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Brock H, Lambrineas L, Ong HI, Chen WY, Das A, Edsell A, Proud D, Carrington E, Smart P, Mohan H, Burgess A. Preventative strategies for low anterior resection syndrome. Tech Coloproctol 2023; 28:10. [PMID: 38091118 DOI: 10.1007/s10151-023-02872-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/11/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly understood and challenging to treat. Despite this, prevention strategies are commonly overlooked. Our aim was to review the pathophysiology of LARS and explore current evidence on the efficacy and feasibility of prophylactic techniques. METHODS A literature review was performed between [1st January 2000 to 1st October 2023] for studies which investigated preventative interventions for LARS. Mechanisms by which LARS develop are described, followed by a review of prophylactic strategies to prevent LARS. Medline, Cochrane, and PubMed databases were searched, 189 articles screened, 8 duplicates removed and 18 studies reviewed. RESULTS Colonic dysmotility, anal sphincter dysfunction and neorectal dysfunction all contribute to the development of LARS, with the complex mechanism of defecation interrupted by surgery. Transanal irrigation (TAI) and pelvic floor rehabilitation (PFR) have shown benefits in preventing LARS, but may be limited by patient compliance. Intraoperative nerve monitoring (IONM) and robotic-assisted surgery have shown some promise in surgically preventing LARS. Nerve stimulation and other novel strategies currently used in treatment of LARS have yet to be investigated in their roles prophylactically. CONCLUSIONS To date, there is a limited evidence base for all preventative strategies including IONM, RAS, PFP and TAI. These strategies are limited by either access (IONM, RAS and PFP) or acceptability (PFP and TAI), which are both key to the success of any intervention. The results of ongoing trials will serve to assess acceptability, while technological advancement may improve access to some of the aforementioned strategies.
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Affiliation(s)
- H Brock
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Western General, Melbourne, Australia
| | - L Lambrineas
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - H I Ong
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia.
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia.
| | - W Y Chen
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - A Das
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - A Edsell
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - D Proud
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | | | - P Smart
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - H Mohan
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - A Burgess
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
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Li R, Zhou J, Zhao S, Sun Q, Wang D. Propensity matched analysis of robotic and laparoscopic operations for mid-low rectal cancer: short-term comparison of anal function and oncological outcomes. J Robot Surg 2023; 17:2339-2350. [PMID: 37402961 DOI: 10.1007/s11701-023-01656-1] [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: 05/10/2023] [Accepted: 06/17/2023] [Indexed: 07/06/2023]
Abstract
Laparoscopic surgery for rectal cancer, while in some respects equivalent or even preferable to open surgery, is challenged in specific conditions where the tumor is located in the middle and lower third of the rectum. Robotic surgery equipped with a superior arm of machinery and gained better visualization can compensate for the deficiency of the laparoscopic approach. This study adopted a propensity matched analysis to compare the functional and oncological short-term outcomes of laparoscopic and robotic surgery. All patients who underwent proctectomy have been collected prospectively between December 2019 and November 2022. After censoring for inclusion criteria, we performed a propensity matching analysis. A detailed collection of post-operative examination indicators was performed, while the K-M survival curves were plotted to analyze post-operative oncology outcomes. The LARS scale was designed to evaluate the anal function of patients in the form of questionnaires. Totally, 215 patients underwent robotic operations while 1011 patients selected laparoscopic operations. Patients matched 1∶1 by propensity score were divided into the robotic and laparoscopic groups, 210 cases were included in each group. All patients underwent a follow-up for a median period of 18.3 months. Robotic surgery was connected with an enhanced recovery including the earlier time to first flatus passage without ileostomy (P = 0.050), the earlier time to liquid diet without ileostomy (P = 0.040), lower incidence of urinary retention (P = 0.043), better anal function 1 month after LAR without ileostomy (P < 0.001), longer operative time (\P = 0.042), compared with laparoscopic operations. The oncological outcomes and occurrence of other complications were comparable between the two approaches. For mid-low rectal cancer, robotic surgery could be recognized as an effective technique with identical short-term outcomes of oncology and better anal function in comparison to laparoscopic surgery. However, multi-center studies with larger samples are expected to validate the long-term outcomes of robotic surgery.
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Affiliation(s)
- Ruiqi Li
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Jiajie Zhou
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Shuai Zhao
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Qiannan Sun
- Northern Jiangsu People's Hospital, Yangzhou, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Daorong Wang
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China.
- Northern Jiangsu People's Hospital, Yangzhou, China.
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China.
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Ye SP, Yu HX, Liu DN, Lu WJ, Wu C, Xu HC, Li TY. Comparison of robotic-assisted and laparoscopic-assisted natural orifice specimen extraction surgery in short-terms outcomes of middle rectal cancer. World J Surg Oncol 2023; 21:196. [PMID: 37403084 DOI: 10.1186/s12957-023-03083-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/17/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Surgery is becoming less invasive as technology advances. Natural orifice specimen extraction surgery (NOSES) ushered in a new era of minimally invasive techniques. At the same time, NOSES is gaining popularity in the world. With their distinct advantages, surgical robots have advanced the development of NOSES. The aim of current study was to compare the short-term outcomes between robotic-assisted NOSES and laparoscopic-assisted NOSES for the treatment of middle rectal cancer. METHODS Patients with middle rectal cancer who underwent robotic-assisted or laparoscopic-assisted NOSES at the First Affiliated Hospital of Nanchang University between January 2020 and June 2022 had their clinicopathological data collected retrospectively. 46 patients were enrolled in the study: 23 in the robotic group and 23 in the laparoscopic group. Short-term outcomes and postoperative anal function in the two groups were compared. RESULTS There was no significant difference in the clinicopathological data between the two groups. The robotic group had less intraoperative blood loss (p = 0.04), less postoperative abdominal drainage (p = 0.02), lower postoperative white blood cell counts (p = 0.024) and C-reactive protein levels (p = 0.017), and shorter catheter removal time when compared to the laparoscopic group (p = 0.003). Furthermore, there were no significant difference in mean operative time (159 ± 31 min vs 172 ± 41 min) between the robotic and laparoscopic groups (p = 0.235), but time to naked the rectum (86.4 ± 20.9 min vs. 103.8 ± 31.5 min p = 0.033) and time of digestive tract reconstruction (15.6 ± 3.88 min vs. 22.1 ± 2.81 min p < 0.01) in the robotic group were significantly shorter than laparoscopic group. The robotic group had lower postoperative Wexner scores than the laparoscopic group. CONCLUSIONS This research reveals that combining a robotic surgical system and NOSES results in superior outcomes, with short-term outcomes preferable to laparoscopic-assisted NOSES.
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Affiliation(s)
- Shan-Ping Ye
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Hong-Xin Yu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Dong-Ning Liu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Wei-Jie Lu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Can Wu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Hao-Cheng Xu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Tai-Yuan Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China.
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„Low anterior resection syndrome“ (LARS) in Zahlen. COLOPROCTOLOGY 2023. [DOI: 10.1007/s00053-022-00674-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Yang B, Zhang S, Yang X, Wang Y, Li D, Zhao J, Li Y. Analysis of bowel function, urogenital function, and long-term follow-up outcomes associated with robotic and laparoscopic sphincter-preserving surgical approaches to total mesorectal excision in low rectal cancer: a retrospective cohort study. World J Surg Oncol 2022; 20:167. [PMID: 35624511 PMCID: PMC9137207 DOI: 10.1186/s12957-022-02631-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 05/10/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The present study comparatively analyzed short-term clinical effectiveness and long-term follow-up endpoints associated with robotic-assisted sphincter-preserving surgery (RAS) and laparoscopic-assisted sphincter-preserving surgery (LAS) when used to treat low rectal cancer. METHOD Within such a single-center retrospective cohort analysis, low rectal cancer patients that underwent RAS (n=200) or LAS (n=486) between January 2015 and beginning of July 2018 were enrolled. RESULTS The mean operative durations in the RAS and LAS cohorts were 249±64 min and 203±47 min, respectively (P<0.001). Temporary ileostomy rates in the RAS and LAS cohorts were 64.5% and 51.6% (P = 0.002). In addition, major variations across such cohorts regarding catheter removal timing, time to liquid intake, time to first leaving bed, and length of hospitalization (all P<0.001). This distal resection margin distance within the RAS cohort was diminished in comparison to LAS cohort (P=0.004). For patients within the LAS cohort, the time required to recover from reduced urinary/female sexual function was > 6 months post-surgery (P<0.0001), whereas within the RAS cohort this interval was 3 months (P<0.0001). At 6 months post-surgery, male sexual function within RAS cohort was improved in comparison to LAS cohort (P<0.001). At 6 months post-surgery, Wexner scores revealed similar results (P<0.001). No major variations within overall or disease-free survival were identified across these cohorts at 3 or 5 years post-surgery. CONCLUSION Robotic sphincter-preserving surgery is a safe and effective surgical technique in low rectal patients in terms of postoperative oncological safety and long-term endpoints. And the RAS strategy provides certain additional benefits with respect to short-term urogenital/anorectal functional recovery in treated patients compared to LAS.
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Affiliation(s)
- Bo Yang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, China
| | - Shangxin Zhang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, China
| | - Xiaodong Yang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, China
| | - Yigao Wang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, China
| | - Deguan Li
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, China
| | - Jian Zhao
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, China
| | - Yongxiang Li
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, China.
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Robotic Surgery in Rectal Cancer: Potential, Challenges, and Opportunities. Curr Treat Options Oncol 2022; 23:961-979. [PMID: 35438444 PMCID: PMC9174118 DOI: 10.1007/s11864-022-00984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/09/2022]
Abstract
The current standard treatment for locally advanced rectal cancer is based on a multimodal comprehensive treatment combined with preoperative neoadjuvant chemoradiation and complete surgical resection of the entire mesorectal cancer. For ultra-low cases and cases with lateral lymph node metastasis, due to limitations in laparoscopic technology, the difficulties of operation and incidence of intraoperative complications are always difficult to overcome. Robotic surgery for the treatment of rectal cancer is an emerging technique that can overcome some of the technical drawbacks posed by conventional laparoscopic approaches, improving the scope and effect of radical operations. However, evidence from the literature regarding its oncological safety and clinical outcomes is still lacking. This brief review summarized the current status of robotic technology in rectal cancer therapy from the perspective of several mainstream surgical methods, including robotic total mesorectal excision (TME), robotic transanal TME, robotic lateral lymph node dissection, and artificial intelligence, focusing on the developmental direction of robotic approach in the field of minimally invasive surgery for rectal cancer in the future.
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The effect of preoperative patient-reported anxiety on morbidity and mortality outcomes in patients undergoing major general surgery. Sci Rep 2022; 12:6312. [PMID: 35428818 PMCID: PMC9012824 DOI: 10.1038/s41598-022-10302-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/05/2022] [Indexed: 01/03/2023] Open
Abstract
Excessive levels of anxiety may negatively influence treatment outcomes and likely increase patient suffering. We designed a prospective observational study to assess whether preoperative patient-reported anxiety affects major general surgery outcomes. We prospectively administered the State-Trait Anxiety Inventory (STAI) to measure preoperative anxiety in patients awaiting major general surgical procedures. Patients were grouped by STAI scores according to established cutoffs: no anxiety (STAI < 40) and anxiety (STAI ≥ 40). Four hundred patients completed the questionnaires and underwent surgery, with an average interval from questionnaire completion to surgery of 4 days. Applying a state anxiety (STAI-S) score ≥ 40 as a reference point, the prevalence of patient-reported anxiety was 60.5% (241 of 400). The mean STAI-S score for these patients was 50.48 ± 7.77. The mean age of the entire cohort was 58.5 ± 14.12 years. The majority of participants were male (53.8%). The distribution of sex by anxiety status showed that 53.5% of women and 46.5% of men had anxiety (p = 0.003). In the entire cohort, postoperative complications occurred in 23.9% and 28.6% of the no anxiety and anxiety groups, respectively. The difference was nonsignificant. In a subgroup of patients who underwent high-risk complex procedures (N = 221), however, postoperative complications occurred in 31.4% and 45.2% of the no anxiety and anxiety groups, respectively. This difference was significant at p = 0.004. Of the patients who were anxious, 3.3% (8 of 241) died during hospitalization following surgery, compared with 4.4% of the patients (7 of 159) who were not anxious (p = 0.577). In the multivariable analysis adjusted for covariates and based on the results of subgroup analysis, preoperative anxiety assessed by the STAIS score was associated with morbidity (OR 2.12, CI 1.14–3.96; p = 0.018) but not mortality. The majority of enrolled patients in this study were classified as having high- to very high-level preoperative clinical anxiety, and we found a significant quantitative effect of patient-reported anxiety on morbidity but not mortality after surgery.
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Hahn SJ, Sylla P. Technological Advances in the Surgical Treatment of Colorectal Cancer. Surg Oncol Clin N Am 2022; 31:183-218. [DOI: 10.1016/j.soc.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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[Oncological surgery in the interdisciplinary context-On the way to personalized medicine]. Chirurg 2022; 93:234-241. [PMID: 35201386 DOI: 10.1007/s00104-022-01614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 11/03/2022]
Abstract
Oncological surgery is a discipline which closely interacts with other clinical partners and remains in many cases the cornerstone of a curative treatment of solid tumors. Due to the progress in the field of systemic tumor treatment as well as innovations in surgical techniques, the indications in oncological surgery are also changing, such as extended indications for patients with oligometastatic disease. Surgery of metastases has long been established for colorectal cancer and is being further tested for other entities, such as pancreatic and gastric cancer, within randomized controlled clinical trials (e.g. RENAISSANCE and METAPANC). A new challenge is the handling of a clinical complete remission after total neoadjuvant therapy, for example in locally advanced rectal cancer or in esophageal cancer. Here, organ and function preservation are increasingly propagated but should only be performed within clinical trials until stratification enables the identification of patients in whom this concept is oncologically safe. The personalized use of oncological surgery is dependent on the patient, the tumor and on the total multimodal concept.
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Solaini L, Bocchino A, Avanzolini A, Annunziata D, Cavaliere D, Ercolani G. Robotic versus laparoscopic left colectomy: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:1497-1507. [PMID: 35650261 PMCID: PMC9262793 DOI: 10.1007/s00384-022-04194-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to review the new evidence to understand whether the robotic approach could find some clear indication also in left colectomy. METHODS A systematic review of studies published from 2004 to 2022 in the Web of Science, PubMed, and Scopus databases and comparing laparoscopic (LLC) and robotic left colectomy (RLC) was performed. All comparative studies evaluating robotic left colectomy (RLC) versus laparoscopic (LLC) left colectomy with at least 20 patients in the robotic arm were included. Abstract, editorials, and reviews were excluded. The Newcastle-Ottawa Scale for cohort studies was used to assess the methodological quality. The random-effect model was used to calculate pooled effect estimates. RESULTS Among the 139 articles identified, 11 were eligible, with a total of 52,589 patients (RLC, n = 13,506 versus LLC, n = 39,083). The rate of conversion to open surgery was lower for robotic procedures (RR 0.5, 0.5-0.6; p < 0.001). Operative time was longer for the robotic procedures in the pooled analysis (WMD 39.1, 17.3-60.9, p = 0.002). Overall complications (RR 0.9, 0.8-0.9, p < 0.001), anastomotic leaks (RR 0.7, 0.7-0.8; p < 0.001), and superficial wound infection (RR 3.1, 2.8-3.4; p < 0.001) were less common after RLC. There were no significant differences in mortality (RR 1.1; 0.8-1.6, p = 0.124). There were no differences between RLC and LLC with regards to postoperative variables in the subgroup analysis on malignancies. CONCLUSIONS Robotic left colectomy requires less conversion to open surgery than the standard laparoscopic approach. Postoperative morbidity rates seemed to be lower during RLC, but this was not confirmed in the procedures performed for malignancies.
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Affiliation(s)
- Leonardo Solaini
- grid.6292.f0000 0004 1757 1758Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy ,grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Antonio Bocchino
- grid.6292.f0000 0004 1757 1758Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Andrea Avanzolini
- grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Domenico Annunziata
- grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Davide Cavaliere
- grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Giorgio Ercolani
- grid.6292.f0000 0004 1757 1758Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy ,grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
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Varela C, Kim NK. Surgical Treatment of Low-Lying Rectal Cancer: Updates. Ann Coloproctol 2021; 37:395-424. [PMID: 34961303 PMCID: PMC8717072 DOI: 10.3393/ac.2021.00927.0132] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023] Open
Abstract
Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.
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Affiliation(s)
- Cristopher Varela
- Coloproctology Unit, Department of General Surgery, Hospital Dr. Domingo Luciani, Caracas, Venezuela
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Robotic versus transanal total mesorectal excision in sexual, anorectal, and urinary function: a multicenter, prospective, observational study. Int J Colorectal Dis 2021; 36:2749-2761. [PMID: 34537862 PMCID: PMC8589758 DOI: 10.1007/s00384-021-04030-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Improved long-term survival after low anterior resection (LAR) for rectal cancer highlights the importance of functional outcome. Urogenital and anorectal dysfunction is frequently reported after conventional LAR. Advanced minimally invasive techniques such as robotic (RoTME) and transanal total mesorectal excision (TaTME) might improve functional results by precisely dissecting and preserving autonomic nerves. We compared functional outcomes after RoTME or TaTME in a multicenter study. METHODS One hundred twenty patients (55 RoTME/65 TaTME) were prospectively included in four participating centers. Anorectal (Wexner and low anterior resection syndrome (LARS) Score), urinary (International Consultation on Incontinence-Male/Female Lower Urinary Tract Symptoms Score (ICIQ-MLUTS/ICIQ-FLUTS) and International Prostate Symptom Scale (IPSS)), and sexual (International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI)) outcomes at 12 months after surgery were compared to preoperative scores. The response rate to the 1-year postoperative functional assessment by questionnaire was 79.5%. RESULTS RoTME enabled better anorectal function compared to TaTME (LARS score 4.3 ± 2.2 vs. 9.8 ± 1.5, p = 0.038, respectively). TaTME proved superior at preserving male urinary function, while female urinary function was comparable in both groups, with only mild postoperative impairment (RoTME vs. TaTME, respectively: ICIQ-MLUTS 13.8 ± 4.9 vs. 1.8 ± 5.8, p = 0.038; ICIQ-FLUTS Incontinence Score - 0.3 ± 1.0 vs. - 0.2 ± 0.9, p = 0.844). Both techniques demonstrated comparable male (RoTME - 13.4 ± 2.7 vs. TaTME - 11.7 ± 3.4, p = 0.615) and female (RoTME 5.2 ± 4.6 vs. TaTME 10.5 ± 6.4, p = 0.254) sexual function. CONCLUSION After adjustment for risk factors, RoTME provided better anorectal functional results, whereas TaTME was better at preserving male urinary function. Overall, both techniques demonstrated only mild postoperative functional impairment.
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