1
|
de’Angelis N, Marchegiani F, Martínez-Pérez A, Biondi A, Pucciarelli S, Schena CA, Pellino G, Kraft M, van Lieshout AS, Morelli L, Valverde A, Lupinacci RM, Gómez-Abril SA, Persiani R, Tuynman JB, Espin-Basany E, Ris F. Robotic, transanal, and laparoscopic total mesorectal excision for locally advanced mid/low rectal cancer: European multicentre, propensity score-matched study. BJS Open 2024; 8:zrae044. [PMID: 38805357 PMCID: PMC11132137 DOI: 10.1093/bjsopen/zrae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 03/11/2024] [Accepted: 04/01/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Total mesorectal excision (TME) is the standard surgery for low/mid locally advanced rectal cancer. The aim of this study was to compare three minimally invasive surgical approaches for TME with primary anastomosis (laparoscopic TME, robotic TME, and transanal TME). METHODS Records of patients undergoing laparoscopic TME, robotic TME, or transanal TME between 2013 and 2022 according to standardized techniques in expert centres contributing to the European MRI and Rectal Cancer Surgery III (EuMaRCS-III) database were analysed. Propensity score matching was applied to compare the three groups with respect to the complication rate (primary outcome), conversion rate, postoperative recovery, and survival. RESULTS A total of 468 patients (mean(s.d.) age of 64.1(11) years) were included; 190 (40.6%) patients underwent laparoscopic TME, 141 (30.1%) patients underwent robotic TME, and 137 (29.3%) patients underwent transanal TME. Comparative analyses after propensity score matching demonstrated a higher rate of postoperative complications for laparoscopic TME compared with both robotic TME (OR 1.80, 95% c.i. 1.11-2.91) and transanal TME (OR 2.87, 95% c.i. 1.72-4.80). Robotic TME was associated with a lower rate of grade A anastomotic leakage (2%) compared with both laparoscopic TME (8.8%) and transanal TME (8.1%) (P = 0.031). Robotic TME (1.4%) and transanal TME (0.7%) were both associated with a lower conversion rate to open surgery compared with laparoscopic TME (8.8%) (P < 0.001). Time to flatus and duration of hospital stay were shorter for patients treated with transanal TME (P = 0.003 and 0.001 respectively). There were no differences in operating time, intraoperative complications, blood loss, mortality, readmission, R0 resection, or survival. CONCLUSION In this multicentre, retrospective, propensity score-matched, cohort study of patients with locally advanced rectal cancer, newer minimally invasive approaches (robotic TME and transanal TME) demonstrated improved outcomes compared with laparoscopic TME.
Collapse
Affiliation(s)
- Nicola de’Angelis
- Unit of Robotic and Minimally Invasive Digestive Surgery, Department of Surgery, Ferrara University Hospital, Ferrara (Cona), Italy
| | - Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital (AP-HP), Clichy, France
- University Paris Cité, Paris, France
| | - Aleix Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
- Biosanitary Research Institute, Valencian International University (VIU), Valencia, Spain
| | - Alberto Biondi
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Salvatore Pucciarelli
- General Surgery 3, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Carlo Alberto Schena
- Unit of Robotic and Minimally Invasive Digestive Surgery, Department of Surgery, Ferrara University Hospital, Ferrara (Cona), Italy
| | - Gianluca Pellino
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Miquel Kraft
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Annabel S van Lieshout
- Department of Surgery, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alain Valverde
- Department of Digestive Surgery, Groupe Hospitalier Diaconesses, Croix Saint-Simon, Paris, France
| | - Renato Micelli Lupinacci
- Department of Digestive Surgery, Groupe Hospitalier Diaconesses, Croix Saint-Simon, Paris, France
| | - Segundo A Gómez-Abril
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Roberto Persiani
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Eloy Espin-Basany
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Frederic Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| |
Collapse
|
2
|
Svoboda M, Procházka V, Grolich T, Pavlík T, Mazalová M, Kala Z. Does Pathological Complete Response after Neoadjuvant Therapy Influence Postoperative Morbidity in Rectal Cancer after Transanal Total Mesorectal Excision? J Gastrointest Cancer 2023; 54:528-535. [PMID: 35524090 DOI: 10.1007/s12029-022-00826-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE It is still unclear if pathological complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) in patients treated for rectal cancer causes worse postoperative outcomes, especially after transanal total mesorectal excision (TaTME). Worse postoperative outcomes might be an argument for an organ preserving watch and wait strategy in fragile patients and patients with comorbidities. The aim of this study is to evaluate whether patients treated for rectal cancer who had pCR to neoadjuvant therapy develop worse postoperative outcomes after TaTME than patients without complete response. METHODS Comparative retrospective analysis (with nearest neighbor matching algorithm) of postoperative outcomes in two groups of patients, with pCR, n = 15 and without pCR (non-pCR), n = 57. All patients were operated on only by one surgical approach, TaTME, for middle and distal rectal tumors. All procedures were performed by one surgical team between 2014 and 2020 at the University Hospital Brno in Czech Republic. RESULTS Overall morbidity was comparable between the groups (pCR group - 53.8% vs. non-pCR - 38.6%, p = 0.381). Anastomotic leak (AL) was observed in 33.3% of patients with pCR and in 17.5% of patients in the non-pCR group without statistical significance (p = 0.281). CONCLUSION In conclusion, pathological complete response after neoadjuvant therapy does not appear to affect postoperative morbidity in rectal cancer after TaTME. Therefore, in patients with complete response who are not adherent to W&W surveillance, surgical resection can be perform without increased postoperative complications.
Collapse
Affiliation(s)
- Martin Svoboda
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
| | - Vladimír Procházka
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic.
| | - Tomáš Grolich
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
| | - Tomáš Pavlík
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Monika Mazalová
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdeněk Kala
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
| |
Collapse
|
3
|
Efficacy of Laparoscopic Radical Resection Combined with Neoadjuvant Chemotherapy and Its Impact on Long-Term Prognosis of Patients with Colorectal Cancer. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4774531. [PMID: 35983001 PMCID: PMC9381182 DOI: 10.1155/2022/4774531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/09/2022] [Accepted: 07/13/2022] [Indexed: 12/04/2022]
Abstract
Objective The aim of the study is to examine the efficacy of laparoscopic radical resection of colorectal cancer combined with neoadjuvant chemotherapy and its impact on the overall prognosis of patients with colorectal cancer (CC). Methods A total of 80 CC patients hospitalized and treated at our hospital between November 2019 and June 2021 were selected at random as research subjects and divided equally into two groups: the surgical group (n = 40) and the combination group (n = 40). Patients in the surgical group were treated with laparoscopic radical resection, while patients in the combination group received laparoscopic radical resection combined with neoadjuvant chemotherapy. The two groups were compared in terms of surgery-related indicators, tumor markers (serum carcinoembryonic antigen (CEA), glycoprotein 199 (CA199), vascular endothelial growth factor (VEGF), and matrix metalloproteinase 9 (MMP9)), postoperative complications, and 1–3 years postoperative survival rate and recurrence rate. Results The surgical duration of the combination group was significantly shorter than the surgical group (P < 0.05). No significant differences were found in intraoperative blood loss, time to get out of bed, exhaust time, or hospital stay between the two groups (P < 0.05). In the combination group, serum tumor markers (carcinoembryonic antigen (CEA), carbohydrate antigen 199 (CA199), vascular endothelial growth factor (VEGF), and matrix metalloproteinase 9 (MMP9)) were markedly lower than those in the surgical group (P < 0.05). The combination group exhibited fewer postoperative complications than those in the operation group (P < 0.05). In the combination group, the 1–3 years postoperative survival rate was higher, while the 1–3 years postoperative recurrence rate was considerably lower than that in the surgical group (P < 0.05). Conclusion CC patients benefit well from laparoscopic radical resection coupled with neoadjuvant chemotherapy. The approach is efficient in lowering blood tumor markers in patients and lowering the risk of surgery-related complications. It has the potential to enhance patients' long-term prognoses, allowing them to live longer and lower their chance of recurrence.
Collapse
|
4
|
Yang J, Wang W, Luo Y, Huang S, Fu Z. Effect of pathological complete response after neoadjuvant chemoradiotherapy on postoperative complications of rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:163-174. [PMID: 35048217 DOI: 10.1007/s10151-021-02564-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 12/05/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Standard total mesorectal resection has become an important treatment option for locally advanced or high-risk rectal cancer after neoadjuvant chemo-radiotherapy. 15-27% of patients can achieve pathological complete response (PCR) after neoadjuvant chemo-radiotherapy (nCRT). However, the relationship between PCR and postoperative complications remains an important unsolved problem. The objective of this study was to determine whether PCR was associated with the rate of postoperative complications. METHODS This meta-analysis was implemented following the recommendations from Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched electronic literature by PubMed, EMBASE, and Google Scholar. Major outcomes of interest included anastomotic leakage, surgical-site infection, reoperation, and any postoperative complications. Other outcomes comprised postoperative hemorrhage, ileus, and mortality. RESULTS Eleven thousand two hundred ninety patients in 9 studies were included in the meta-analysis. The pooled analysis revealed that patients with PCR did not have a higher risk of anastomotic leakage (OR = 1.22, 95% CI 0.92-1.62, p = 0.17), reoperation (OR = 1.13, 95% CI 0.93-1.37, p = 0.22), and any postoperative complications (OR = 1.02, 95% CI 0.91-1.15, p = 0.72) than patients with non-PCR. However, the meta-analysis showed that the PCR group was superior to the non-PCR group in terms of surgical-site infection (9.38% vs. 12.44%OR = 0.68, 95% CI 0.47-0.98; p = 0.04). CONCLUSION PCR might not be related to the occurrence of postoperative complications in rectal cancer patients following nCRT. In addition, PCR might be associated with a lower risk of surgical-site infection.
Collapse
Affiliation(s)
- J Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - W Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Y Luo
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - S Huang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Z Fu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| |
Collapse
|
5
|
Anastomotic leak risk in complete responders to neoadjuvant therapy for rectal cancer: a systematic review. Int J Colorectal Dis 2021; 36:671-676. [PMID: 33427960 DOI: 10.1007/s00384-021-03833-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The oncological benefits of achieving a complete pathological response following neoadjuvant chemoradiotherapy for rectal cancer are well defined. How a pathological response affects anastomotic healing or leak rates is not clear. The aim of this systematic review was to compare anastomotic leak rates among patients who did and did not achieve a complete pathological response. METHODS Three major databases (PubMed, Embase, and Scopus) were searched. Predetermined inclusion criteria included prospective and retrospective articles published in English reporting complete pathological response and anastomotic leak rates following total mesorectal excision in ≥ 30 patients with rectal cancer who underwent neoadjuvant chemoradiotherapy and total mesorectal excision. The primary outcomes measured included complete pathological response and 30-day postoperative morbidity. RESULTS From a total of 8919 patients with rectal cancer in 7 studies, 4165 fulfilled the criteria for inclusion. The majority (> 80%) of patients had clinical stage II or III disease. A defunctioning loop ileostomy was formed in 76.5%. A total of 589 (14.1%) patients achieved a pCR of whom 63 (10.7%) developed an anastomotic leak compared to 272/3576 (7.6%) patients without a pCR (p = 0.02). CONCLUSION Patients with complete pathological response following neoadjuvant chemoradiotherapy and total mesorectal excision may be at higher risk of anastomotic leak than incomplete responders. This may need to be taken into account when counseling patients about the relative risks of organ preservation versus anterior resection.
Collapse
|
6
|
Pathologic complete response is associated with decreased morbidity following rectal cancer resection. Am J Surg 2020; 222:390-394. [PMID: 33261851 DOI: 10.1016/j.amjsurg.2020.11.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND There are conflicting data regarding the relationship between pathologic complete response (pCR) and post-operative complications following rectal cancer resection. The objective of this study was to compare the rates of morbidity among pCR patients and non-pCR patients and to identify factors that predict pCR morbidity in a large national database. METHODS This is a retrospective study using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy data (2016-18). Patients with neoadjuvant chemoradiation therapy followed by proctectomy were included, and divided into pCR and non-pCR groups according to final stage. The groups were compared with Student's t-test, Chi-squared or Fisher's exact test. Multivariate logistic regression models were constructed to estimate the association between pCR status and post-operative morbidity while adjusting for key covariates. RESULTS 244 pCR and 1656 non-pCR patients were included. pCR patients had higher body mass index (28.1 ± 6.2 vs. 29.1 ± 5.9 kg/m2; p = 0.01) and lower pre-operative stage (T stage, p = 0.03; N stage, p < 0.001). The groups were equivalent with respect to surgical approach, type of surgery, and operative time (p > 0.05). Post-operative complications in pCR patients were less frequent than in non-pCR patients (23.0% vs. 29.3%; p = 0.04). This association was robust to adjustment for confounders in logistic regression, as patients with pCR had decreased odds of post-operative morbidity (OR 0.66, CI [0.43, 0.96], p = 0.04). CONCLUSION pCR is associated with fewer post-operative complications compared to non-pCR, suggesting that pCR is not a marker of severe pelvic fibrosis. This difference may be due to underlying tumor biology, and associated increased technical challenges resecting larger, non-responsive tumors.
Collapse
|
7
|
Huang Y, Lee D, Young C. Predictors for complete pathological response for stage II and III rectal cancer following neoadjuvant therapy - A systematic review and meta-analysis. Am J Surg 2020; 220:300-308. [PMID: 31937416 DOI: 10.1016/j.amjsurg.2020.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/22/2019] [Accepted: 01/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND There has been an increasing interest in the complete pathological response (pCR) in rectal cancers following neoadjuvant therapy. The aim of this study was to identify predictive factors of pCR in locally advanced rectal cancer following neoadjuvant therapy. METHODS The studies identified were appraised with standard selection criteria. The selection criteria included studies on patients with stage II or III rectal cancer who underwent neoadjuvant therapy. RESULTS Patients with pCR are more likely to be older (p = 0.0002), have cancers closer distance to the anal verge (p < 0.00001), smaller tumors (P < 0.0001), no clinical lymph nodes involvement (p=<0.00001) and waited more than eight weeks until definitive surgery (p = 0.002). There was no difference in gender (p = 0.15) and tumor differentiation (p = 0.21). CONCLUSIONS The 'Watch and Wait' approach may be appropriate for selected patients. Patients with lower rectal cancers, smaller tumors, and negative clinical lymph node involvement may be more likely to achieve pCR following neoadjuvant therapy.
Collapse
Affiliation(s)
- Yeqian Huang
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia, 2050; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia.
| | - Daniel Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia, 2050; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia
| | - Christopher Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia, 2050; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia.
| |
Collapse
|
8
|
van der Sluis FJ, Couwenberg AM, de Bock GH, Intven MPW, Reerink O, van Leeuwen BL, van Westreenen HL. Population-based study of morbidity risk associated with pathological complete response after chemoradiotherapy for rectal cancer. Br J Surg 2019; 107:131-139. [DOI: 10.1002/bjs.11324] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/31/2022]
Abstract
Abstract
Background
Neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer may induce a pathological complete response (pCR) but increase surgical morbidity due to radiation-induced fibrosis. In this study the association between pCR and postoperative surgical morbidity was investigated.
Methods
Patients in the Netherlands with rectal cancer who underwent nCRT followed by total mesorectal excision between 2009 and 2017 were included. Data were stratified into patients who underwent resection with creation of a primary anastomosis and those who had a permanent stoma procedure. The association between pCR and postoperative morbidity was investigated in univariable and multivariable logistic regression analyses.
Results
pCR was observed in 976 (12·2 per cent) of 8003 patients. In 3472 patients who had a primary anastomosis, the presence of pCR was significantly associated with surgical complications (122 of 443 (27·5 per cent) versus 598 of 3029 (19·7 per cent) in those without pCR) and anastomotic leak (35 of 443 (7·9 per cent) versus 173 of 3029 (5·7 per cent) respectively). Multivariable analysis also showed associations between pCR and surgical complications (adjusted odds ratio (OR) 1·53, 95 per cent c.i. 1·22 to 1·92) and pCR and anastomotic leak (adjusted OR 1·41, 1·03 to 2·05). Of 4531 patients with a permanent stoma, surgical complications were observed in 120 (22·5 per cent) of 533 patients with a pCR, compared with 798 (20·0 per cent) of 3998 patients with no pCR (adjusted OR 1·17, 0·94 to 1·46).
Conclusion
Patients with a pCR in whom an anastomosis was created were at increased risk of developing an anastomotic leak.
Collapse
Affiliation(s)
| | - A M Couwenberg
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - G H de Bock
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - M P W Intven
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - O Reerink
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - B L van Leeuwen
- Department of Surgical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | | |
Collapse
|
9
|
|
10
|
de'Angelis N, Pigneur F, Martínez-Pérez A, Vitali GC, Landi F, Gómez-Abril SA, Assalino M, Espin E, Ris F, Luciani A, Brunetti F. Assessing surgical difficulty in locally advanced mid-low rectal cancer: the accuracy of two MRI-based predictive scores. Colorectal Dis 2019; 21:277-286. [PMID: 30428156 DOI: 10.1111/codi.14473] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/29/2018] [Indexed: 02/08/2023]
Abstract
AIM Predicting surgical difficulty is a critical factor in the management of locally advanced rectal cancer (LARC). This study evaluates the accuracy and external validity of a recently published morphometric score to predict surgical difficulty and additionally proposes a new score to identify preoperatively LARC patients with a high risk of having a difficult surgery. METHODS This is a retrospective study based on the European MRI and Rectal Cancer Surgery (EuMaRCS) database, including patients with mid/low LARC who were treated with neoadjuvant chemoradiation therapy and laparoscopic total mesorectal excision (L-TME) with primary anastomosis. For all patients, pretreatment and restaging MRI were available. Surgical difficulty was graded as high and low based upon a composite outcome, including operative (e.g. duration of surgery) and postoperative variables (e.g. hospital stay). Score accuracy was assessed by estimating sensitivity, specificity and area under the receiver operating characteristic curve (AROC). RESULTS In a total of 136 LARC patients, 17 (12.5%) were graded as high surgical difficulty. The previously published score (calculated on body mass index, intertuberous distance, mesorectal fat area, type of anastomosis) showed low predictive value (sensitivity 11.8%; specificity 92.4%; AROC 0.612). The new EuMaRCS score was developed using the following significant predictors of surgical difficulty: body mass index > 30, interspinous distance < 96.4 mm, ymrT stage ≥ T3b and male sex. It demonstrated high accuracy (AROC 0.802). CONCLUSION The EuMaRCS score was found to be more sensitive and specific than the previous score in predicting surgical difficulty in LARC patients who are candidates for L-TME. However, this score has yet to be externally validated.
Collapse
Affiliation(s)
- N de'Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - F Pigneur
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - A Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - G C Vitali
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - F Landi
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - S A Gómez-Abril
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - M Assalino
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - E Espin
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - F Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - A Luciani
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - F Brunetti
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | | |
Collapse
|
11
|
de’Angelis N, Pigneur F, Martínez-Pérez A, Vitali GC, Landi F, Torres-Sánchez T, Rodrigues V, Memeo R, Bianchi G, Brunetti F, Espin E, Ris F, Luciani A. Predictors of surgical outcomes and survival in rectal cancer patients undergoing laparoscopic total mesorectal excision after neoadjuvant chemoradiation therapy: the interest of pelvimetry and restaging magnetic resonance imaging studies. Oncotarget 2018; 9:25315-25331. [PMID: 29861874 PMCID: PMC5982752 DOI: 10.18632/oncotarget.25431] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Locally advanced rectal cancer (LARC) requires a multimodal therapy tailored to the patient and tumor characteristics. Pretreatment magnetic resonance imaging (MRI) is necessary to stage the primary tumor, while restaging MRI, which is not systematically performed, may be of interest to identify poor responders to neoadjuvant chemoradiation therapy (NCRT), and redefine therapeutic approach. The EuMaRCS study group aimed to investigate the role and accuracy of pretreatment (including pelvimetry) and restaging MRIs in predicting surgical difficulties and surgical outcomes in LARC therapy. METHODS Patients with mid or low LARC who were administered NCRT, who underwent laparoscopic total mesorectal excision, and for whom pretreatment and restaging MRIs were available, were included. RESULTS MRIs of 170 patients (median age: 61 years) were reanalyzed by the same radiologist. Pelvimetry differed significantly between males and females, but no gender difference was noted in the clinical and tumor characteristics. Tumor volume and tumor height assessed on the restaging MRI were associated, respectively, with operative time and estimated blood loss. Conversion was predicted by tumor volume, interischial distance and pubic tubercle height. The quality of the surgical resection was found to be a predictor of overall and disease-free survival. The sensitivity and specificity of tumor regression grade 1 to identify a pathologic complete response were 76.9% and 89.3%, respectively. CONCLUSIONS In LARC management, pelvimetry and restaging MRI may be useful to predict surgical difficulties and surgical outcomes. However, the main independent predictor of patient survival appears to be the achievement of a successful surgical resection.
Collapse
Affiliation(s)
- Nicola de’Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Frederic Pigneur
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Aleix Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Giulio Cesare Vitali
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Filippo Landi
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Teresa Torres-Sánchez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Victor Rodrigues
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Riccardo Memeo
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Giorgio Bianchi
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Francesco Brunetti
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Eloy Espin
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Frederic Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Alain Luciani
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | | |
Collapse
|
12
|
Martínez-Pérez A, Carra MC, Brunetti F, de’Angelis N. Short-term clinical outcomes of laparoscopic vs open rectal excision for rectal cancer: A systematic review and meta-analysis. World J Gastroenterol 2017; 23:7906-7916. [PMID: 29209132 PMCID: PMC5703920 DOI: 10.3748/wjg.v23.i44.7906] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/09/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To review evidence on the short-term clinical outcomes of laparoscopic (LRR) vs open rectal resection (ORR) for rectal cancer. METHODS A systematic literature search was performed using Cochrane Central Register, MEDLINE, EMBASE, Scopus, OpenGrey and ClinicalTrials.gov register for randomized clinical trials (RCTs) comparing LRR vs ORR for rectal cancer and reporting short-term clinical outcomes. Articles published in English from January 1, 1995 to June, 30 2016 that met the selection criteria were retrieved and reviewed. The Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statements checklist for reporting a systematic review was followed. Random-effect models were used to estimate mean differences and risk ratios. The robustness and heterogeneity of the results were explored by performing sensitivity analyses. The pooled effect was considered significant when P < 0.05. RESULTS Overall, 14 RCTs were included. No differences were found in postoperative mortality (P = 0.19) and morbidity (P = 0.75) rates. The mean operative time was 36.67 min longer (95%CI: 27.22-46.11, P < 0.00001), the mean estimated blood loss was 88.80 ml lower (95%CI: -117.25 to -60.34, P < 0.00001), and the mean incision length was 11.17 cm smaller (95%CI: -13.88 to -8.47, P < 0.00001) for LRR than ORR. These results were confirmed by sensitivity analyses that focused on the four major RCTs. The mean length of hospital stay was 1.71 d shorter (95%CI: -2.84 to -0.58, P < 0.003) for LRR than ORR. Similarly, bowel recovery (i.e., day of the first bowel movement) was 0.68 d shorter (95%CI: -1.00 to -0.36, P < 0.00001) for LRR. The sensitivity analysis did not confirm a significant difference between LRR and ORR for these latter two parameters. The overall quality of the evidence was rated as high. CONCLUSION LRR is associated with lesser blood loss, smaller incision length, and longer operative times compared to ORR. No differences are observed for postoperative morbidity and mortality.
Collapse
Affiliation(s)
- Aleix Martínez-Pérez
- Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, Université Paris Est - UPEC, 94010 Créteil, France
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, 46017 Valencia, Spain
| | | | - Francesco Brunetti
- Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, Université Paris Est - UPEC, 94010 Créteil, France
| | - Nicola de’Angelis
- Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, Université Paris Est - UPEC, 94010 Créteil, France
| |
Collapse
|