The application of a new stapling device for open surgery (Contour Curved Cutter Stapler) in the laparoscopic resection of rectal cancer

Predicting multiple linear stapler firings in double stapling technique with an MRI-based deep-learning model

Multiple linear stapler firings is a risk factor for anastomotic leakage (AL) in laparoscopic low anterior resection (LAR) using double stapling technique (DST) anastomosis. In this study, our objective was to establish the risk factors for ≥ 3 linear stapler firings, and to create and validate a predictive model for ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. We retrospectively enrolled 328 mid-low rectal cancer patients undergoing laparoscopic LAR using DST anastomosis. With a split ratio of 4:1, patients were randomly divided into 2 sets: the training set (n = 260) and the testing set (n = 68). A clinical predictive model of ≥ 3 linear stapler firings was constructed by binary logistic regression. Based on three-dimensional convolutional networks, we built an image model using only magnetic resonance (MR) images segmented by Mask region-based convolutional neural network, and an integrated model based on both MR images and clinical variables. Area under the curve (AUC), sensitivity, specificity, accuracy, positive predictive value (PPV), and Youden index were calculated for each model. And the three models were validated by an independent cohort of 128 patients. There were 17.7% (58/328) patients received ≥ 3 linear stapler firings. Tumor size ≥ 5 cm (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.15-5.60, p = 0.021) and preoperative carcinoma embryonic antigen (CEA) level > 5 ng/mL [OR = 2.20, 95% CI = 1.20-4.04, p = 0.011] were independent risk factors associated with ≥ 3 linear stapler firings. The integrated model (AUC = 0.88, accuracy = 94.1%) performed better on predicting ≥ 3 linear stapler firings than the clinical model (AUC = 0.72, accuracy = 86.7%) and the image model (AUC = 0.81, accuracy = 91.2%). Similarly, in the validation set, the integrated model (AUC = 0.84, accuracy = 93.8%) performed better than the clinical model (AUC = 0.65, accuracy = 65.6%) and the image model (AUC = 0.75, accuracy = 92.1%). Our deep-learning model based on pelvic MR can help predict the high-risk population with ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. This model might assist in determining preoperatively the anastomotic technique for mid-low rectal cancer patients.

Rational Gastric Conduit Stump Closure Method Using Endo GIA Radial Reload in End-to-Side Anastomosis of the Esophagogastric Conduit

Background: The lack of tension at the anastomosis site and the blood flow of the gastric conduit are important to prevent anastomotic leakage in the anastomosis of the esophagogastric conduit. This study reports a gastric conduit stump closure method using Endo GIA™ Radial Reload in end-to-side anastomosis of the esophagogastric conduit, especially focusing on blood flow. Methods: A 4-cm conduit was created to ensure an intramural vascular network. The gastric conduit was elevated to the neck through the posterior mediastinal route, and end-to-side anastomosis of the esophagus and gastric conduit was performed using a circular stapler. Closure of the gastric stump with an Endo GIA Radial Reload was performed 2 cm proximal to the anastomosis on the end side of the esophagogastric conduit. The lesser curvature of the stump of the gastric conduit is the most frequent site of anastomotic leakage as it has the least blood flow, and the pressure is highest when the pressure inside the gastric conduit increases. Therefore, the gastric conduit stump was closed using the Endo GIA Radial Reload to resect the intersection of the gastric stump and lesser curvature from which the gastric conduit was created. The gastric conduit stump is gently curved; therefore, the pressure applied to the gastric conduit stump could be dispersed when the intragastric pressure increases. Results: No anastomotic leakage was observed among the 21 patients who underwent this method. Conclusion: This method is a novel anastomosis method to prevent anastomotic leakage in an end-to-side anastomosis of the esophagogastric conduit.

Magnetic resonance imaging-based deep learning model to predict multiple firings in double-stapled colorectal anastomosis

BACKGROUND

Multiple linear stapler firings during double stapling technique (DST) after laparoscopic low anterior resection (LAR) are associated with an increased risk of anastomotic leakage (AL). However, it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.

AIM

To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging (MRI).

METHODS

We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis, which were randomly divided into a training set (n = 260) and testing set (n = 68). Binary logistic regression was adopted to create a clinical model using six factors. The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed. Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks. Sensitivity, specificity, accuracy, positive predictive value (PPV), and area under the receiver operating characteristic curve (AUC) was calculated for each model.

RESULTS

The prevalence of ≥ 3 linear stapler cartridges was 17.7% (58/328). The prevalence of AL was statistically significantly higher in patients with ≥ 3 cartridges compared to those with ≤ 2 cartridges (25.0% vs 11.8%, P = 0.018). Preoperative carcinoembryonic antigen level > 5 ng/mL (OR = 2.11, 95%CI 1.08-4.12, P = 0.028) and tumor size ≥ 5 cm (OR = 3.57, 95%CI 1.61-7.89, P = 0.002) were recognized as independent risk factors for use of ≥ 3 linear stapler cartridges. Diagnostic performance was better with the integrated model (accuracy = 94.1%, PPV = 87.5%, and AUC = 0.88) compared with the clinical model (accuracy = 86.7%, PPV = 38.9%, and AUC = 0.72) and the image model (accuracy = 91.2%, PPV = 83.3%, and AUC = 0.81).

CONCLUSION

MRI-based deep learning model can predict the use of ≥ 3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery. This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for ≥ 3 linear stapler cartridges.

Association of Complications with Healthcare Utilization and Hospital-Borne Costs Among Patients Undergoing Open Low Anterior Resection Using Curved Cutter Staplers

Purpose

The ability of curved cutter staplers (CCS) to conform to the complex anatomy of the rectum has led to their widespread use in open low anterior resection (LAR). We describe the incidence of complications and their association with healthcare utilization and hospital-borne costs among patients who underwent open LAR with CCS, with the intent to provide contextual epidemiologic and economic burden data for future evaluations of innovations that may lead to a reduced incidence of complications.

Methods

Retrospective cohort study using Premier Healthcare Database. Studied patients were ≥18 years who underwent inpatient open LAR with CCS between October 1, 2016 and March 30, 2020 (index admission). Complications of interest included anastomotic leak, bleeding, infection, transfusion, and device complications/adverse incidents during the index admission. Outcomes included index admission hospital length of stay (LOS), non-home discharge status, total operating room (OR) time, total hospital-borne costs, and all-cause readmissions within 30, 60, and 90 days post discharge from index admission. Multivariable regression models were used to compare outcomes between patients with vs without any complication of interest.

Results

The study included 618 patients with a mean age of 61 years, of whom 57% were males. The incidence proportion of any complication during the index admission for open LAR with CCS was 28% (95% CI: [23.9%, 31.0%], n=170). As compared with patients experiencing no complications, those with a complication had higher adjusted mean total hospital costs ($38,159 vs $22,303, p<0.001), non-home discharge status (21.8% vs 9.2%, p=0.004), mean LOS (13 days vs 6 days, p<0.001), and mean OR time (362 mins vs 291 mins, p<0.001). There were no significant differences in all-cause readmissions between patients with vs without complications.

Conclusion

Among patients undergoing open LAR with CCS, over a quarter of patients experienced a complication, resulting in a substantial burden to the healthcare system.

Superiority of laparoscopic rectal surgery: Towards a new era

While laparoscopic colon surgery has been established to some degree over this decade, laparoscopic rectal surgery is not standard yet because of the difficulty of making a clear surgical field, the lack of precise anatomy of the pelvis, immature procedures of rectal transaction and so on. On the other hand, maintaining a clear surgical field via the magnified laparoscopy may allow easier mobilization of the rectum as far as the levetor muscle level and may result less blood loss and less invasiveness. However, some unique techniques to keep a clear surgical field and knowledge about anatomy of the pelvis are required to achieve the above superior operative outcomes. This review article discusses how to keep a clear operative field, removing normally existing abdominal structures, and how to transact the rectum and restore the discontinuity based on anatomical investigations. According to this review, laparoscopic rectal surgery will become a powerful modality to accomplish a more precise procedure which has been technically impossible so far, actually entering a new era.

Rectal transection by the Nelaton catheter pulling method during a laparoscopic low anterior resection

BACKGROUND

A laparoscopic low anterior resection with double-stapling technique for lower rectal cancer is considered to be technically challenging because it is difficult to perform rectal transection and anastomosis in the narrow pelvic cavity.

METHODS

We developed a new method for transecting the rectum with stapling a small number of cartridges. In laparoscopic low anterior resection, a 70-mm endovascular clip clamps the rectal wall at the anal side of the tumor. An endolinear stapler is applied at the rectal wall parallel and caudal to the 70-mm endovascular clip. A Nelaton catheter of 3.5 to 4.5 mm in outer diameter is inserted, and the loop of the Nelaton catheter is made behind the rectum. The Nelaton catheter loop is applied at the rectal wall parallel and caudal to the endolinear stapler and is pulled parallel the endolinear stapler toward the anterior side of the rectum. The endolinear stapler with opened jaws can be pushed deeper into the space, then the jaws can be closed in a position that can transect the rectum with one firing using only one cartridge.

RESULTS

Curative low anterior resection with rectal transection using the Nelaton catheter pulling method was performed in 13 patients with rectal cancer. The median value and range of tumor distance from the anal verge were 6.0 and 4.5 to 10.0 cm. The median duration of the operation was 284 minutes, and median blood loss was 10 mL. The number of stapling cartridges used for rectal transection was 1 in all cases, and there were no major complications.

CONCLUSIONS

We have demonstrated a safe, easy, and effective new transection method for rectal cancer resection using one firing with a Nelaton catheter.

Robotic pursestring technique in low anterior resection

PURPOSE

Rectal division and anastomosis are difficult steps in a laparoscopic low anterior resection. This difficulty is due to the limitations of laparoscopic instrumentation within the anatomical confines of the pelvis. Robotic technology overcomes most of these limitations to simplify the procedure. We describe our technique of controlled rectal transection and robotic purse-string placement by use of the da Vinci Robotic system.

METHODS

Three patients with rectal cancer who were scheduled to undergo a robot-assisted low anterior resection were selected to undergo this procedure. Safety, feasibility, and immediate postoperative outcomes were assessed.

RESULTS

The procedure was successfully completed in all 3 patients with no intraoperative complications. One patient had a postoperative bilateral femoral neuropathy that resolved spontaneously. The mean operating time was 339.6 minutes, and all 3 patients were sent home by the fifth postoperative day.

CONCLUSIONS

The advanced surgical dexterity of the da Vinci Robot enables a controlled rectal transection and purse-string suture placement on the rectal stump. This achieves a right-angled rectal division and a secure, single-stapled anastomosis in a low anterior resection. The feasibility of this technique has been demonstrated in 3 patients, in whom this technique has been safely performed with acceptable results. A larger series of patients and a long-term follow-up is required to demonstrate an objective benefit.

Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique

BACKGROUND

Laparoscopic rectal transection carries the risk of anastomotic leakage because of its technical difficulty and long staple line with an inadequate cutting angle. Our objective was to investigate the risk factors affecting anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique.

STUDY DESIGN

Between November 2006 and September 2008, 270 consecutive patients underwent laparoscopic sigmoidectomy and anterior resection with double stapling technique for distal sigmoid and rectal cancer. Data were collected prospectively. Univariate and multivariate analyses were performed to determine risk factors for anastomotic leakage. Additionally, we evaluated the relationship between the number of stapler firings and clinical parameters.

RESULTS

Anastomotic leakage was noted in 17 (6.3%) of 270 patients. In univariate analyses, tumor location (p = 0.021), operation time (p = 0.025), number of stapler firings (p = 0.040), and diameter of the circular stapler (p = 0.022) were significant risk factors for anastomotic leakage. Multivariate analyses showed that middle or lower rectal cancer was an independent factor affecting anastomotic leakage (p = 0.013). The number of stapler firings increased significantly in men (p = 0.023), in patients with a tumor at a lower level (p = 0.034), and in those with longer operation times (p < 0.001).

CONCLUSIONS

A reduction in the number of linear stapler firings is necessary to avoid anastomotic leakage after laparoscopic colorectal anastomosis with a double stapling technique. We recommend that a diverting ileostomy is mandatory in patients with middle and lower rectal cancer where multiple linear staplers were used.

Combined application of ultrasonically activated scalpel and curved cutter stapler in ultra low anterior resection for low rectal cancer

AIM: To investigate the clinical value of combined use of ultrasonically activated scalpel (UAS) and curved cutter stapler in ultra low anterior resection for low rectal cancer.

METHODS: The clinical data of 32 patients who underwent ultra low anterior resection for low rectal cancer from July 2005 to February 2009 were retrospectively analyzed. Of these patients, 12 were treated with UAS and curved cutter stapler, and 20 with electric scalpel and linear stapler. Operation success rate, operation duration, blood loss during operation, drainage volume within the first three days after operation, drainage duration, recovery duration and postoperative complications were compared between the two groups of patients.

RESULTS: Compared with patients treated with electric scalpel and linear stapler, the operation success rate achieved in patients treated with UAS and curved cutter stapler was significantly raised (P < 0.05), and the operation duration (U = 12.5, W = 90.5, P < 0.05), volume of blood loss (t = -4.968, P < 0.05) , drainage volume within the first three days after operation (t = -6.507, P < 0.05), drainage duration (t = -3.888, P < 0.05) and recovery duration (U = 27.0, W = 105.0, P < 0.05) were significantly reduced.

CONCLUSION: Combined use of UAS and curved cutter stapler shows good efficacy in ultra low anterior resection for low rectal cancer.

Laparoscopic low rectal anastomosis using a new stapling device: early experience with the Contour stapler

Rectal cancer was initially considered a contraindication for the laparoscopic approach to low rectal resection due to the greater difficulty of deep pelvic dissection, but several studies have demonstrated its potential clinical advantages. The currently accepted technique for this intervention includes total mesorectal excision, which entails complete dissection of the mesorectum followed by low transection of the rectum. The laparoscopic approach provides good visualization and magnification of the operative field, but transection of the rectum may be more difficult. This is illustrated by the conversion rate of around 15% in most series, mainly due to technical difficulties. Contour placement may overcome these difficulties. Two key points support the interest in the use of devices with the features of the Contour. First, the current feeling and evidence indicate that with presently available laparoscopic devices, the section of the low rectum in selected patients (males and mid-third rectal tumors) is often difficult. Secondly, although the Contour device was designed for open surgery, surgeons have the intuitive perception that it perfectly accomplishes the functions an ideal laparoscopic stapler should include. There is clearly a need for more appropriate laparoscopic instruments for low rectal transection. The Contour device could be considered a prototype because it meets the surgeon's requirements when operating on the low rectum, providing one shot, simultaneous sewing and cutting function and a symmetric rectum section. However, a number of technical modifications would enhance the utility of the instrument in this setting.

The occlusive tourniquet: a simple method for rectal stump washout during open and laparoscopic surgery

Rectal stump washout with cytolytic agents is recommended and usually performed during anterior rectal or rectosigmoid resection. The use of a linear stapler instrument during ultralow anterior resection makes the placement of pelvic clamps difficult for rectal stump washout prior to resection. The objective of this work is to demonstrate the use of a simple procedure, the occlusive tourniquet for rectal stump washout. Occlusive tourniquet applied to open technique: after complete dissection of the rectum and sigmoid colon according to the usual technique, a simple piece of tubing from an intravenous line is passed behind and around the rectum/sigmoid colon at some point distal to the tumor to form an occlusive tourniquet. Occlusive tourniquet applied to laparoscopic technique: similar to the open technique, tubing is passed through the left iliac fossa trocar and passed behind the sigmoid mesocolon. This simple procedure allows easy exposure and dissection of the mesorectum, without traumatizing the rectum/sigmoid colon or the tumor and lavage can be performed without the need for clamps or other instruments which may traumatize the rectum and provoke anastomotic failure. In conclusion, the occlusive tourniquet is a simple method for rectal stump washout so this step can be done.

Colorectal anastomotic leakage: a new experimental model

BACKGROUND

Anastomotic leakage is the major complication after colorectal surgery. To date, animal experiments concerning colorectal anastomosis focus on anastomotic healing instead of anastomotic leakage. This study aims to develop a new experimental model for colorectal anastomotic leakage.

METHODS

A control group, receiving an anastomosis with 12 interrupted sutures, was compared to a group receiving an anastomosis with 6 interrupted sutures. When the leakage rate was observed to be too low, the number of sutures was decreased stepwise, to 5 or less. Each group contained 9 "C57Bl6-mice". After 7 d the Anastomotic Bursting Pressure (ABP) was determined.

RESULTS

In the first experiment, one mouse (11.1%) in the case group and none in the control group developed leakage. Average ABP was 152.2 mmHg in the control group and 138,8 mmHg in the case group (P=0.111). In the second experiment, case group receiving an anastomosis with 5 sutures, 4 mice (44.4%) in the case group developed leakage. This experiment was repeated twice resulting in leakage rates of 33.3% and 44.4%. The average overall ABP in the case group was 142.7 mmHg vs. 179.9 mmHg (P=0.022) in the control group. The mice without leakage showed a stabilization of average weight loss around day 2 and 3 and a decrease afterwards. The mice with leakage showed a decrease only after day 5. The difference in wellness-scores between the groups with- and without leakage was 2 points, increasing during follow-up.

CONCLUSIONS

The model of anastomotic leakage caused by creating an anastomosis with 5 interrupted sutures is feasible. Weight loss and wellness-scores are good predictors of leakage.

Ultrasonically activated scalpel versus monopolar electrocautery shovel in laparoscopic total mesorectal excision for rectal cancer

AIM: To investigate the feasibility and safety of monopolar electrocautery shovel (ES) in laparoscopic total mesorectal excision (TME) with anal sphincter preservation for rectal cancer in order to reduce the cost of the laparoscopic operation, and to compare ES with the ultrasonically activated scalpel (US).

METHODS: Forty patients with rectal cancer, who underwent laparoscopic TME with anal sphincter preservation from June 2005 to June 2007, were randomly divided into ultrasonic scalpel group and monopolar ES group, prospectively. White blood cells (WBC) were measured before and after operation, operative time, blood loss, pelvic volume of drainage, time of anal exhaust, visual analogue scales (VAS) and surgery-related complications were recorded.

RESULTS: All the operations were successful; no one was converted to open procedure. No significant differences were observed in terms of preoperative and postoperative d 1 and d 3 WBC counts (P = 0.493, P = 0.375, P = 0.559), operation time (P = 0.235), blood loss (P = 0.296), anal exhaust time (P = 0.431), pelvic drainage volume and VAS in postoperative d 1 (P = 0.431, P = 0.426) and d 3 (P = 0.844, P = 0.617) between ES group and US group. The occurrence of surgery-related complications such as anastomotic leakage and wound infection was the same in the two groups.

CONCLUSION: ES is a safe and feasible tool as same as US used in laparoscopic TME with anal sphincter preservation for rectal cancer on the basis of the skillful laparoscopic technique and the complete understanding of laparoscopic pelvic anatomy. Application of ES can not only reduce the operation costs but also benefit the popularization of laparoscopic operation for rectal cancer patients.

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.

Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection

BACKGROUND

Rectal transection and anastomosis at the lower rectum is the most challenging part of laparoscopic low anterior resection. Therefore, some have demonstrated that rectal transection should be performed using instruments for open surgery with small laparotomy. In our institute, however, rectal transection using a currently available endostapler followed by anastomosis with a double stapling technique is usually performed.

METHODS

The important points of our technique are as follows: trocar placement, optimal device choice, harmonious movement between the operator and assistant for rectal transection, optimal point of piercing with the center rod of the circular stapler, and ideal positioning of the proximal colon.

RESULTS

Seventy-eight patients underwent low anterior resection using this technique. There were no conversions to open surgery. All rectal transections were completed laparoscopically with an available endostapler. A diverting ileostomy was created in six cases. Anastomotic leakage occurred in only two patients (2.6%) and rectovaginal fistula in only one patient (1.3%).

CONCLUSIONS

Our standardized technique is considered to be safe and feasible for rectal transection and anastomosis using the double stapling technique (DST).

Laparoscopic approach in surgical treatment of rectal cancer

Background

High rates of conversion to open operation and morbidity have been reported after laparoscopic total mesorectal excision (TME) with sphincter preservation for rectal cancer. This study examined risk factors for conversion and morbidity to determine which patients with rectal cancer could benefit from a laparoscopic resection.

Methods

Two hundred patients (117 men) with mid and low rectal cancer treated by laparoscopic TME were studied. The impact of clinical and pathological characteristics on conversion and complications was assessed by multivariable analysis.

Results

Reconstruction after TME included 79 low colorectal and 121 coloanal anastomoses. Conversion was necessary in 31 patients (15·5 per cent), and was independently associated with sex, type of anastomosis and intraoperative rectal fixity. Postoperative morbidity in 50 patients (25·0 per cent) was independently associated with sex and type of anastomosis. Men with a stapled anastomosis had a threefold higher rate of conversion (13 (34 per cent) of 38 versus 18 (11·1 per cent) of 162; P &lt; 0·001) and morbidity (22 (58 per cent) versus 28 (17·3 per cent); P &lt; 0·001) than other patients.

Conclusion

Laparoscopic TME is a good option for women and for men treated by coloanal anastomosis. Technical improvement of laparoscopic stapling is needed before the laparoscopic approach can be offered to all patients.

Short- and midterm outcomes of laparoscopic surgery compared for 131 patients with rectal and rectosigmoid cancer

BACKGROUND

This study aimed to clarify and compare the short- and midterm surgical outcomes of laparoscopic surgery for rectal and rectosigmoid cancer.

METHODS

Between June 1992 and December 2004, 131 selected patients with cancer of the rectum (n = 60) and rectosigmoid (n = 71) underwent laparoscopic surgery. The indications for laparoscopy included a preoperative diagnosis of T1/T2 tumor in the rectum and T1-T3 tumors in the rectosigmoid.

RESULTS

The mean follow-up period was 42 months. The procedures included anterior resection for 117 patients, abdominoperineal resection for 11 patients, Hartmann's procedure for 1 patient, and restorative proctocolectomy for 1 patient. Conversion to an open procedure occurred for four patients (3.1%). Postoperative complications developed in 29 patients (22.1%), including anastomotic leakage in 14 patients (11.8%). The length of hospital stay for the rectal cases was significantly longer than for the rectosigmoid cases (10 vs 7 days; p = 0.0049). The tumor node metastasis (TNM) stages included 0 (n = 14), I (n = 72), II (n = 15), III (n = 29), and IV (n = 1). Recurrences were experienced by 13 patients, including local recurrence (n = 7) and recurrences involving the liver ((n = 2), lung (n = 3), and distant lymph nodes (n = 1). The 5-year disease-free and overall survival rates were, respectively 91.7% and 97.9% for stage I, 86.7% and 90.9% for stage II, and 77.1% and 90.0% for stage III.

CONCLUSIONS

Laparoscopic surgery is feasible and safe for selected patients with rectal or rectosigmoid cancer. The selected patients in this study experienced favorable short- and midterm outcomes.