analysis. Compared with LACS,RACS has significantly longer operation time(MD=5.19,95%CI: 18.00,39.82, P<0.00001), but shorter hospital stay(MD=2.97,95%CI:-1.60,-0.33,P = 0.003),lower conversion rate(RR=3.62,95%CI:0.40,0.76,P = 0.0003), lower complication rate(RR=3.31,95%CI:0.64,0.89,P=0.0009),fewer blood loss(MD=2.71,95%CI:-33.24,-5.35,P = 0.007),lower reoperation rate(RR=2.12, 95%CI:0.33,0.96,P=0.03)and longer distal resection margin(MD=2.16, 95%CI:0.04,0.94, P = 0.03). There was no significantly difference in harvested lymph nodes, the time of first flatus, the time of first defecation,the time of first resume diet, proximal resection margin, readmission rates, mortalities and CRM+ rates between two group.

Conclusions

Our study indicated that RACS is a feasible and safe technique that can achieve better surgical efficacy compared with LACS in terms of short-term outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023447088.

Laparoscopic rectal cancer resection yields comparable clinical and oncological results with shorter hospital stay compared to open access: a 5-year national cohort

PURPOSE

Although widely applied, the results following laparoscopic rectal resection (LRR) compared to open rectal resection (ORR) are still debated. The aim of this study was to assess clinical short- and long-term results as well as oncological resection quality following LRR or ORR for cancer in a 5-year national cohort.

METHODS

Data from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry were retrieved from January 2014 to December 2018 for patients who underwent elective resection for rectal cancer. Primary end point was 5-year overall survival. Secondary end points were local recurrence rates within 5 years, oncological resection quality, and short-term outcome measures.

RESULTS

A total of 1796 patients were included, of whom 1284 had undergone LRR and 512 ORR. There was no difference in 5-year survival rates between the groups after adjusting for relevant covariates with Cox regression analyses. Crude 5-year survival was 77.1% following LRR compared to 74.8% following ORR (p = 0.015). The 5-year local recurrence rates were 3.1% following LRR and 4.1% following ORR (p = 0.249). Length of hospital stay was median 8.0 days (quartiles 7.0-13.0) after ORR compared to 6.0 (quartiles 4.0-8.0) days after LRR. After adjusting for relevant covariates, estimated additional length of stay after ORR was 3.1 days (p < 0.001, 95% CI 2.3-3.9). Rates of positive resection margins and number of harvested lymph nodes were similar. There were no other significant differences in short-term outcomes between the groups.

CONCLUSION

LRR was performed with clinical and oncological outcomes similar to ORR, but with shorter hospital stay.