Laparoscopic total mesorectal excision with autonomic nerve preservation

Comparison of Clinical Efficacy and Safety Between da Vinci Robotic and Laparoscopic Intersphincteric Resection for Low Rectal Cancer: A Meta-Analysis

Background and Aims: The intersphincteric resection (ISR) is beneficial for saving patients' anus to a large extent and restoring original bowel continuity. Laparoscopic ISR (L-ISR) has its drawbacks, such as two-dimensional images, low motion flexibility, and unstable lens. Recently, da Vinci robotic ISR (R-ISR) is increasingly used worldwide. The purpose of this article is to compare the feasibility, safety, oncological outcomes, and clinical efficacy of R-ISR vs. L-ISR for low rectal cancer. Methods: PubMed, EMBASE, Cochrane Library, and Web of Science were searched to identify comparative studies of R-ISR vs. L-ISR. Demographic, clinical, and outcome data were extracted. Mean difference (MD) and risk ratio (RR) with their corresponding confidence intervals (CIs) were calculated. Results: Five studies were included. In total, 510 patients were included, of whom 273 underwent R-ISR and 237 L-ISR. Compared with L-ISR, R-ISR has significantly lower estimated intraoperative blood loss (MD = -23.31, 95% CI [-41.98, -4.64], P = 0.01), longer operative time (MD = 51.77, 95% CI [25.68, 77.86], P = 0.0001), hospitalization days (MD = -1.52, 95% CI [-2.10, 0.94], P < 0.00001), and postoperative urinary complications (RR = 0.36, 95% CI [0.16, 0.82], P = 0.02). Conclusions: The potential benefits of R-ISR are considered as a safe and feasible alternative choice for the treatment of low rectal tumors.

Short-Term and Long-Term Outcomes of Laparoscopic Versus Open Surgery for Low Rectal Cancer

AIM

To compare the short-term and long-term outcomes of laparoscopic versus open surgery for low rectal cancer.

METHODS

Patients with low rectal cancer who underwent laparoscopic or open surgery at our department from January 2009 to December 2013 were enrolled in this retrospective study. The primary end points were 3-year local recurrence and overall and disease-free survival (DFS) rates. Secondary end points were intraoperative and postoperative outcomes.

RESULTS

Laparoscopic group had longer operative time (165.0 versus 140.0, P < .001), less blood loss (20.0 versus 40.0, P < .001), shorter length of incision (5.0 versus 18.0, P < .001), and more lymph node harvested (11.0 versus 9.0, P = .002). However, time to first flatus (P = .941), postoperative hospital stay (P = .095), postoperative complications (P = .155), and 30-day mortality (P = .683) was similar between two groups. With the median follow-up period of 65 months, the 3-year local recurrence rate was 4.3% in laparoscopic group and 7.5% in open group (P = .077); the 3-year overall and DFS rates were similar in two groups (85.9% versus 88.8%, P = .229 and 76.9% versus 79.2%, P = .448, respectively); and the overall and DFS curves were comparable between two groups (hazard ratio [HR] = 0.858, 95% confidence intervals [CI] 0.709-1.037, P = .112 and HR = 1.076, 95% CI 0.834-1.389, P = .275, respectively).

CONCLUSIONS

Laparoscopic surgery is safe and has equivalent long-term oncologic outcomes for low rectal cancer when compared to open surgery. Furthermore, large-scale, prospective randomized clinical trials are needed to confirm the present findings.

Current Status of Minimally Invasive Surgery for Rectal Cancer

Recent randomized controlled data have shown possible limitations to laparoscopic treatment of rectal cancer. The retrospective data, used as the basis for designing the trials, and which showed no problems with the technique, are discussed. The design of the randomized trials is discussed relative to the future meta-analysis of the recent data. The implications of the current findings on practice are discussed as surgeons try to adjust their practice to the new findings. The possible next steps for clinical and research innovations are put into perspective as new technology is considered to compensate for newly identified limitations in the laparoscopic treatment of rectal cancer.

Laparoscopic bowel-lifting technique: a novel and standardized technique for laparoscopic low anterior resection for rectal cancer

INTRODUCTION

Although surgeons have tried to reduce the number of ports in order to achieve better cosmesis and less postoperative pain, it may lead to increased risk for complications. Herein, we introduce a technique, "laparoscopic bowel-lifting (LBL) technique," which helps to reduce ports without additional trocars.

METHODS

The mesocolon is pierced near the line of transaction using the pair of dissecting forceps. A 1-0 Vicryl suture is introduced into the abdominal cavity using a grasping needle and passed through the mesocolon. The colon is retracted using the suture and fixed to the abdominal wall using a pair of forceps. Thereafter, traction is placed on the main nutrient artery. Mobilization of the rectum is performed after moving the traction to the cranial side by using a grasping needle. As the rectal tube was pulled toward the cranial side, it is possible to identify the mesorectum with a good visual field.

RESULTS

We performed this procedure in 100 consecutive patients with rectal cancer who underwent curative laparoscopic low anterior resection (Lap-LAR) between November 2001 and March 2010. The median duration of follow-up after Lap-LAR was 53.2 months. The tumor was located in the middle rectum in 75 patients and in the lower rectum in 25 patients. The stage grouping on the basis of the TNM classification was as follows: stage 0, 6; stage I, 46; stage II, 18; and stage III, 30. The number of trocars used in the LBL group was 3 or 4. No LBL cases used 5 trocars. No operative complications were attributable to this technique. The overall rates of anastomotic leakage and morbidity were 10.0% and 33.0%, respectively. The 5-year relapse-free and 5-year overall survival rates were stage 0, 100/100; stage I, 93.3/96.8; stage II, 81.5/88.5; and stage III, 74.5/75.7.

CONCLUSIONS

LBL technique is feasible for performing Lap-LAR. This method reduces the number of ports and might help to introduce a single-incisional surgery.

Robot-assisted low anterior resection for situs inversus totalis: a novel technical approach for an uncommon condition

INTRODUCTION

Situs inversus totalis (SIT) is an uncommon condition, with an incidence of 1 in 10,000. Surgery for SIT patients is more difficult because of the uncommon anatomy. Experience in laparoscopic surgery for patients with SIT is very limited. Only a few cases of laparoscopic colorectal resections have been reported in the literature. We present the first robot-assisted low anterior resection for rectal cancer in a patient with SIT.

PATIENT

A 70-year-old woman with SIT who presented with rectal bleeding underwent a colonoscopy and barium enema. This workup revealed a rectal cancer 10 cm from the anal verge. The magnetic resonance imaging scan revealed a T3/4 tumor in the rectum with perirectal lymph node involvement, whereas the computed tomography positron emission tomography scan did not reveal any distal metastasis. She underwent neoadjuvant chemoradiotherapy 6 weeks before surgery. Postoperatively, she made an uneventful recovery and was discharged on day 6.

SURGICAL TECHNIQUE

After laparoscopic examination and displacement of the small bowel, 4 robot trocars were inserted into 4 quadrants of the abdomen. A fifth port was inserted and used by the assistant. The robot cart was docked from the right side with arms 1, 2, and 3 in the right upper quadrant (Cadiere grasper), left lower quadrant (bipolar Maryland grasper), and left upper quadrant (monopolar scissors), respectively, for colonic mobilization without splenic flexure takedown. For pelvic dissection, arms 1 and 3 were moved to the right upper quadrant and right lower quadrant, respectively. After adequate pelvic dissection, the robot cart was undocked, and a laparoscopic articulating linear stapler was used to transect the rectum from the left lower quadrant port. Bowel continuity was restored with a circular stapler. A loop ileostomy was created through the extraction site in the right lower quadrant.

CONCLUSIONS

Robot-assisted low anterior resection for SIT patients can be performed safely and confers the benefits of laparoscopic low anterior resection with additional advantages unique to the da Vinci system.

Robot-Assisted Rectal Surgery for Malignancy: A Review of Current Literature

Laparoscopic colorectal surgery is rapidly gaining acceptance for the management of colorectal cancer. However, laparoscopic colorectal surgery is technically more challenging than conventional surgery. This challenge is more profound for laparoscopic rectal cancer, where there is a need to perform a total mesorectal excision (TME), in the confines of the pelvis, with the limitations of the laparoscopic system. The Da Vinci robotic surgical system was designed to overcome the pitfalls of laparoscopic surgery, hence the use of this novel system in colorectal surgery seems logical, in particular with regards to rectal cancer surgery. Recently, there have been an increasing number of reports in the literature on robotic colorectal surgery. The advantages of the robotic surgical system include; 7 degrees of movement, 3 dimensional views, tremor filtration, motion scaling and superior ergonomics. These advantages when applied to robotic TME for rectal cancer surgery may potentially translate to better outcomes. The aim of this review is to summarise the current evidence on clinical and oncological outcomes of robotic rectal cancer surgery. Key words: Malignancy, Rectal, Robot

Laparoscopic sphincter-preserving total mesorectal excision: 10-year report

AIM

Total mesorectal excision (TME) is currently the gold standard for resection of mid or low rectal cancer and is associated with a low local recurrence rate. However, few studies have reported the long-term oncological outcome following use of a laparoscopic approach. The aim of this study was to evaluate the long-term oncological outcome after laparoscopic sphincter-preserving TME with a median follow up of about 4 years.

METHOD

Patients with mid or low rectal cancer who underwent laparoscopic sphincter-preserving TME with curative intent between March 1999 and March 2009 were prospectively recruited for analysis.

RESULTS

During the 10-year study period, 177 patients underwent laparoscopic sphincter-preserving TME with curative intent for rectal cancer. Conversion was required in two (1%) patients. There was no operative mortality. At a median follow-up period of 49 months, local recurrence had occurred in nine (5.1%) patients. The overall metastatic recurrence rate after curative resection was 22%. The overall 5-year survival and 5-year disease-free survival in the present study were 74% and 71%, respectively.

CONCLUSION

The results of this study show that laparoscopic sphincter-preserving TME is safe with long-term oncological outcomes comparable to those of open surgery.

Robot-assisted intersphincteric resection for low rectal cancer: technique and short-term outcome for 29 consecutive patients

BACKGROUND

Intersphincteric resection (ISR) for low rectal cancer has been described as the ultimate sphincter-saving procedure. Laparoscopic ISR has been proved safe with early postoperative benefits. Recently, some colorectal surgeons have begun to perform robot-assisted ISR to harness the advantages of the da Vinci robotic system. The authors present their short-term results for a robotic technique of ISR.

METHODS

Data from 29 consecutive patients at a single institution with very low rectal cancer (<4 cm) from the anal verge who underwent robot-assisted ISR were prospectively collected between December 2007 and March 2010.

RESULTS

The study enrolled 23 men and 6 women with a median age of 61.5 years (range, 36-82 years). Their median body mass index (BMI) was 23.3 kg/m(2) (range, 17.9-32.5 kg/m(2)). The median distance of the tumor from the anal verge was 3 cm (range, 1-4 cm). The median operative time was 325 min (range, 235-435 min), with a console time of 130 min (range, 110-210 min). There were no conversions to open surgery. A protecting ileostomy was performed for all the patients. The median blood loss was less than 50 ml (range, < 50-1,000 ml). The median size of the tumor was 3 cm (range, 0-6.9 cm), and the median number of lymph nodes harvested was 16 (range, 1-44). The median distal margin was 0.8 cm (range, 0-4 cm), and one margin was positive. The circumferential margin was negative (>2 mm) for 27 patients. Therefore, complete resection (R0) was achieved for 26 (90%) of the 29 patients. The median hospital stay was 9 days (range, 5-15 days). Nine patients experienced complications, including three anastomotic leaks (10%). All the leaks were managed conservatively. No surgical mortalities occurred.

CONCLUSION

Robot-assisted intersphincteric resection for very low rectal cancer is feasible, and its short-term outcome is acceptable.

A new application of the four-arm standard da Vinci® surgical system: totally robotic-assisted left-sided colon or rectal resection

BACKGROUND

The key to successful rectal cancer resection is to perform complete total mesorectal excision (TME). Laparoscopic TME can be challenging, especially in the narrow confines of the pelvis. Robotic-assisted surgery can overcome these limitations through superior three-dimensional (3-D) visualization and the increased range of movements provided by the endowrist function. To date, all totally robotic resections of the rectum have been described using da Vinci® S or Si systems. Due to the limitations of the standard system, only hybrid procedures have been described so far.

AIM

To evaluate the feasibility and short-term outcomes of performing totally robotic-assisted laparoscopic colorectal resections using the standard da Vinci® system with a fourth arm extension.

METHODS

The standard system was docked from the patient's left hip. Four 8-mm robotic trocars were inserted. Upon completion of phase 1 (pedicle ligation, colonic mobilization, splenic flexure takedown), the two left-sided arms are repositioned to allow phase 2 (pelvic dissection), enabling the entire procedure except for the distal transection and anastomosis to be performed robotically.

RESULTS

Twenty-one robotic procedures were performed from August 2008 to September 2009. The mean age of the patients was 61 years (13 males). The procedures performed included seven anterior resections, seven low anterior resections, five ultralow anterior resections, one abdominoperineal resection, and one resection rectopexy. The majority of the cases were performed in patients with colon or rectal cancer. Operative time ranged from 232 to 444 (mean 316) min. Postoperative morbidity occurred in three patients (14.3%) with no mortalities or conversions. Average hospital stay was 6.4 days. Mean lymph node yield for the cases with cancer was 17.8.

CONCLUSIONS

The standard da Vinci® system with four arms can be used to perform totally robotic-assisted colorectal procedures for the left colon and rectum with short-term outcomes similar to those of conventional laparoscopic techniques.

Laparoscopic total mesorectal excision for rectal cancer: experience of a single center with a series of 174 patients

BACKGROUND

Laparoscopic total mesorectal excision for low rectal cancer is not considered a gold standard treatment due to the high conversion rate and the long operation time.

METHODS

A retrospective review examined a surgical series of 174 laparoscopic low rectal resections involving total mesorectal excision (1995-2006), with particular reference to technical points as well as surgical and oncologic outcomes. Miles operations and partial mesorectal excisions were excluded.

RESULTS

The cancer affected the low rectum in 110 cases and the medium rectum in 64 cases. A total of 68 patients were subjected to neoadjuvant radiochemotherapy. The anastomosis was mechanical for 83.3% of the cases and intersphinteric through the perineum for 16.6% of the cases. Protective ileostomy was performed in 112 cases. The conversion rate was 4.6%. The mesorectum remained intact in 91.6% of the cases and was partially interrupted in 15 of the cases. In no case was it totally discontinued. The postoperative morbidity rate was 16.7%, and the mortality rate was 0.57%. The incidence of anastomotic fistulas was 14.4%. The percentage was higher for males (18.6 vs 8.3%) and correlated with the low distance of the tumor from the anal verge (18.2 vs 7.8%) and the absence of a protection ileostomy (20.9 vs 10.7%). After an average follow-up period of 48.6 months (range, 24-149 months), six patients (3.44%) experienced a pelvic recurrence. The 5-year overall survival rate was 75.4%, and the disease-free survival rate was 61.9%.

CONCLUSION

Laparoscopic total mesorectal excision for low rectal cancer is safe and effective, allowing surgical and oncologic outcomes similar to those reported for open surgery.

Multimedia article. Autonomic nerve-preserving total mesorectal excision in the laparoscopic era

PURPOSE

Although technically demanding, laparoscopy may be advantageous in magnifying the anatomy of the pelvic autonomic nervous system when performing total mesorectal excision for rectal cancer. We present our method for laparoscopic total mesorectal excision for men.

METHODS

We performed laparoscopic total mesorectal excision for 36 men with middle or low rectal cancer. The rectum was mobilized through a medial approach down to the pelvic floor without minilaparotomy or hand assist. Anteriorly, the dissection plane was in front of Denonvilliers fascia. Anterolaterally, to preserve the pelvic plexus and neurovascular bundle, Denonvilliers fascia must be cut at its lateral continuity. We found that the most important factor in obtaining a good surgical view is keeping adequate tension in the dissection plane by coordination between the surgeon and assistant. Dissection was performed by using only electrocautery without an ultrasonic dissector or vessel sealing device.

RESULTS

No case was converted to open surgery. The short-term feasibility was acceptable.

CONCLUSIONS

Our method of laparoscopic total mesorectal excision is a feasible approach and may be beneficial for the standardization and popularization of laparoscopic total mesorectal excision. Long-term results, including survival data and urogenital function, are needed to evaluate the true efficacy of this procedure.

Does laparoscopic surgery offer adequate clearance in rectal cancer?--A discussion

Currently in the UK, the national institute of clinical excellence (NICE), only advocates laparoscopic surgery for rectal cancer as part of commissioned clinical trials. Laparoscopic teaching, training and techniques have evolved greatly and offer many benefits to patients, whilst remaining technically demanding to surgeons still on the slope of the learning curve. Can such minimally invasive techniques be used with the same results as open surgery in the treatment of rectal cancer? Are laparoscopic colorectal surgeons able to achieve the same clearance of tumours and so avoid recurrence at the same rate compared to conventional techniques? The discussion to follow, aims to shed some light on such questions and briefly review some of the literature. If laparoscopic anterior resections and abdominoperineal resections achieve the same results as open procedures, then should these techniques be more widely taught and practised? Surely the peri-operative cost of these laparoscopic procedures does not over shadow the potential outcome from much less traumatic surgery?

Long-term results of laparoscopic treatment for advanced rectal cancer

BACKGROUND

The management of advanced rectal cancer has changed into a multidisciplinary treatment model. Only limited randomized data are available for patients with rectal cancer treated laparoscopically.

AIM

We report a multimodal treatment of advanced rectal cancer: preoperative oncological treatment, use of endoscopic stent (for malignant obstruction), minimal invasive treatment.

METHODS

The Authors reported a series of 45 laparoscopic rectal resections for adenocarcinoma, some of them with malignant obstruction. Long-term oncological results were reviewed.

RESULTS

The 30-day mortality was 2.2%. Of 45 adenocarcinoma, 4 cases were obstructed. Successful stent positioning was obtained in all patients and treated with radiochemiotherapy before laparoscopic resection. The 5-year global survival rate (including stage IV) was 62.2%; for stage II was 77.9% and 53.8% for stage III.

CONCLUSION

This study indicates that laparoscopy for advanced rectal cancer have good long-term results. In high and middle rectal malignant obstructions, we considered the use of stents to be useful.

New laparoscopic double-stapling technique

BACKGROUND

Laparoscopic surgery for colon cancer has been shown by several randomized, controlled trials to be an acceptable alternative to open surgery; however, laparoscopic rectal surgery has not been evaluated in a randomized trial. One of the most serious problems associated with laparoscopic rectal surgery are bowel clamping, irrigation, and transection of the rectum, and laparoscopic rectal surgery has not been as reliable as open rectal surgery.

MATERIALS AND METHODS

We present our new technique, the laparoscopic double-stapling technique, which eliminates these problems. This technique uses curved Doyen forceps introduced through the wound just above pubis symphysis for clamping the rectal wall at the anal side of the tumor. An endolinear stapler (length 60 mm) is inserted through the same wound, applied at the rectal wall parallel and caudal to the Doyen forceps, and transects the rectum under pneumoperitoneum. We used this technique for eight cases of rectal surgery.

RESULTS AND DISCUSSION

The laparoscopic double-stapling technique provided secure bowel clamping and rectal irrigation. The number of cartridges used in laparoscopic double-stapling technique cases was not more than 2, with an average of 1.6 per patient. None of the laparoscopic double-stapling technique cases experienced major complications.

CONCLUSION

We consider that many cases of rectal cancer that are suitable for laparoscopic low anterior resection can undergo laparoscopic surgery by using this technique, which will improve the quality of rectal surgery.

Laparoscopic assisted distal rectal cancer resection with preoperative concurrent chemoradiotherapy

PURPOSE

Anatomy of deep pelvis, narrow distal margin and tumor invasion into neighbor organ are obstacles for curative radical resection for advanced cancer of distal rectum. Technically, laparoscopic application after downstaging the tumor with preoperative concurrent chemotherapy (CCRT) may give a solution to overcome the anatomical difficulties. We compared the results of laparoscopic surgery in the patients who received CCRT with those of patients who had conventional surgery.

MATERIALS AND METHODS

A continuous infusion of 5FU plus leucovorin and radiotherapy (50.4 Gy) in 28 fractions was given each patient as CCRT. They underwent D2 radical resection with TME and ANP for the rectal cancer in 4 weeks.

RESULTS

Thirty three patients had laparoscopic resection such as LAR, colo-anal anastomosis and APR. The results were compared with 12 cases of the conventional resections. As a result of preoperative CCRT, the cancer was down-staged in 71%. Two year disease free survival was 75% and 74% in the group of conventional and laparoscopic resection, respectively (p=0.427). Ileus, voiding difficulty and leakage after surgery were not different between two groups. Weakness of ejaculation was noted in 9 approximately 11% of both groups. The DFS of the preoperative CCRT followed by radical resection in the groups with a response was more favorable than that in the group with progressive or stable disease.

CONCLUSION

Radical resection of advanced distal rectal cancer could be done with performing a laparoscopic assisted operation after CCRT induced down-staging. We may suggest that laparoscopic assisted resection is a good treatment option as it doesn't increase the complications and it has a compatible survival rate to conventional surgery.

Restorative proctectomy with colon pouch-anal anastomosis by laparoscopic transanal pull-through: an available option for low rectal cancer?

BACKGROUND

There are sporadic reports, with different verdicts, of restorative proctectomy by laparoscopic transanal pull-through (LTPT) without the use of a minilaparotomy for a part of the procedure. This study aimed to explore the applicability and advantages of LTPT with colon pouch-anal anastomosis for low rectal cancer, and to evaluate the results.

METHODS

From January 2002 to July 2003, 10 of 12 patients (6 men and 4 women) undergoing a laparoscopic procedure for low rectal cancer (<6 cm from the anal verge) underwent LTPT. The mean age of these patients was 58 years. The results have been compared with those for 12 similar non-pull-through procedures performed during the same period.

RESULTS

There was no operative mortality. An anastomotic leakage and a hemorrhagic gastropathy occurred in the LTPT group. During a mean follow-up period of 18 months (range, 12-26 months), there was no local relapse. Four patients manifested moderate incontinence. No significant differences in functional outcome were observed between the LTPT and control groups.

CONCLUSION

The authors' experience supports use of the LTPT procedure with colonic pouch-anal anastomosis for selected lower rectal cancers with indications for a laparoscopic approach as an appropriate and reproducible surgical treatment.

Laparoscopic versus open total mesorectal excision for rectal cancer

BACKGROUND

Because definitive long-term results are not yet available, the oncological safety of laparoscopic surgery for treatment of rectal cancer remains controversial. However, laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME).

OBJECTIVES

To evaluate whether there are any relevant differences in safety and efficacy after elective LTME, for the resection of rectal cancer, compared with OTME.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Cochrane Central register of Controlled Trials (CENTRAL), and Current Contents from 1990 to December 2005. Searches were conducted using MESH terms: "laparoscopy", "minimally invasive","colorectal neoplasms". Furthermore we used the following text words: laparoscopy, surgical procedures, minimally invasive, rectal cancer, rectal carcinoma, rectal adenocarcinoma, rectal neoplasms, anterior resection, abdominoperineal resection, total mesorectal excision.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled clinical trials and case series comparing LTME versus OTME. Furthermore case reports which describe LTME were also included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality. All relevant studies have been categorized according to the evidence they provide according to the guidelines for "Levels of Evidence and Grades of Recommendation" supplied by the "Oxford Centre for Evidence-based Medicine". Disagreements were solved by discussion.

MAIN RESULTS

80 studies were identified of which 48 studies, representing 4224 patients, met the inclusion criteria. Methodological quality of most of the included studies was poor; three studies were grade 1b (individual randomised trial), 12 grade 2b (individual cohort study), 5 grade 3b (individual case-control study) and 28 grade 4 (case-series). As only one RCT described primary outcome, 3-year and 5-year disease-free survival rates, no meta-analyses could be performed. No significant differences in terms of disease-free survival rate, local recurrence rate, mortality, morbidity, anastomotic leakage, resection margins, or recovered lymph nodes were found. There is evidence that LTME results in less blood loss, quicker return to normal diet, less pain, less narcotic use and less immune response. It seems likely that LTME is associated with longer operative time and higher costs. No results of quality of life were reported.

AUTHORS' CONCLUSIONS

Based on evidence mainly from non-randomized studies, LTME appears to have clinically measurable short-term advantages in patients with primary resectable rectal cancer. The long-term impact on oncological endpoints awaits the findings from large on-going randomized trials.

Laparoscopic sphincter-preserving total mesorectal excision with colonic J-pouch reconstruction: five-year results

OBJECTIVE

To prospectively evaluate the oncologic and functional outcomes of laparoscopic total mesorectal excision (TME) with colonic J-pouch reconstruction.

BACKGROUND

TME is considered the established gold standard in rectal cancer surgery. However, data on laparoscopic sphincter-preserving TME are limited.

METHODS

Patients with mid or low rectal cancer underwent laparoscopic TME with colonic J-pouch reconstruction by a single surgical team. Clinical and oncologic data were prospectively recorded and analyzed.

RESULTS

From March 1999 to September 2004, 105 patients underwent laparoscopic TME with colonic J-pouch reconstruction. The mean operating time was 170.4 minutes and mean blood loss was 91.5 mL. The mean anastomotic distance from the anal verge was 3.9 cm. Conversion was required in 2 cases. The mean circumferential and distal margins were 17.1 mm and 3.4 cm, respectively. There was 1 case of microscopic circumferential margin involvement and 1 case of microscopic distal margin involvement. There was no 30-day mortality, and 6 patients underwent reoperation for major complications. There was no port-site metastasis. The mean follow-up time was 26.9 months (range, 1.3-65.6 months). The actuarial 5-year cancer-specific survival and local recurrence rates were 81.3% and 8.9%, respectively. Erectile dysfunction occurred in 13.6% of males, while 2 patients developed incomplete bladder denervation. Bowel function after ileostomy closure was satisfactory, with an average bowel motion of less than 3 times per day at 2 years after ileostomy closure.

CONCLUSIONS

Laparoscopic TME with colonic J-pouch reconstruction is a safe procedure with reasonable operating time and does not appear to pose any threat to the oncologic and functional outcomes.

Minimally invasive surgery for rectal cancer

The present scarcity of literature on laparoscopic rectal cancer surgery makes it premature to determine whether laparoscopic surgery should be the standard of care for rectal cancer. Notwithstanding that, the available evidence proves its safety and adequate oncological clearance. Moreover, current data do not suggest any detrimental effect on the postoperative and early oncological outcomes. On the contrary, there is level three evidence showing that laparoscopic technique results in less blood loss, shorter length of stay, and reduced abdominal wound disorders and pulmonary complications, albeit the overall morbidity remains similar to that of open surgery. Long-term survival outcomes remain largely unclear, however. Hence, it is high time that laparoscopic technique should be further evaluated, preferably by means of large-scale randomized trials, to define its exact role in the treatment of rectal cancer.

Laparoscopic TME: better vision, better results?

One of the most controversial discussions on laparoscopic surgery deals with the question of whether to apply this technique to malignant disease and specifically to rectal cancer. The four major issues are the adequacy of oncologic resection, recurrence rates and patterns, long-term survival and quality of life. There is evidence, from nonrandomized studies, suggesting that margins of excision and lymph node harvest achieved laparoscopically reached comparable results to those known from conventional open resection. Our own experience of laparoscopic surgery on rectal cancer is based on 52 patients treated with curative intent. Focusing on the postoperative long-term run, we gained the following results: The median age of patients was 66.7 years and ranged from 42-88. Anastomotic leakage was seen in 6.1% of cases. In a median follow-up of 48 months (36-136), we reached an overall 3-year survival rate of 93% and a 5-year survival rate of 62%. Local recurrence was 1.9%, distant metastasis occurred in 11.5% of cases. We saw no port-site metastasis. To evaluate functional results following laparoscopic surgery a matched pair analysis was carried out. Matching of patients after laparoscopic and conventional open surgery was performed according to sex, age, type of resection, time period of surgery, and stage of disease classified by UICC. Regarding bladder and sexual dysfunction, using the EORTC QLQ CR38 score we found no statistical significant difference between the examined groups. As far as can be seen, laparoscopic surgery in rectal carcinoma may achieve the same or, in selected patients, even better results than open surgery. However, at present no published study has shown much evidence. Many more studies are necessary to define the place of laparoscopic technique in rectal cancer surgery, regarding appropriate selection of patients and evaluating adjuvant or neoadjuvant treatment in combination with the laparoscopic approach.

Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes

BACKGROUND

Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. However, the laparoscopic approach to resection for colorectal cancer remains controversial due to fears that oncologic principles will be compromised. We assessed the feasibility, safety and long-term outcome of laparoscopic rectal cancer resections following the principles of TME. The aim of this study was to evaluate the perioperative outcome and long-term results of laparoscopic TME.

METHODS

We reviewed the prospective database of 102 consecutive unselected patients undergoing laparoscopic TME for rectal cancer between November 1991 and December 2000. Follow-up was done through office charts or direct patient contact. Recurrence and survival curves were generated by the Kaplan-Meier method.

RESULTS

Laparoscopic TME was completed successfully in 99 patients, whereas conversion to an open approach was required in three cases (3%). The overall morbidity and mortality rates were 27% and 2%, respectively, with an overall anastomotic leak rate of 17%. Of the 102 patients, four were excluded from the oncologic evaluation because final pathology was not confirmatory (two had anal canal squamous cell carcinoma and two had villous adenoma with dysplasia). In 90 of the 98 remaining patients (91.8%), the resection was considered curative. The remainder had a palliative resection due to synchronous metastatic disease or locally advanced disease. Mean follow-up was 36 months (range, 6-96). There were no trocar site recurrences. The local recurrence rate was 6%, and the cancer-specific survival of all curatively resected patients was 75% at 5 years. The overall survival rate of all curatively resected patients was 65% at 5 years; mean survival time was 6.23 years (95% confidence interval [CI], 5.39-7.07).

CONCLUSION

Laparoscopic TME is feasible and safe. The laparoscopic approach to the surgical treatment of operable rectal cancer does not seem to entail any oncologic disadvantages.

Laparoscopy and its current role in the management of colorectal disease

OBJECTIVE

To evaluate the current place of laparoscopy in the management of colorectal disease.

METHOD

A literature search was undertaken on Medline between the period 1991 and 2002.

RESULTS

From the literature there is good evidence that the laparoscopic approach is associated with at least some short-term advantages. Improved cosmesis and better patient's satisfaction are also evident. Because of this laparoscopy has been widely employed in various benign conditions. Among others, laparoscopic stoma formation, laparoscopic resection for diverticular disease and Crohn's disease, laparoscopic rectopexy, as well as laparoscopic assisted reversal of Hartmann's procedure were commonly reported. As port site recurrence and oncological safety are of less concern, there have been increasing reports on laparoscopic resection for colorectal cancer. Although long-term follow up data is still limited, results of large prospective studies as well as various randomized trials show that recurrence and survival rates of the laparoscopic approach were at least comparable to open surgery. As experience and confidence accumulates, there are also increasing reports on technically demanding, laparoscopic sphincter-saving rectal excision. Articles on functional aspects following this type of resection also start to appear, which might be one of the future directions.

CONCLUSION

The applicability of laparoscopy to colorectal disease continues to expand. Laparoscopic approach should be considered for patients with benign conditions. For colorectal cancer, results from randomized trials so far have been favourable. Hence, the authors suggest the utility of laparoscopy in potentially curable cancer can also be judiciously relaxed.

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients

BACKGROUND

Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer.

METHODS

A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patient's choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l-9 years).

RESULTS

We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group ( p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group ( p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group ( p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery ( n = 10) and patients who had undergone surgery in the past year ( n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection ( p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group ( p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection ( p = 0.162), whereas for Dukes' stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 ( p = 0.392), 0.722 vs 0.584 ( p = 0.199), and 0.500 vs 0.417 ( p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free ( p = 0.623).

CONCLUSIONS

Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international randomized controlled trials.

Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer

AIM

The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic total mesorectal excision (TME) with coloanal anastomosis for mid and low rectal cancer.

METHODS

During a 2-year period, 50 patients underwent laparoscopic TME with coloanal anastomosis for rectal carcinoma located at a median of 4.5 (range 2-11) cm from the anal verge. Pre-operative radiotherapy was used in 46 patients. Intersphincteric dissection was combined with the laparoscopic procedure to achieve sphincter preservation.

RESULTS

Conversion to a laparotomy was necessary in six patients. Postoperative mortality and morbidity were 2% and 28%, respectively. Morbidity was lower in patients operated on during the second part of the study, who had extraction of the rectal specimen through a small laparotomy incision, than in those operated on during the first part of the study when removal of the specimen was by transanal extraction. Oncological quality of excision was safe in 44 patients with intact or almost intact rectal fascia in 88% and R0 resection in 90%. At a median follow-up of 18 months, there was no local or port-site recurrence.

CONCLUSION

This study confirms our preliminary results of oncological feasibility of laparoscopic TME with sphincter preservation for mid and low rectal cancer, and showed that morbidity can be decreased by using a standardized surgical procedure.

Laparoscopic total mesorectal excision of low rectal cancer with preservation of anal sphincter: A report of 82 cases

AIM: To assess the feasibility and efficacy of laparoscopic total mesorectal excision (LTME) of low rectal cancer with preservation of anal sphincter.

METHODS: From June 2001 to June 2003, 82 patients with low rectal cancer underwent laparoscopic total mesorectal excision with preservation of anal sphincter. The lowest edge of tumors was below peritoneal reflection and 1.5-7 cm from the dentate line (1.5-5 cm in 48 cases, 5-7 cm in 34 cases).

RESULTS: LTME with anal sphincter preservation was performed on 82 randomized patients with low rectal cancer, and 100% sphincter preservation rate was achieved. There were 30 patients with laparoscopic low anterior resection (LLAR) at the level of the anastomosis below peritoneal reflection and 2 cm above from the dentate line; 27 patients with laparoscopic ultralow anterior resection (LULAR) at the level of anastomoses 2 cm below from the dentate line; and 25 patients with laparoscopic coloanal anastomoses (LCAA) at the level of the anastomoses at or below the dentate line. No defunctioning ileostomy was created in any case. The mean operating time was 120 min (ranged from 110-220 min), and the mean operative blood loss was 20 mL (ranged from 5-120 mL). Bowel function was restored and diet was resumed on day 1 or 2 after operation. The mean hospital stay was 8 d (ranged from 5-14). Postoperative analgesics were used in 45 patients. After surgery, 2 patients had urinary retention, one had anastomotic leakage, and another 2 patients had local recurrence one year later. No interoperative complication was observed.

CONCLUSION: LTME with preservation of anal sphincter is a feasible, safe and minimally invasive technique with less postoperative pain and rapid recovery, and importantly, it has preserved the function of the sphincter.

The pathological assessment of mesorectal excision: implications for further treatment and quality management

BACKGROUND AND AIMS

Most clinical practice guidelines today recommend total mesorectal excision (TME) for carcinoma of the middle and lower rectal thirds and partial mesorectal excision (PME) for the upper rectal third. However, these procedures may not always fulfill the oncological requirements. The pathological examination of resected rectal carcinomas should always include a visual assessment of the mesorectal excision to ensure oncological adequacy and appropriate quality. The clinical practice guideline of the German Cancer Society recommends reporting of the distal extent of mesorectal excision (total or partial without coning) and the excision in an inviolate fascial envelope.

PATIENTS AND METHODS

Reporting schemas of assessment and documentation for daily use and for studies are presented.

RESULTS

Careful macroscopic evaluation of the resection specimen should be standardized. This may be supplemented by stain marking after postoperative filling the inferior mesenteric or superior rectal artery with ink or methylene blue solution. Photodocumentation is highly desirable. The pathological assessment of adequacy of mesorectal excision should be taken into account in selection for adjuvant radiotherapy. Objective macro- and microscopic assessment of mesorectal excision by pathologists is essential for quality management throughout patient care and in clinical trials.

The role of total mesorectal excision in the management of rectal cancer

BACKGROUND

Total mesorectal excision (TME) was described 20 years ago and is now being established as the therapeutic gold standard for middle and lower third rectal cancers in a number of countries worldwide.

METHODS

The authors reviewed published data regarding TME since its first description in 1982. Emphasis was placed on basic principles, achievable recurrence rates, evidence for use of adjunctive strategies, and the potential of TME.

RESULTS

Local recurrence rates following TME approximate 6.6% from published series, accounting for more than 5,000 patients. The available evidence for TME is largely composed of retrospective series, although benefits of TME compare favorably to established conventional controls. Recent studies have clarified the benefit of adjunctive radiotherapy with TME. There is considerable scope for development of TME within the minimal access setting, providing first principles are observed.

CONCLUSIONS

Despite initial controversy, TME is now a feasible, reproducible, adjunctive surgical therapy in the management of rectal cancer.

Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer

BACKGROUND

The feasibility of laparoscopic rectal resection in patients with mid or low rectal cancer was studied prospectively with regard to quality of mesorectal excision, autonomic pelvic nerve preservation and anal sphincter preservation.

METHODS

Laparoscopic rectal excision was performed in 32 patients (21 men) with rectal carcinoma located 5 cm from the anal verge. Most patients had T3 disease and received preoperative radiotherapy. The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, intersphincteric resection, transanal coloanal anastomosis with coloplasty and loop ileostomy.

RESULTS

Three patients needed conversion to a laparotomy. Postoperative morbidity occurred in ten patients, related mainly to coloplasty. Macroscopic evaluation showed an intact mesorectal excision in 29 of 32 excised specimens; microscopically, 30 of the 32 resections were R0. Sphincter preservation was achieved in 31 patients. The hypogastric nerves and pelvic plexuses were identified and preserved in 24 of the 32 patients. Sexual function was preserved in ten of 18 evaluable men.

CONCLUSION

A laparoscopic approach can be considered in most patients with mid or low rectal cancer.

Strategies in the management of mid and distal rectal cancer with total mesorectal excision

In the last two decades, dramatic improvement in outcome has been made in the management of rectal cancer. This has been brought about mainly by advancements in surgical technique for radical resection. With the recognition of the importance of the circumferential margin and presence of spread in the lymphovascular tissues in the mesorectum, total mesorectal excision is now commonly recognized as the optimal surgical technique for cancer of the mid and distal rectum. Not only have local control and disease-specific survival improved with the practice of total mesorectal excision, but various bodily functions have also been preserved following surgery for rectal cancer. New issues have arisen with the practice of total mesorectal excision and the strategies for management of rectal cancer require re-evaluation. In this article, the rationale and the outcomes of total mesorectal excision are reviewed. Issues such as the high anastomotic leakage rate following sphincter-preserving surgery, the poor results of abdominoperineal resection, the role of adjuvant therapy and bowel function disturbances will be addressed. Lastly, the status of the laparoscopic approach to rectal cancer with the principle of total mesorectal excision are discussed.