Laparoscopic surgery in rectal cancer: a retrospective analysis

Natural orifice transluminal endoscopic surgery for colorectal cancer

Background

Natural orifice transluminal endoscopic surgery (NOTES) has theoretical advantages over other approaches.

Methods

This was a prospective cohort study of colorectal cancers operated on by NOTES (transanally for rectal tumours, transvaginally for sigmoid tumours) between December 2013 and December 2015, with a minimum follow‐up of 1 year. Eligibility criteria included ASA fitness grade I–III, BMI below 25 kg/m² and TNM stage T3 N0 M0. Exclusion criteria included pregnancy or distant metastasis. The anastomosis was either handsewn or performed mechanically.

Results

Sixteen patients were operated on by a transanal and four by a transvaginal approach. There were ten men and ten women, with a mean(s.d.) age of 55·6(12·1) years. Mean BMI was 22·4(2·6) kg/m². Four anterior, 11 low anterior and five intersphincteric resections were performed for 16 rectal and four low sigmoid tumours. The mean duration of surgery was 258(11) min. No conversion to laparotomy was needed, and there were no deaths. Five patients required additional ports, for intraoperative bleeding (1), suture of an intraoperative urethral injury with covering ileostomy (1) and difficulty in dissection (3). One patient had an anastomotic leak requiring transanal closure and ileostomy on day 7. Both ileostomies were closed after 2 months. The mean hospital stay was 6·4(1·8) days. All resections were R0.

Conclusion

In carefully selected patients NOTES for colorectal cancer resection was feasible and effective.

Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years?

AIM

Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early postoperative complications in laparoscopic rectal cancer surgery have improved over the past 20 years.

METHOD

A literature search of the EMBASE and MEDLINE databases between August 1991 and August 2011 was conducted using the keywords laparoscopy, rectal cancer and postoperative complications. Data were analysed using linear regression ANOVA performed in GNUMERICS software.

RESULTS

Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in the rate of any early postoperative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (P = 0.01).

CONCLUSION

There was no evidence of a statistically significant change in early postoperative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, the limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of ongoing randomized clinical trials might show improved outcomes.

Laparoscopic total mesorectal excision can be performed on a nonselective basis in patients with rectal cancer with excellent medium-term results

AIM

Concerns exist regarding laparoscopic rectal cancer surgery due to increased rates of open conversion, complications and circumferential resection margin positivity. This study reports medium-term results from consecutive unselected cases in a single surgeon series.

METHOD

The results of laparoscopic total mesorectal excision (TME) for rectal cancer over a 9-year period within the context of an evolving 'enhanced recovery protocol' (ERP) were reviewed from analysis of a prospectively maintained database.

RESULTS

One hundred and fifty patients (91 male, median age 69 years, median BMI 26) underwent laparoscopic TME over 9 years. Median follow up was 28.5 months (range 0-88). Sixteen (10.6%) patients underwent neoadjuvant radiotherapy. Six (4.0%) required open conversion and 13 (9.0%) had an anastomotic leakage. The proportion of Dukes stages were: A, 33.3%; B, 30.7%; C, 31.3%; D, 4.7%. Five (3.3%) patients had an R1 and one an R2 resection. Median length of postoperative stay was 6 days. Three (2.0%) patients died within 30 days. Four (2.7%) developed local recurrence and 14 (9.3%) developed distant metastases. Predicted 5-year disease-free and overall survival rates by Kaplan-Meier analysis were 85.8% and 78.7%, respectively.

CONCLUSION

Laparoscopic TME surgery can safely be offered to unselected patients with rectal cancer with excellent medium-term results.

Abdominoperineal Resection without an Abdominal Incision for Rectal Cancer Has the Advantage of No Abdominal Wound Complication and Easier Stoma Care

Abdominoperineal resection has been used for years for the management of low rectal cancer. However, the abdominal incision is associated with many complications and causes interference of the stoma care. If the abdominal incision can be avoided, it would be beneficial to the patient. The aim of the study is to evaluate the possibility and safety of performing abdominoperineal resection and the oncology result without an abdominal incision. From September 2001 to May 2010, 40 patients with rectal malignancies received excision of the rectum, anus, and perineum through a perineal incision and a skin hole created for stomy. No harmonic scalpel or laser was used during surgery. No laparoscope or hand port was used in the procedure. There were 19 males and 21 females. Age ranged from 31 to 87 years old (average, 62.9 years). There were 39 adenocarcinomas and one malignant gastrointestinal stromal cell tumor. There was no operative mortality. Six patients had postoperative complications; three patients had intestinal obstructions; and one patient each had bleeding, urinary tract infection, and colostomy separation from the skin. The lymph nodes in the specimens ranged from 9 to 33 cm (average, 16.8 cm). The survival is similar to the traditional abdominoperineal resection. This limited experience suggests that an abdominal incision is not necessary for radical resection of the rectum, anus, and perineum in patients with low-lying rectal cancer. It also offers the patient easier care of stoma without interference of the abdominal incision.