Reduced port versus open right hemicolectomy for colorectal cancer: a retrospective comparison study of two centers

Robot-assisted versus laparoscopic short- and long-term outcomes in complete mesocolic excision for right-sided colonic cancer: a systematic review and meta-analysis

BACKGROUND

Complete mesocolic excision (CME) surgery is increasingly implemented for the resection of right-sided colonic cancer, possibly resulting in improved 5-year overall and disease-free survival compared to non-CME surgery. However, it is not clear what surgical platform should be used. The aim of this study was to compare the following outcomes between robot-assisted and laparoscopic CME-surgery for right-sided colonic cancer: (i) short-term clinical outcomes, (ii) pathological specimen quality, and (iii) long-term oncological outcomes.

METHODS

Medline, Embase, and Cochrane Database of Systematic Reviews were searched from inception until August 2021. Pooled proportions were calculated by applying the inverse variance method. Heterogeneity was explored by I-square and supplemented by sensitivity- and meta-regression analyses. The risk of bias was evaluated by either MINORS or Cochrane's risk-of-bias tool (RoB 2).

RESULTS

Fifty-five studies with 5.357 patients (740 robot-assisted and 4617 laparoscopic) were included in the meta-analysis. Overall postoperative morbidity was 17% [95% CI (14-20%)] in the robot-assisted group and 13% [95%CI (12-13%)] in the laparoscopic group. Robot-assisted CME was associated with a shorter hospital stay, lower intraoperative blood loss, a higher amount of harvested lymph nodes, and better 3-year oerall and disease-free survival. MINORS and RoB2 indicated a serious risk of bias across studies included.

CONCLUSIONS

This review which includes predominantly non-randomized studies suggests a possible advantage of the robot-assisted CME compared with a laparoscopic technique for several short-term outcomes.

Are risk factors for anastomotic leakage influencing long-term oncological outcomes after low anterior resection of locally advanced rectal cancer with neoadjuvant therapy? A single-centre cohort study

PURPOSE

Anastomotic leakage (AL) poses the most serious problem following low anterior resection in patients with rectal cancer independent of surgical approach or technique. The aim of this study was to evaluate risk factors for the occurrence of AL and how they affect the oncological long-term outcome of patients who received neoadjuvant therapy.

METHODS

A single centre cohort study of 163 consecutive locally advanced rectal cancer patients (cT3, cT4, N +) that received neoadjuvant therapy followed by resection with primary anastomosis between January 1998 and December 2020 were included in this study. Short- and long-term findings were compared between patients with AL (Leakage +) and without AL (Leakage -).

RESULTS

A complete follow-up was obtained from 163 patients; thereby, 33 patients (20%) developed an AL. We observed more patients with comorbidities (38% vs. 61%, p = 0.049) which developed a leakage in the course. Permanent stoma rate (36% vs. 18%, p = 0.03) was higher, and time between primary operation and stoma reversal was longer (219 days [172-309] vs. 93 days [50-182], p < 0.001) in this leakage group as well. Tumour distance lower than 6 cm from the anal verge (OR: 2.81 [95%CI: 1.08-7.29], p = 0.04) and comorbidities (OR: 2.22 [95%CI: 1.01-4.90], p = 0.049) was evaluated to be independent risk factors for developing an AL after rectal cancer surgery. Oncological outcome was not influenced by AL nor by other associated risk factors.

CONCLUSION

We could clearly detect the distance of tumour from the anal verge and comorbidities independent risk factors for the occurrence of AL. Oncological findings and long-term outcome were not influenced by these particular risk factors.

Is Robotic Assisted Colorectal Cancer Surgery Equivalent Compared to Laparoscopic Procedures during the Introduction of a Robotic Program? A Propensity-Score Matched Analysis

Simple Summary

The introduction of a robotic program is challenging and requires extensive experience in minimally invasive surgery. Short-term outcomes and oncological quality should not differ between robotic and laparoscopic surgery. To our knowledge, no data on the quality of surgery at the time of introduction of the robotic platform are available. The aim of this study was to compare short-term outcomes and oncological findings of robotic-assisted colorectal resections with those of conventional laparoscopic surgery within the first three years after the introduction of the robotic platform.

Abstract

Background: Robotic surgery represents a novel approach for the treatment of colorectal cancers and has been established as an important and effective method over the last years. The aim of this work was to evaluate the effect of a robotic program on oncological findings compared to conventional laparoscopic surgery within the first three years after the introduction. Methods: All colorectal cancer patients from two centers that either received robotic-assisted or conventional laparoscopic surgery were included in a comparative study. A propensity-score-matched analysis was used to reduce confounding differences. Results: A laparoscopic resection (LR Group) was performed in 82 cases, and 93 patients were treated robotic-assisted surgery (RR Group). Patients’ characteristics did not differ between groups. In right-sided resections, an intracorporeal anastomosis was significantly more often performed in the RR Group (LR Group: 5 (26.31%) vs. RR Group: 10 (76.92%), p = 0.008). Operative time was shown to be significantly shorter in the LR Group (LR Group: 200 min (150–243) vs. 204 min (174–278), p = 0.045). Conversions to open surgery did occur more often in the LR Group (LR Group: 16 (19.51%) vs. RR Group: 5 (5.38%), p = 0.004). Postoperative morbidity, the number of harvested lymph nodes, quality of resection and postoperative tumor stage did not differ between groups. Conclusion: In this study, we could clearly demonstrate robotic-assisted colorectal cancer surgery as effective, feasible and safe regarding postoperative morbidity and oncological findings compared to conventional laparoscopy during the introduction of a robotic system.

Short- and Long-Term Outcome of Laparoscopic- versus Robotic-Assisted Right Colectomy: A Systematic Review and Meta-Analysis

Background: There is a rapidly growing literature available on right hemicolectomy comparing the short- and long-term outcomes of robotic right colectomy (RRC) to that of laparoscopic right colectomy (LRC). The aim of this meta-analysis is to revise current comparative literature systematically. Methods: A systematic review of comparative studies published between 2000 to 2021 in PubMed, Scopus and Embase was performed. The primary endpoint was postoperative morbidity, mortality and long-term oncological results. Secondary endpoints consist of blood loss, conversion rates, complications, time to first flatus, hospital stay and incisional hernia rate. Results: 25 of 322 studies were considered for data extraction. A total of 16,099 individual patients who underwent RRC (n = 1842) or LRC (n = 14,257) between 2002 and 2020 were identified. Operative time was significantly shorter in the LRC group (LRC 165.31 min ± 43.08 vs. RRC 207.38 min ± 189.13, MD: −42.01 (95% CI: −51.06−32.96), p < 0.001). Blood loss was significantly lower in the RRC group (LRC 63.57 ± 35.21 vs. RRC 53.62 ± 34.02, MD: 10.03 (95% CI: 1.61−18.45), p = 0.02) as well as conversion rate (LRC 1155/11,629 vs. RRC 94/1534, OR: 1.65 (1.28−2.13), p < 0.001) and hospital stay (LRC 6.15 ± 31.77 vs. RRC 5.31 ± 1.65, MD: 0.84 (95% CI: 0.29−1.38), p = 0.003). Oncological long-term results did not differ between both groups. Conclusion: The advantages of robotic colorectal procedures were clearly demonstrated. RRC can be regarded as safe and feasible. Most of the included studies were retrospective with a limited level of evidence. Further randomized trials would be suitable.

Incidence and risk factors for umbilical incisional hernia after reduced port colorectal surgery (SIL + 1 additional port)-is an umbilical midline approach really a problem?

PURPOSE

Umbilical midline incisions for single incision- or reduced port laparoscopic surgery are still discussed controversially because of a higher rate of incisional hernia compared to conventional laparoscopic techniques. The aim of this study was to evaluate incidence and risk factors for incisional hernia after reduced port colorectal surgery.

METHODS

A total 241 patients underwent elective reduced port colorectal surgery between 2014 and 2020. Follow-up was achieved through telephone interview or clinical examination. The study collective was examined using univariate and multivariate analysis.

RESULTS

A total of 150 patients with complete follow-up were included into this study. Mean follow-up time was 36 (IQR 24-50) months. The study collective consists of 77 (51.3%) female and 73 (48.7%) male patients with an average BMI of 26 kg/m² (IQR 23-28) and an average age of 61 (± 14). Indication for surgery was diverticulitis in 55 (36.6%) cases, colorectal cancer in 65 (43.3%) patients, and other benign reasons in 30 (20.0%) cases. An incisional hernia was observed 9 times (6.0%). Obesity (OR 5.8, 95% CI 1.5-23.1, p = 0.02) and pre-existent umbilical hernia (OR 161.0, 95% CI 23.1-1124.5, p < 0.01) were significant risk factors for incisional hernia in the univariate analysis. Furthermore, pre-existent hernia is shown to be a risk factor also in multivariate analysis.

CONCLUSION

We could demonstrate that reduced port colorectal surgery using an umbilical single port access is feasible and safe with a low rate of incisional hernia. Obesity and pre-existing umbilical hernia are significant risk factors for incisional hernia.

Pelvic floor peritoneum reconstruction is a protective factor for defecation dysfunction after laparoscopic anterior resection in patients with middle and low rectal cancer

PURPOSE

The pelvic cavity is a monolithic structure whose integrity plays an important role in the pelvic organ function. Currently, pelvic floor peritoneum reconstruction (PFPR) is rarely performed during laparoscopic surgery for middle and low rectal cancer patients. This study evaluated the effect of PFPR using barbed wire during laparoscopic surgery on the postoperative defecation function in middle and low rectal cancer patients.

METHODS

This was a retrospective study involving a total of 252 middle and low rectal cancer patients who had been subjected to laparoscopic-assisted anterior resection of rectal cancer at Shanghai Changhai Hospital from March 2018 to April 2020. The Wexner and low anterior resection syndrome (LARS) scores were used to evaluate the postoperative defecation function among patients. A Wexner score ≥ 8 and LARS score ≥ 30 were considered to indicate major defecation dysfunction.

RESULTS

A total of 229 patients (52 patients subjected to PFPR) were followed up, and the Wexner and LARS scores were recorded. The follow-up rate was 90.87%, the mean follow-up time was 22.88 ± 6.93 months, the stoma rate was 64.29%, the ileostomy reduction surgical rate was 90.74%, and the stoma duration was 7.64 ± 2.94 months. Regarding the assessment of postoperative defecation dysfunction using the Wexner score, a multivariate analysis revealed that a long operation time (odds ratio [OR], 0.991; 95% confidence interval [CI], 0.984-0.999, p = 0.026) and radiotherapy (OR, 0.352; 95% CI, 0.156-0.797, p = 0.012) were independent risk factors for major defecation dysfunction, while a high tumor location (OR, 1.318; 95% CI, 1.151-1.657, p = 0.001) and PFPR (OR, 4.770; 95% CI, 1.435-15.857, p = 0.011) were independent protective factors for major defecation dysfunction. Regarding the assessment of the postoperative defecation function using the LARS score, a multivariate analysis revealed that a high tumor location (OR, 1.293; 95% CI, 1.125-1.486, p < 0.001) and PFPR (OR, 3.010; 95% CI, 1.345-6.738, p = 0.007) were independent protective factors for major defecation dysfunction. A subgroup analysis showed that the postoperative Wexner score (3.13 ± 2.79 vs. 4.71 ± 3.45 p = 0.003) and LARS score (21.77 ± 8.62 vs. 25.14 ± 8.78 p = 0.015) were lower for patients with PFPR than for patients without PFPR. Regarding patients with low rectal cancer, those with PFPR had a lower LARS score than those without it (23.62 ± 8.94 vs. 28.40 ± 7.90, p = 0.022), but there was no significant difference in the Wexner score between the groups. A total of 9.76% of patients with PFPR and 48.89% of those without PFPR showed an intestinal accumulation in the sacral front (p < 0.001).

CONCLUSIONS

PFPR and a high tumor location are protective factors for postoperative defecation dysfunction in middle and low rectal cancer patients. PFPR can be routinely performed during laparoscopic surgery.