Operative Behandlung von Rektumkarzinomen im Vergleich

Effect of placing double-lumen irrigation-suction tube on closure of anastomotic defect following rectal cancer surgery

PURPOSE

This study aimed to investigate the effect of placement of double-lumen irrigation-suction tubes (DLIST) on the closure of anastomotic defect (AD) after rectal cancer surgery.

METHODS

The study was carried out at two centers managed by one surgeon, both adopted the same treatments. Patients with postoperative AD after rectal cancer surgery from January 2011 to June 2020 were eligible and were divided into a passive drainage (PD) group and a DLIST group according to whether the PD, placed in the rectal cancer surgery, had been replaced with the DLIST. The effect of DLIST on the AL was evaluated.

RESULT

There distributed 76 patients in the DLIST group and 52 in the PD group. A higher closure rate was reported in the DLIST group (46 patients in DLIST group, for a closure rate of 60.5%, and 21 patients in PD group, for a closure rate of 40.4%. HR = 3.05; 95% CI: 1.79-5.19; P < 0.001). Both length of stay and costs of the treatment in the DLIST group were lower (54 days [interquartile range, IQR: 41-17] days vs. 112 days [IQR: 66-27] days, P = 0.005; and $18,721 [IQR: $14,982-4,960] vs. $40,840 [IQR: $20,932-50,529], P < 0.001).

CONCLUSION

Placement of DLIST might serve as an effective method for treating AD following rectal cancer surgery. In comparison with PD, it costs lower to apply DLIST in the treatment of AD and the length of stay is shorter.

T stage-dependent lymph node and distant metastasis and the accuracy of lymph node assessment in rectal cancer

Objective

To analyze data obtained in a representative number of patients with primary rectal cancer with respect to lymph node diagnostics and related tumor stages.

Methods

In pT2-, pT3-, and pT4 rectal cancer lesions, the impact of investigated lymph nodes on the frequency of pN+ status, the cumulative risk of metachronous distant metastases, and overall survival was studied by means of a prospective multicenter observational study over a defined period of time.

Results

From 2000 to 2011, the proportion of surgical specimens with ≥ 12 investigated lymph nodes increased significantly, from 73.6% to 93.2% (p < 0.001; the number of investigated lymph nodes from 16.2 to 20.8; p < 0.001). Despite this, the percentage of pN+ rectal cancer lesions varied only non-significantly (39.9% to 45.9%; p = 0.130; median, 44.1%). For pT2-, pT3-, and pT4 rectal cancer lesions, there was an increasing proportion of pN+ findings correlating significantly with the number of investigated lymph nodes up to n = 12 investigated lymph nodes. Only in pT3 rectal cancer was there a significant increase in pN+ findings in case of > 12 lymph nodes (p = 0.001), but not in pT2 (p = 0.655) and pT4 cancer lesions (p = 0.256). For pT3pN0cM0 rectal cancer, the risk of metachronous distant metastases and overall survival did not depend on the number of investigated lymph nodes.

Conclusion

In rectal cancer, at least n = 12 lymph nodes are to be minimally investigated. The investigation of fewer lymph nodes is associated with a higher risk of false-negative pN0 findings. In particular, in pT3 rectal cancer, the investigation of more than 12 lymph nodes lowers the risk of false-negative pN0 findings. An upstaging effect by the investigation of a possibly maximal number of lymph nodes could not be detected.

Visceral obesity and short-term outcomes after laparoscopic rectal cancer resection

BACKGROUND

Complications after rectal resection are frequent. Recently, methods to assess visceral obesity (VO) have become available as an alternative to measurement of body mass index (BMI). The aim of this study was to examine the association between visceral fat volume (VFV) and the short-term outcomes after laparoscopic low anterior resection (LLAR) in patients with rectal cancer.

METHODS

We studied a consecutive series of patients undergoing LLAR at Bispebjerg University Hospital from 01.01.2013 to 01.01.2016. Preoperative VFV was calculated from abdominal CT scans using an automatic segmentation tool. The primary outcome was anastomotic leakage (AL). Secondary outcomes included conversion to open surgery, number of lymph nodes harvested, the rates of 30-day complications as well as reoperations, and 1-year survival.

RESULTS

A total of 102 patients were included. VO was defined as a VFV above the 75 percentile. Thirteen (12.7%) patients developed AL, four (15.4%) of whom were in the VO group (p = 0.900). At least one postoperative complication developed in 38 (37.3%) patients, with no significant difference between the VO and non-VO patients after univariable analysis (42.3% vs. 35.4%, p = 0.702) or multivariable adjustment (OR 1.01, 95% CI 0.38-2.65, p = 0.984). VO was significantly associated with an increased incidence of conversion to open surgery (OR 4.30, 95% CI 1.29-14.86, p = 0.018). There was a significant difference in the number of harvested lymph nodes between the two groups (mean 23.5 vs. 29.1, p = 0.045).

CONCLUSIONS

In this study on patients undergoing laparoscopic rectal resection, VO was not associated with development of AL or other complications. However, we found that visceral obesity was associated with an increased risk of conversion to open surgery.

Are Colon and Rectal Cancer Two Different Tumor Entities? A Proposal to Abandon the Term Colorectal Cancer

Colon cancer (CC) and rectal cancer (RC) are synonymously called colorectal cancer (CRC). Based on our experience in basic and clinical research as well as routine work in the field, the term CRC should be abandoned. We analyzed the available data from the literature and results from our multicenter Research Group Oncology of Gastrointestinal Tumors termed FOGT to confirm or reject this hypothesis. Anatomically, the risk of developing RC is four times higher than CC, while physical activity helps to prevent CC but not RC. Obvious differences exist in molecular carcinogenesis, pathology, surgical topography and procedures, and multimodal treatment. Therefore, we conclude that CC is not the same as RC. The term "CRC" should no longer be used as a single entity in basic and clinical research as well as other areas of classification.

[Laparoscopic rectal resection technique]

The quality of radical oncological operations for patients with rectal cancer determines the rate of local recurrence and long-term survival. Neoadjuvant chemoradiotherapy for locally advanced tumors, a standardized surgical procedure for rectal tumors less than 12 cm from the anus with total mesorectal excision (TME) and preservation of the autonomous nerve system for sexual and bladder function have significantly improved the oncological results and quality of life of patients. The TME procedure for rectal resection has been performed laparoscopically in Germany for almost 20 years; however, no reliable data are available on the frequency of laparoscopic procedures in rectal cancer patients in Germany. The rate of minimally invasive procedures is estimated to be less than 20 %. A prerequisite for using the laparoscopic approach is implicit adherence to the described standards of open surgery. Available data from prospective randomized trials, systematic reviews and meta-analyses indicate that in the early postoperative phase the generally well-known positive effects of the minimally invasive approach to the benefit of patients can be realized without any long-term negative impact on the oncological results; however, the results of many of these studies are difficult to interpret because it could not be confirmed whether the hospitals and surgeons involved had successfully completed the learning curve. In this article we would like to present our technique, which we have developed over the past 17 years in more than 1000 patients. Based on our experiences the laparoscopic approach can be highly recommended as a suitable alternative to the open procedure.

Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes

The aim of our study was to compare short-term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid-low RC after NCRT.

Integration of open and laparoscopic approaches for rectal cancer resection: oncologic and short-term outcomes

BACKGROUND

Laparoscopy is increasingly used for rectal cancer surgery. Laparoscopic surgery is not attempted for some suitable patients because of concerns for conversion or technical difficulty. This study aimed to evaluate oncologic and short-term outcomes for patients undergoing curative resection for rectal cancer via laparoscopic and open approaches.

METHODS

A prospective database was reviewed to identify rectal cancer resections from 2005 to 2011. Patients who had primary rectal cancer within 15 cm of the anal verge were included in the study. Those with recurrent or metastatic disease were excluded. Patients were assigned to laparoscopic or open approaches preoperatively based on clinical criteria and imaging. All patients underwent a standard total mesorectal excision and followed a standardized enhanced recovery pathway. The oncologic and clinical outcomes were evaluated by approach.

RESULTS

The analysis included 81 patients. The preoperative assignments consisted of 62 laparoscopic (77%) and 19 open (23%) procedures. Nine laparoscopic procedures (14.5%) were converted to open procedures. After a median follow-up period of 25 months, all oncologic outcomes were comparable. Three patients (two laparoscopic, one open) had a positive circumferential margin (≤1 mm). The laparoscopic and open groups were similar in terms of their 3-year disease-free periods (93.6 vs. 88.2%; P = 0.450) and overall survival periods (93.5 vs. 90.9%; P = 0.766). The local recurrence rate was 2.5%.

CONCLUSIONS

Laparoscopic resection for rectal cancer can be attempted for most patients. Conversion to open procedure does not compromise clinical or oncologic outcomes. In practice, combining laparoscopic and open surgery optimizes resource use and results in at least equivalent outcomes.

Robotic versus laparoscopic surgery for mid-low rectal cancer after neoadjuvant chemoradiation therapy: comparison of oncologic outcomes

PURPOSE

Minimal invasive surgery for mid and low rectal cancer after neoadjuvant long-course chemoradiotherapy (LCRT) can be challenging. The aim of our study was to compare outcomes of laparoscopic and robotic resections in mid and low rectal cancers after LCRT.

METHODS

Between Jan 2006 and Dec 2010, all patients who underwent robotic or laparoscopic resections for mid and low rectal cancers after LCRT were identified from a prospective database. These patients received treatment (5FU-based chemotherapy, 50.4 Gy radiotherapy), as they were T3 or T4 and/or node + ve. Patients in the two groups were compared with respect to demographics, clinical safety, and oncological outcomes.

RESULTS

One hundred thirty-eight patients underwent rectal cancer resection after LCRT, either robotic (n = 74) or laparoscopic (n = 64). The patients in both groups were comparable in terms of demographics, distance of tumor from anal verge, and type of procedures. There were four (6.3 %) conversions in laparoscopic group and one (1.4 %) in the robotic group (p = 0.183). The morbidity rates in the laparoscopic and robotic group were 26.6 % and 16.2 %, respectively (p = 0.137). With a median follow up of 3 years, the local recurrence in the laparoscopic and robotic group was four (6.3 %) and two (2.7 %), respectively (p = 0.420). The 3-year overall survival rate for laparoscopic and robotic group was 92.1 and 90.0 %, respectively (p = 0.803). The 3-year disease-free survival was also comparable, 78.8 % (laparoscopic) versus 77.7 % (robotic) (p = 0.390).

CONCLUSION

With a median follow up of 3 years, robotic surgery for mid and low rectal cancer was associated with oncological outcomes comparable to laparoscopic surgery.

Long-term oncologic outcome after laparoscopic surgery for rectal cancer

BACKGROUND

Recent studies demonstrated favorable short- and mid-term results after laparoscopic surgery for rectal cancer. However, long-term results from large series are lacking. The present study analyses long-term results of laparoscopic rectal cancer surgery from a large-volume center.

METHODS

From January 1998 until March 2005, 225 patients underwent laparoscopic rectal resection due to carcinoma at the Medical Centre of the University of Regensburg. From 224 patients, a follow-up over 10 years was performed using the data of the Tumour Centre of the University of Regensburg. The data were analysed using oncological data (tumour recurrence) as well as overall survival. In addition, the effect of conversion to open resection on overall survival was analysed.

RESULTS

With a median of 10 years at follow-up, the overall and disease-free survival was 50.5 and 50.1 %, respectively. Local recurrence of all patients was 5.8 % and none of the converted patients was within this group. The median time interval for the development of local recurrence was 30 months. Six of the 13 patients with local recurrence (46.1 %) had received neoadjuvant radiochemotherapy before surgery. Patients with a conversion to open surgery had primarily a significantly worse outcome than patients resected completely laparoscopically (p = 0.003). However, this difference was no longer apparent using a multivariant analysis (hazard ratio 1.221; p = 0.478).

CONCLUSIONS

Overall survival and local recurrence rate of patients undergoing laparoscopic resection of rectal cancer are comparable to open surgery. However, in our analysis, patients undergoing laparoscopic anterior resection had a higher survival rate compared with patients with abdominoperineal resection.

Laparoscopy in the surgical treatment of rectal cancer in Germany 2000-2009

AIM

The goal of this registry study was to compare open surgery with planned laparoscopy and then with laparoscopic to open conversion for rectal cancer surgery.

METHOD

The study included 17,964 rectal cancer patients, operated on between 1 January 2000 and 31 December 2009, from 345 hospitals in Germany. All statistical tests were two-sided, with the χ(2) test (Pearson correlation) for patients and tumour characteristics. Fisher's exact test was used for complications and 30-day mortality.

RESULTS

Of the 17,964 rectal cancer patients, 16,308 (90.8%) had an open procedure and 1656 (9.2%) were started with a laparoscopy. The 1455 patients with completed laparoscopic operations had fewer intra-operative and postoperative complications (5.4%vs 7.0%, P = 0.020, and 20.5%vs 25.8%, P < 0.001, respectively) and a lower 30-day mortality rate (1.1%vs 1.9%, P = 0.023). Of the 1656 planned laparoscopies, 201 (12.1%) were converted to open. The converted group suffered more intra-operative complications (18.9%vs 3.6% for completed laparoscopy and 7.0% for open surgery, P < 0.0001) and postoperative complications (32.3%vs 18.9% for completed laparoscopy and 25.8% for open operations, P < 0.0001). The converted group also had a higher 30-day mortality rate (2.0%vs 1.0% for completed laparoscopy and 1.9% for open surgery, P = 0.043).

CONCLUSION

The more favourable patient profile provided justification for a laparoscopic procedure. For those converted to an open procedure, however, there were significantly more complications than planned open surgery patients. A move away from the standard open procedure for rectal cancer surgery and towards laparoscopy is not yet feasible.

European quality assurance programme in rectal cancer--are we ready to launch?

AIM

There have been initiatives to create a European audit project. This paper addresses the issue of differences in data collected by different registries.

METHOD

Patients with rectal cancer treated in 2008 and recorded in quality registries from Belgium, Germany/Poland, Spain and Sweden were analyzed. The comparison included number of patients, gender, age, American Society of Anesthesiology (ASA) classification, preoperative diagnostic and staging procedures, neoadjuvant therapy, surgical treatment and quality of surgery, postoperative complications and adjuvant treatment.

RESULTS

The Belgian database consisted of 622 patients, the German/Polish database consisted of 3,393 patients, the Spanish database consisted of 1,641 patients and the Swedish database consisted of 1,826 patients. The percentage of patients in each ASA stage was highly variable. MRI use was highest in Spain and Sweden and very low in Germany/Poland. The percentage of cT4 stage tumours in Sweden was much higher than in all other countries. Sweden recorded the highest percentage of primary metastatic disease (20.3%) and Belgium recorded the lowest (10.2%). Neoadjuvant therapy in different protocols was administered to 41.2% patients in Germany/Poland, to 50.8% in Spain, to 55.2% in Belgium and to 62% in Sweden. Laparoscopic surgery (conversion rate) was performed for cure in 5% (28%) of patients in Sweden, in 20.8% (20.6%) in Spain, in 28.6% (15.2%) in Belgium and in 14.5% (8.9%) in Germany/Poland. The 30-day mortality for anterior resection, abdominoperineal excision and Hartmann's procedure in Sweden, Belgium and Spain was 2.0%, 2.3% and 3.1%, respectively. The German/Polish database reported an in-hospital mortality of 3.2%.

CONCLUSION

A European quality assurance project in rectal cancer is possible only after data collection is standardized.

Laparoscopic colorectal resection for cancer: effects of conversion on long-term oncologic outcomes

BACKGROUND

The effects of conversion to open surgery during laparoscopic resection for colorectal cancer on long-term oncologic outcomes still are unclear.

METHODS

All 450 laparoscopic colorectal resections for cancer performed at a single center between 1994 and 2008 and included in a prospectively maintained database were considered. Patients who required conversion to open surgery (CONV) were matched 1:2 with laparoscopically completed cases (LAP) and 1:5 with open surgery cases (OPEN) for age, American Society of Anesthesiologists (ASA) score, year of surgery, tumor location, and tumor stage. Fisher's exact, chi-square, and Wilcoxon tests were used as appropriate. Kaplan-Meier curves were compared to analyze survival.

RESULTS

In this study, 31 CONV cases were independently compared with 62 LAP and 155 OPEN cases. Compared with the LAP and OPEN patients, the CONV patients were characterized by a numerically higher rate of preoperative comorbidity (61.3% vs LAP, 51.6; P = 0.4 and OPEN, 48.4%; P = 0.2), male gender (77.4% vs LAP, 59.7%; P = 0.09 and OPEN, 58.1%; P = 0.05), and a significantly higher mean body mass index (29.6 vs LAP, 26.8; P = 0.012 and OPEN, 28.8; P = 0.3). The pathologic tumor stage, location, and chemotherapy and radiotherapy rates were comparable among the groups. After a median follow-up period of 4.1, 4.2, and 4.6 years, the 5-year disease-free survival rate was significantly lower for the CONV patients (40.2%) than for the LAP (70.7%, P = 0.01) or the OPEN (63.3%, P = 0.04) patients. However, the 5-year cancer-specific survival rates were similar among the CONV (94.4%), LAP (86.1%, P = 0.36), and OPEN (84.9%, P = 0.14) patients.

CONCLUSIONS

Conversion to open surgery does not affect oncologic outcomes, although CONV patients have increased comorbidity rates affecting long-term mortality.

Impact of conversion on outcome in laparoscopic colorectal cancer surgery

INTRODUCTION

Long-term results after laparoscopic surgery with conversion to open surgery for colorectal cancer are seldom published.

AIM

The study analysed the impact of conversion of laparoscopic surgery to open resection for colorectal cancer on short- and long-term results.

MATERIAL AND METHODS

The prospectively collected data of 469 patients with colorectal cancer in the period from 1 January 2001 to 31 December 2006 were analysed. Short- and long-term results were compared.

RESULTS

The relative frequency of conversion was 7%. The subgroups were statistically similar regarding age, gender, body mass index (BMI), localization of tumour, T stage, and TNM stage. We observed a lower frequency of previous surgery (p = 0.018) in the group of patients with conversions to open surgery as well as statistically significantly higher frequency of patients with American Society of Anesthesiologists (ASA) score II (p = 0.039). There was no statistical difference in morbidity, mortality, or the length of hospital stay between both the groups of patients. The operating time was significantly higher in the group of patients with conversion (p = 0.00001). There was a significantly higher blood loss in the patient groups with conversion to open surgery and in the group with primarily open surgery (p = 0.00023). There was no difference in the overall survival (p = 0.712), disease-free survival (p = 0.072) or in the local (p = 0.432) or distant (p = 0.957) recurrence.

CONCLUSIONS

No negative impact on short- or long-term results of conversion to open surgery was verified in patients with colorectal surgery.

Impact of prior abdominal surgery on curative resection of colon cancer via minilaparotomy

PURPOSE

To evaluate the impact of prior abdominal surgery on curative resection of colon cancer via a minilaparotomy approach.

METHODS

Feasibility, safety, and oncological outcomes were evaluated retrospectively in 263 patients scheduled to undergo curative resection of colon cancer via a minilaparotomy approach, defined as a skin incision of ≤ 7 cm, between September 2000 and March 2009.

RESULTS

Abdominal adhesions were found in 59 (77.6%) of 76 patients who had undergone prior abdominal surgery (PAS group) and in 4 (2.1%) of 187 patients who had not (control group). The success rate of the minilaparotomy approach was 92.1% in the PAS group and 97.3% in the control group (P = 0.08). The incidence of extending the minilaparotomy wound for adhesiolysis was significantly higher in the PAS group than in the control group (6.6% vs 0.5%; P < 0.01). The two groups did not differ significantly in terms of the types of surgery, pathological stage, body mass index, operative time, blood loss, incidence of postoperative complications, length of postoperative hospital stay, and disease-free survival.

CONCLUSIONS

These results suggest that prior abdominal surgery might require an extension of the minilaparotomy incision but that it does not seem to contraindicate a minilaparotomy approach for curative colectomy.

[Quality criteria for treatment of colorectal cancer. From a surgeon's viewpoint]

The surgeon is the key "prognosis factor" for colorectal cancer. For this reason quality criteria were recently established (including minimum numbers) in order to treat patients who are entitled to the best quality of care and to improve the prognosis. The aim of this study was to critically discuss the existing demands on the surgeon based on the current literature and our own results and to formulate evidence-based quality criteria for surgical clinics. After reviewing the current literature criteria were compiled, discussed and finally presented in a summarized form. These are based on current developments on the diagnostic and therapy of large intestine and colorectal carcinoma. New developments of the German Cancer Society for planning of organ centers are incorporated. The quintessence of our study is that the number of cases alone is not decisive for the success of therapy. Important are the application of the correct surgical-oncology operation procedure, adherence to standards and the training of surgeons. Following the S3 guidelines stage-oriented therapy should additionally be carried out in a structured sequence. This includes an interdisciplinary decision making on the diagnostic and therapy strategy (tumor board). The organization structure of the hospital (teams, tumor board, emergency care with intensive care unit, emergency diagnostic and options for interventional measures) can be more important than the hospital case numbers alone. These demands which have been evaluated from published data and own results are designed to raise the therapy of colorectal cancer to the best possible level of quality and to effect a further improvement in the prognosis.

Postoperative complications following surgery for rectal cancer

OBJECTIVE

This systematic review was designed to determine postoperative complication rates of radical surgery for rectal cancer (abdominal perineal resection and anterior resection).

SUMMARY OF BACKGROUND DATA

Lack of accepted complication rates for rectal cancer surgery may hinder quality improvement efforts and may impede the conception of future studies because of uncertainty regarding the expected event rates.

METHODS

All prospective studies of rectal cancer receiving radical surgery published between 1990 and August 2008 were obtained by searching Ovid MEDLINE, EMBASE, as well as ASCO GI, CAGS, and ASCRS meeting abstracts between 2004 and 2008. There was no language restriction. The outcomes extracted were anastomotic leak, pelvic sepsis, postoperative death, wound infection, and fecal incontinence. Summary complication rates were obtained using a random effects model; the Z-test was used to test for study heterogeneity.

RESULTS

Fifty-three prospective cohort studies and 45 randomized controlled studies with 36,315 patients (24,845 patients had an anastomosis) were eligible for inclusion. Most of the studies found were based in continental Europe (58%), followed by Asia (25%), United Kingdom (10%), North America (5%), and Australia/New Zealand. The anastomotic leak rate, reported in 84 studies, was 11% (95% CI: 10, 12); the pelvic sepsis rate, in 29 studies, was 12% (9, 16); the postoperative death rate, in 75 studies, was 2% (2, 3); and the wound infection rate, in 50 studies, was 7% (5, 8). Fecal incontinence rates were reported in too few studies and so heterogeneously that numerical summarization was inappropriate. Year of publication, use of preoperative radiation, use of laparoscopy, and use of protecting stoma were not significant variables, but average age, median tumor height, and method of detection (clinical vs. radiologic) showed significance to explain heterogeneity in anastomotic leak rates. Year of publication, study origin, average age, and use of laparoscopy were significant, but median tumor height and preoperative radiation use were not significant in explaining heterogeneity among observed postoperative death rates. With multivariable analysis, only average age for anastomotic leak and year of publication for postoperative death remained significant.

CONCLUSIONS

Benchmark complication rates for radical rectal cancer surgery were obtained for use in sample size calculations in future studies and for quality control purposes. Postoperative death rates showed improvement in recent years.

Laparoscopically assisted reversal of Hartmann procedure

INTRODUCTION

Restoration of intestinal continuity following Hartmann procedure is an operation associated with a lengthy stay in hospital, protracted convalescence, and a high morbidity rate. With the aim of using the advantages of minimally invasive surgery, such as rapid mobilization, less postoperative pain, early restoration of bowel function, and a rapid return to a normal diet, and reduced morbidity, the laparoscopic modality was employed. The objective of the present study was to investigate the usefulness of laparoscopic restoration of intestinal continuity following Hartmann procedure.

METHOD

A total of 71 patients who, in the period between 1995 and 2005 within the framework of the prospective multicenter study "Laparoscopic Colorectal Surgery Study Group," underwent a laparoscopically assisted restoration of bowel continuity following Hartmann procedure, were investigated.

RESULTS

In 62 patients (87%), the laparoscopic procedure was completed as planned, whereas 9 cases had to be converted to open surgery-mostly on account of massive intra-abdominal adhesions. The 39 male (55%) and 32 female (45%) patients had an average body mass index of 25 (range, 19 to 38), a height of 168 cm (range, 150 to 190 cm), and a weight of 72 kg (range, 49 to 103 kg). Mean operating time was 164 min (range, 60 to 410 min) and the intraoperative blood loss 196 mL (range, 10 to 1000 mL). Five patients (7%) received packed red cells. In all, 85.9% of the procedures (n=61) were free of complications. The most common intraoperative complications were injuries to the bowel and problems with the anastomosis (dehiscence, difficult stapling), each occurring in 5.6% of the cases (n=4). Intraoperative lesions to the ureters (0%), the bladder (n=1/1.4%), and blood vessels (n=1/1.4%) played a numerically subordinate role. Purely parenteral nutrition was applied up to the third postoperative day (range, 0 to seventh postoperative day). In those patients who were able to take a liquid meal on the third postoperative day (range, first to eighth postoperative day), enteral nutrition was initiated on the fifth postoperative day (range, second to tenth postoperative day). On average, bowel movements were restored on the fourth postoperative day (range, second to ninth postoperative day). Patients in whom a bladder catheter was placed for the operation had it removed on the third postoperative day (range, first to twelfth postoperative day) and had normal urination thereafter. In Hartmann procedure, patients without such a catheter, normal urination was possible from postoperative day 1 onward (range, 0 to second postoperative day). Postoperative complications included hematomas/abscesses (n=3/4.2%), transit disorders (n=2/2.8%), surgery-requiring ileus (n=2/2.8%), cardiopulmonary complications (n=1/1.4%), and surgery-requiring hemorrhage (n=1/1.4%), with other complications accounting for 4.2% (n=3). The median hospital stay was 11 days (range, 5 to 35 d); the mortality rate was 1.4% (n=1).

CONCLUSIONS

Reversal of Hartmann procedure employing the laparoscopic modality is compatible with acceptable morbidity and mortality rates. The elevated conversion rate is a reflection of the fact that the operation is technically demanding.

Laparoscopic rectal resection for cancer: effects of conversion on short-term outcome and survival

BACKGROUND

Laparoscopic rectal resection (LRR) is an oncologically safe procedure. The impact of conversion to open surgery on outcomes has not been fully elucidated. The aim of the study is to compare short- and long-term outcomes of converted (CR) and not converted (NCR) patients undergoing LRR.

METHODS

Data were drawn from a prospective database of LRR performed between 1999 and 2008. Statistical analysis employed the chi-squared or Wilcoxon test and Kaplan-Meier estimation.

RESULTS

Of 173 patients undergoing LRR, 26 (15%) required conversion. No differences in age, gender, American Society of Anesthesiologists (ASA) score, and T and N stages were observed between CR and NCR patients. Conversion was associated with higher body mass index (BMI) (27.3 versus 24.9 kg/m(2), P < 0.001) and American Joint Committee on Cancer (AJCC) stage IV (26.9% versus 4.8%, P < 0.001), and resulted in longer operative time (342 versus 285 min, P = 0.006) and increased intraoperative complication rate (31% versus 5%, P < 0.001). No differences were observed in postoperative outcome between CR and NCR patients. After a mean follow-up of 46 and 36 months, 5-year disease-free survival was 55.7% in CR group and 79.2% in NCR group (P = 0.007). After exclusion of stage IV patients from the analysis, 5-year disease-free survival was 71.1% in CR group and 85.3% in NCR group (P = 0.17), while the overall recurrence rate was 26.3% in CR patients and 11.4% in NCR patients (P = 0.07).

CONCLUSIONS

Our study suggests that conversion to open surgery does not affect postoperative outcome, but could have a negative impact on long-term overall recurrence rate. LRR should be performed by experienced surgeons in selected patients.

Conversion rate in 300 laparoscopic rectal resections and its influence on morbidity and oncological outcome

INTRODUCTION

The negative influence of conversion from laparoscopic to open colorectal resection on early postoperative morbidity and outcome has been demonstrated several times. In this study, we analyzed the conversion rate and its influence on early postoperative morbidity and short-term oncological outcome following laparoscopic rectal resections.

METHODS

From January 1998 to December 2006, 300 patients underwent laparoscopic resection due to rectal carcinoma at our institution. We compared the converted patient group with the non-converted patient group regarding demographical, clinical, surgical, and histological data, compounded with the early and late postoperative results.

RESULTS

Two hundred seventy-four (91.3%) patients underwent laparoscopic rectal resection (LR), while conversion resection (CR) was necessary in 26 cases (8.6%). Conversion rate was 13% during the first 100 resections and decreased to 3% during the last 100 procedures (p = 0.035). Male gender, higher body mass index, and presence of T4-tumor were risk factors for conversion. Early postoperative complications were more frequent in the CR group than in the LR group. Concerning local tumor recurrence and overall survival, there was no significant difference between both groups (local recurrence, CR at 3.8% vs. LR at 4.5% and overall survival rate, CR at 76.9% vs. LR at 89.1%) after a median follow-up period of 22.5 months.

CONCLUSION

Conversion to an open procedure during laparoscopic rectal resection correlates with an increased postoperative morbidity, however, without impairment of the short-term oncological outcome. The conversion rate is minimized by the growing experience of the operating surgeon and, therefore, is a marker of the learning curve.