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Ishizuka M, Shibuya N, Hachiya H, Nishi Y, Kono T, Takayanagi M, Nemoto T, Ihara K, Shiraki T, Matsumoto T, Mori S, Nakamura T, Aoki T, Mizushima T. 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. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108538. [PMID: 39053042 DOI: 10.1016/j.ejso.2024.108538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/14/2024] [Accepted: 07/07/2024] [Indexed: 07/27/2024]
Abstract
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.
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Affiliation(s)
- Mitsuru Ishizuka
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan.
| | - Norisuke Shibuya
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Hiroyuki Hachiya
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Yusuke Nishi
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takahiro Kono
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Masashi Takayanagi
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Tetsutaro Nemoto
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Keisuke Ihara
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takayuki Shiraki
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takatsugu Matsumoto
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Shozo Mori
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takatoshi Nakamura
- Department of Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Taku Aoki
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
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Flynn J, Larach JT, Kong JCH, Rahme J, Waters PS, Warrier SK, Heriot A. Operative and oncological outcomes after robotic rectal resection compared with laparoscopy: a systematic review and meta-analysis. ANZ J Surg 2023; 93:510-521. [PMID: 36214098 DOI: 10.1111/ans.18075] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most studies comparing robotic and laparoscopic surgery, show little difference in clinical outcomes to justify the expense. We systematically reviewed and pooled evidence from studies comparing robotic and laparoscopic rectal resection. METHOD Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), and Cochrane databases were searched for studies between 1996 and 2021 comparing clinical outcomes between laparoscopic and robotic rectal surgeries involving total mesorectal excision. Outcome measures included operative times, conversions to open, complications, recurrence and survival rates. RESULTS Fifty eligible studies compared outcomes between robotic and laparoscopic rectal resections; three were randomized trials. Pooled results showed significantly longer operating times for robotic surgery but lower conversion and complications rates, shorter lengths of stay in hospital, better rates of complete mesorectal resection and better three-year overall survival. However, the low number of randomized studies makes most data subject to bias. CONCLUSION Available evidence supports the safety and ongoing use of robotic rectal cancer surgery, while further high-quality evidence is sought to justify the expense.
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Affiliation(s)
- Julie Flynn
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jose T Larach
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Departamento de Cirugía Digestiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joseph C H Kong
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jessica Rahme
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- General Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Peadar S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Department of Surgery, Epworth Healthcare, Richmond, Victoria, Australia
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of post graduate studies, University of Melbourne, Parkville, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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3
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Woelfel I, Wang T, Pieper H, Meara M, Chen XP. Distortions in the Balance Between Teaching and Efficiency in the Operating Room. J Surg Res 2023; 283:110-117. [PMID: 36402083 DOI: 10.1016/j.jss.2022.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 08/20/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The balance between teaching and operative efficiency (i.e., continuing operative case progression) is difficult for even the most experienced master surgeon educators. The purpose of this study was to explore influencing factors behind attending surgeons' decisions to break the balance between operative efficiency and teaching in the operating room. METHODS Semistructured interviews were conducted with surgeons across the United States via Web-based video conferencing. The interviews were audio-recorded and transcribed. Qualitative analysis using the framework method was utilized, and emergent themes were identified. RESULTS Twenty-three attending surgeons from 8 academic institutions and 11 surgical specialties completed interviews (14 men and 9 women). Attending surgeons consider a variety of factors associated with their dual roles (surgeon versus teacher) when balancing operative efficiency and providing appropriate independence for residents with oversight to promote autonomy. These were divided into surgeon-role-related factors (patient safety, financial factors, scheduling factors, preservation of faculty reputation for efficiency, and mode of operation) as well as teacher-role-related factors (preparation, level, and technical skill of the resident). These factors then informed attending surgeons' determinations about how the case was progressing, which prompted them to intervene and reduce resident autonomy or allow the resident to continue. CONCLUSIONS Surgeons consider numerous factors when deciding how to balance resident teaching and autonomy while preserving operative efficiency. These findings provide helpful insights for surgical departments to consider inclusion in faculty-development programs, resident education, and systematic improvements.
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Affiliation(s)
- Ingrid Woelfel
- Department of Surgery, Ohio State University, Columbus, Ohio.
| | - Theresa Wang
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Heidi Pieper
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Michael Meara
- Department of Surgery, Ohio State University, Columbus, Ohio
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Somashekhar SP, Saklani A, Dixit J, Kothari J, Nayak S, Sudheer OV, Dabas S, Goud J, Munikrishnan V, Sugoor P, Penumadu P, Ramachandra C, Mehendale S, Dahiya A. Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer. Front Oncol 2022; 12:1002530. [PMID: 36267970 PMCID: PMC9577482 DOI: 10.3389/fonc.2022.1002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework. Conclusion The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.
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Affiliation(s)
- S. P. Somashekhar
- Department of Surgical Oncology, Manipal Hospital, Bengaluru, Karnataka, India
- *Correspondence: S. P. Somashekhar,
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jagannath Dixit
- Department of GI Surgery, HCG Hospital, Bengaluru, Karnataka, India
| | - Jagdish Kothari
- Department of Surgical Oncology HCG Hospital, Ahmedabad, Gujarat, India
| | - Sandeep Nayak
- Department of Surgical Oncology, Fortis Hospital, Bengaluru, Karnataka, India
| | - O. V. Sudheer
- Department of GI Surgery and Surgical Oncology, Amrita Institute of Medical Science, Kochi, Kerala, India
| | - Surender Dabas
- Department of Surgical Oncology, BL Kapur-Max Superspeciality Hospital, Delhi, India
| | - Jagadishwar Goud
- Department of Surgical Oncology, AOI Hospital, Hyderabad, Telangana, India
| | | | - Pavan Sugoor
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - C. Ramachandra
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Shilpa Mehendale
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Akhil Dahiya
- Department of Clinical and Medical Affairs, Intuitive Surgical, California, CA, United States
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5
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Morohashi H, Sakamoto Y, Miura T, Ichinohe D, Kubota S, Yamazaki K, Ichisawa A, Mitsuhashi Y, Wakiya T, Hakamada K. Short-term outcomes of robotic-assisted surgery following neoadjuvant chemotherapy for lower rectal cancer. Asian J Endosc Surg 2022; 15:577-584. [PMID: 35304815 DOI: 10.1111/ases.13055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There have been reports about robotic surgery for rectal cancer with chemoradiotherapy (CRT), but only a few studies have compared the use of robotic surgery with and without neoadjuvant chemotherapy (NAC). The aim of our study was to compare the perioperative outcomes of robotic surgery with and without NAC for lower rectal cancer and to examine the effects of NAC on robotic surgery. METHODS From January 2016 to July 2021, we compared the short-term outcomes of 45 patients who did not undergo NAC and 55 patients who underwent NAC. RESULTS The rate of sphincter-preserving surgeries was higher in the NAC group than in the non-NAC group (P = .024). The total operative time was significantly longer in the NAC group than in the non-NAC group (P < .001). The rate of lateral lymph node dissection was significantly higher in the NAC group than in the non-NAC group (P < .001). No significant differences were identified in the rate of incisional surgical site infections (SSI), organ/space SSI postoperative bleeding, small bowel obstruction, anastomotic leakage, urinary dysfunction, or urinary infections between the groups. There were eight incidences of lateral lymph node metastasis (15%) and two cases with positive resection margins (4.0%) in the NAC group. CONCLUSIONS Robotic surgery after NAC has few complications and a higher sphincter-preserving rate that without NAC.
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Affiliation(s)
- Hajime Morohashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Takuya Miura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Daichi Ichinohe
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Shunsuke Kubota
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Keisuke Yamazaki
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Aika Ichisawa
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuto Mitsuhashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
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Robotic-Assisted vs. Standard Laparoscopic Surgery for Rectal Cancer Resection: A Systematic Review and Meta-Analysis of 19,731 Patients. Cancers (Basel) 2021; 14:cancers14010180. [PMID: 35008344 PMCID: PMC8750860 DOI: 10.3390/cancers14010180] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Surgery remains a mainstay of combined modality treatment at patients with rectal cancer; however, there is a growing interest in using laparoscopic techniques (LG); including robotic-assisted techniques (RG). Therefore, we have prepared a meta-analysis of the literature regarding the safety and efficacy of robotic versus laparoscopic approaches in patients undergoing curative surgery for rectal cancer. The results indicate a number of advantages of RG in terms of both safety and efficacy. Operative time in the RG group was shorter and associated with a statistically significantly lower conversion of the procedure to open surgery. RG technique provided a shorter duration of hospital stay and lowered urinary risk retention. No differences were found between these techniques regarding TNM stage; N stage or lymph nodes harvested. Survival to hospital discharge or 30-day overall survival rate was 99.6% in RG vs. 98.8% for LG. Abstract Robotic-assisted surgery is expected to have advantages over standard laparoscopic approach in patients undergoing curative surgery for rectal cancer. PubMed, Cochrane Library, Web of Science, Scopus and Google Scholar were searched from database inception to 10 November 2021, for both RCTs and observational studies comparing robotic-assisted versus standard laparoscopic surgery for rectal cancer resection. Where possible, data were pooled using random effects meta-analysis. Forty-Two were considered eligible for the meta-analysis. Survival to hospital discharge or 30-day overall survival rate was 99.6% for RG and 98.8% for LG (OR = 2.10; 95% CI: 1.00 to 4.43; p = 0.05). Time to first flatus in the RG group was 2.5 ± 1.4 days and was statistically significantly shorter than in LG group (2.9 ± 2.0 days; MD = −0.34; 95%CI: −0.65 to 0.03; p = 0.03). In the case of time to a liquid diet, solid diet and bowel movement, the analysis showed no statistically significant differences (p > 0.05). Length of hospital stay in the RG vs. LG group varied and amounted to 8.0 ± 5.3 vs. 9.5 ± 10.0 days (MD = −2.01; 95%CI: −2.90 to −1.11; p < 0.001). Overall, 30-days complications in the RG and LG groups were 27.2% and 19.0% (OR = 1.11; 95%CI: 0.80 to 1.55; p = 0.53), respectively. In summary, robotic-assisted techniques provide several advantages over laparoscopic techniques in reducing operative time, significantly lowering conversion of the procedure to open surgery, shortening the duration of hospital stay, lowering the risk of urinary retention, improving survival to hospital discharge or 30-day overall survival rate.
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Haddad P, Ghalehtaki R, Saeedian A, Farhan F, Babaei M, Aghili M. Current approaches in intensification of long-course chemoradiotherapy in locally advanced rectal cancer: a review. Radiat Oncol J 2021; 39:83-90. [PMID: 34619824 PMCID: PMC8497854 DOI: 10.3857/roj.2021.00108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/01/2021] [Indexed: 12/24/2022] Open
Abstract
Rectal cancer is one of the most prevalent cancers in the world. In many countries, the current standard of care is long-course chemoradiation (CRT), followed by total mesorectal excision. Some efforts have been made by intensifying radiation or chemotherapy components of the neoadjuvant therapy to further decrease the local recurrence and augment surgery’s feasibility and improve the oncological outcomes. This paper reviews recent intensified neoadjuvant interventions in locally advanced rectal cancer (LARC) in terms of efficacy and treatment-related toxicity. Many maneuvers have been made so far to improve the oncological outcomes of rectal cancer with intensified neoadjuvant long-course CRT. Some of these approaches seem compelling and deserve further study, while some have just increased the treatment-related toxicities without evident benefits. Those endeavors with greater pathological complete response than the standard of care may make us await the long-term results on survival rates and chronic treatment-related toxicity. After introduction of neoadjuvant CRT for LARC there have been many efforts to improve its outcomes. Here, this study gathered most of these efforts that intensified the neoadjuvant therapy with some being promising and some being futile.
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Affiliation(s)
- Peiman Haddad
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Arefeh Saeedian
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshid Farhan
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Babaei
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Aghili
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Laparoscopic intersphincteric resection with hand-sewn coloanal anastomosis in the treatment of low rectal cancer: 10-year experience. Eur Surg 2021. [DOI: 10.1007/s10353-021-00694-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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9
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Hoshino N, Sakamoto T, Hida K, Takahashi Y, Okada H, Obama K, Nakayama T. Difference in surgical outcomes of rectal cancer by study design: meta-analyses of randomized clinical trials, case-matched studies, and cohort studies. BJS Open 2021; 5:6173855. [PMID: 33724337 PMCID: PMC7962725 DOI: 10.1093/bjsopen/zraa067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/07/2020] [Indexed: 02/01/2023] Open
Abstract
Background RCTs are considered the standard in surgical research, whereas case-matched studies and propensity score matching studies are conducted as an alternative option. Both study designs have been used to investigate the potential superiority of robotic surgery over laparoscopic surgery for rectal cancer. However, no conclusion has been reached regarding whether there are differences in findings according to study design. This study aimed to examine similarities and differences in findings relating to robotic surgery for rectal cancer by study design. Methods A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane CENTRAL to identify RCTs, case-matched studies, and cohort studies that compared robotic versus laparoscopic surgery for rectal cancer. Primary outcomes were incidence of postoperative overall complications, incidence of anastomotic leakage, and postoperative mortality. Meta-analyses were performed for each study design using a random-effects model. Results Fifty-nine articles were identified and reviewed. No differences were observed in incidence of anastomotic leakage, mortality, rate of positive circumferential resection margins, conversion rate, and duration of operation by study design. With respect to the incidence of postoperative overall complications and duration of hospital stay, the superiority of robotic surgery was most evident in cohort studies (risk ratio (RR) 0.83, 95 per cent c.i. 0.74 to 0.92, P < 0.001; mean difference (MD) –1.11 (95 per cent c.i. –1.86 to –0.36) days, P = 0.004; respectively), and least evident in RCTs (RR 1.12, 0.91 to 1.38, P = 0.27; MD –0.28 (–1.44 to 0.88) days, P = 0.64; respectively). Conclusion Results of case-matched studies were often similar to those of RCTs in terms of outcomes of robotic surgery for rectal cancer. However, case-matched studies occasionally overestimated the effects of interventions compared with RCTs.
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Affiliation(s)
- N Hoshino
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - T Sakamoto
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - K Hida
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Y Takahashi
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - H Okada
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - K Obama
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - T Nakayama
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Kumar NA, Sasi SP, Shinde RS, Verma K, Sugoor P, Desouza A, Engineer R, Saklani A. Minimally Invasive Surgery for Pelvic Exenteration in Primary Colorectal Cancer. JSLS 2021; 24:JSLS.2020.00026. [PMID: 32714002 PMCID: PMC7347395 DOI: 10.4293/jsls.2020.00026] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Minimally invasive surgery (MIS) for pelvic exenteration is not a well-established technique. The aim was to assess the safety and feasibility of MIS for pelvic exenteration in locally advanced primary colorectal cancer and to compare the perioperative outcomes with open surgery. Methods: This is a retrospective analysis of patients, who had undergone pelvic exenteration for primary colorectal adenocarcinoma from May 2013 to July 2018. The short-term outcomes like perioperative details and histopathological characteristics were compared between the two groups. Results: MIS was performed in 23 patients and open pelvic exenteration was carried out in 72 patients. The mean operative time was significantly more in the MIS group (640 vs. 432 min, p = 0.00). The intraoperative blood loss (900 vs. 1550 ml, p = 0.00) and the requirement for blood transfusion (170 vs. 250 ml, p = 0.03) was significantly less in the MIS group. The overall morbidity (60% vs. 49%, p = 0.306) was comparable between the two groups. The median length of hospital stay in the MIS group was 11 d, compared to 12 d in the open surgery group, (p = 0.634). The rate of R0 resection (87% vs. 89%, p = 0.668) was comparable between the two groups. Conclusion: MIS is feasible and safe for total pelvic exenteration and posterior exenteration in carefully selected locally advanced primary colorectal cancer, when performed by an experienced surgical team in high volume centers. An R0 resection with adequate margin can be achieved with good perioperative outcomes in MIS. Long-term oncological outcomes would require further follow up to confirm.
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Affiliation(s)
- Naveena An Kumar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Care Center, Kasturba Medical College, Manipal Academy of Higher Education
| | - Sajith P Sasi
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Rajesh S Shinde
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Kamlesh Verma
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Pavan Sugoor
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Ashwin Desouza
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Reena Engineer
- Department Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Avanish Saklani
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
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Gavriilidis P, Wheeler J, Spinelli A, de'Angelis N, Simopoulos C, Di Saverio S. Robotic vs laparoscopic total mesorectal excision for rectal cancers: has a paradigm change occurred? A systematic review by updated meta-analysis. Colorectal Dis 2020; 22:1506-1517. [PMID: 32333491 DOI: 10.1111/codi.15084] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 03/05/2020] [Indexed: 12/30/2022]
Abstract
AIM The debate about the oncological adequacy, safety and efficiency of robotic vs laparoscopic total mesorectal excision for rectal cancers continues. Therefore, an updated, traditional and cumulative meta-analysis was performed with the aim of assessing the new evidence on this topic. METHOD A systematic search of the literature for data pertaining to the last 25 years was performed. Fixed- and random-effects models were used to cumulatively assess the accumulation of evidence over time. RESULTS Patients with a significantly higher body mass index (BMI), tumours located approximately 1 cm further distally and more patients undergoing neoadjuvant therapy were included in the robotic total mesorectal excision (RTME) cohort compared with those in the laparoscopic total mesorectal excision (LTME) cohort [RTME, mean difference (MD) = 0.22 (0.07, 0.36), P = 0.005; LTME, MD = -0.97 (-1.57, 0.36), P < 0.002; OR = 1.47 (1.11, 1.93), P = 0.006]. Significantly lower conversion rates to open surgery were observed in the RTME cohort than in the LTME cohort [OR = 0.33 (0.24, 0.46), P < 0.001]. Operative time in the LTME cohort was significantly reduced (by 50 min) compared with the RTME cohort. Subgroup analysis of the three randomized controlled trials (RCTs) challenged all the significant results of the main analysis and demonstrated nonsignificant differences between the RTME cohort and LTME cohort. CONCLUSION Although the RTME cohort included patients with a significantly higher BMI, more distal tumours and more patients undergoing neoadjuvant therapy, this cohort demonstrated lower conversion rates to open surgery when compared with the LTME cohort. However, subgroup analysis of the RCTs demonstrated nonsignificant differences between the two procedures.
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Affiliation(s)
- P Gavriilidis
- Division of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - J Wheeler
- Colorectal Surgery Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - A Spinelli
- Department of Biomedical Sciences, Humanitas University, Rozzano Milano, Italy.,Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Rozzano Milano, Italy
| | - N de'Angelis
- Department of Digestive Surgery, AP-HP, University Hospital Henri Mondor, Créteil, France.,University Paris Est, Créteil, France
| | - C Simopoulos
- 2nd Department of Surgery, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - S Di Saverio
- Colorectal Surgery Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.,Department of General Surgery, ASST Sette Laghi, University of Insubria, University Hospital of Varese, Regione Lombardia, Italy
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Wang Y, Liu Y, Han G, Yi B, Zhu S. The severity of postoperative complications after robotic versus laparoscopic surgery for rectal cancer: A systematic review, meta-analysis and meta-regression. PLoS One 2020; 15:e0239909. [PMID: 33002066 PMCID: PMC7529204 DOI: 10.1371/journal.pone.0239909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023] Open
Abstract
Objective Robotic surgery (RS) has been increasingly used for the resection of rectal cancer, and its advantages over laparoscopic surgery (LS) have been demonstrated. However, few studies focused on the severity of postoperative complications. This study aimed to compared the postoperative complications within 30 days after RS over LS according to the Clavien-Dindo (C-D) classification. Methods A literature research of PubMed, Embase, Cochrane Library and Web of Science were systematically performed. The studies comparing the complications of RS and LS for rectal cancer based on the C-D classification were enrolled. Primary outcomes were C-D grade III, IV, V, III-V (severe complications). Results Seventeen studies (3193 patients) were included in the final analysis: 1554 underwent RS and 1639 underwent LS. The RS group was associated with significantly lower rates of severe complications (OR = 0.69, 95% CI 0.53–0.90, P = 0.005), C-D grade IV (OR = 0.69, 95% CI 0.53–0.90, P = 0.005), and anastomotic leak (OR = 0.66, 95% CI 0.48–0.91, P = 0.01). There was no significant difference in C-D grade III, C-D grade I, II, I-II (minor complications), overall complications, bleeding, wound complications, postoperative ileus, urinary retention, readmission, reoperation between two groups. Conclusions Robotic surgery is safe for rectal cancer and may be an effective alternative to laparoscopic surgery, with lower rates of severe complications, C-D grade IV, and anastomotic leak. Further large randomized controlled trials are necessary to confirm this conclusion.
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Affiliation(s)
- Yanlei Wang
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yanfei Liu
- School of Nursing, Capital Medical University, You An Men, Beijing, China
| | - Gaoyang Han
- Department of Thoracic Surgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Henan, China
| | - Bo Yi
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- * E-mail: (SZ); (BY)
| | - Shaihong Zhu
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- * E-mail: (SZ); (BY)
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