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

Has the open surgical approach in colorectal cancer really become uncommon?

Colorectal cancer is the third most common cancer in the world. Surgery is mandatory to treat patients with colorectal cancer. Can colorectal cancer be treated in laparoscopy? Scientific literature has validated the oncological quality of laparoscopic approach for the treatment of patients with colorectal cancer. Randomized non-inferiority trials with good remote control have answered positively to this long-debated question. Early as 1994, first publications demonstrated technical feasibility and compliance with oncological imperatives and, as far as short-term outcomes are concerned, there is no difference in terms of mortality and post-operative morbidity between open and minimally invasive surgical approaches, but only longer operating times at the beginning of the experience. Subsequently, from 2007 onwards, long-term results were published that demonstrated the absence of a significant difference regarding overall survival, disease-free survival, quality of life, local and distant recurrence rates between open and minimally invasive surgery. In this editorial, we aim to summarize the clinical and technical aspects which, even today, make the use of open surgery relevant and necessary in the treatment of patients with colorectal cancer.

Long-term oncological outcome of reduced-port laparoscopic surgery (single-incision plus one port) as a technical option for rectal cancer

BACKGROUND

The purpose of this study was to clarify the oncological safety of reduced-port laparoscopic surgery (single-incision plus one port) (RPS) for patients with rectal cancer.

METHODS

The clinicopathological data of 63 selected patients with clinical Stage I-III (T1-3 and N0-2) rectal cancer who underwent RPS of radical anterior resection between 2012 and 2017 were retrospectively analyzed. The median distance of tumor from anal verge was 11 cm. Ordinarily, a multiport platform with three channels was placed in the 3-cm umbilical incision, and another 5- or 12-mm port was placed in the right lower abdomen.

RESULTS

The median operative time, amount of intraoperative bleeding, number of harvested lymph nodes, and length of distal margin were 272 min, 10 mL, 22 nodes, and 4.0 cm, respectively, and there was one (2%) patient with involvement of the radial margin. There were eight patients (13%) who required additional ports, and one patient (2%) who converted to open surgery. Intra- and postoperative complications occurred in one (2%) and 12 patients (19%), respectively. The median length of postoperative hospital stay was 8 days. The median follow-up period was 79 months, and incisional hernia was observed in 3 (5%) patients at the platform site not the port site, and cancer recurrence occurred in four patients (6%). The 5-year relapse-free and overall survival rates were 100% and 100% in the patients with pathological Stage I disease, 94% and 100% in the patients with pathological Stage II disease, and 83% and 89% in the patients with pathological Stage III disease, respectively.

CONCLUSION

RPS in the selected patients with rectal cancer, performed by an expert laparoscopic surgeon, may be technically safe and oncologically acceptable as well as multiport laparoscopic surgery.

The impact of laparoscopic surgery in colorectal cancer resection with respect to the development of liver metastasis in the long-term

Introduction Colorectal cancer (CRC) shows high incidence and mortality worldwide, particularly in Western and developed countries. The objective of this study is to evaluate the oncologic results during a minimum follow-up of 2 years of curable CRC patients submitted to laparoscopic resection in our environment, regarding to the development of hepatic metastases.

Methods Medical records of 189 colon and rectal patients with potentially curable adenocarcinoma who have been submitted to laparoscopic resection have been reviewed through a retrospective cohort between January 2005 and March 2012 at a single institution regarded as reference to this type of treatment. Pearson's χ 2 and Long-rank tests have been used for statistical analysis and data was analyzed by statistic package STATA version 11.0.

Results The eligible population for the study was 146 patients, 91 women (62%), with a mean age of 61 ± 13 years. Minimum follow-up was 24 months, having an mean follow-up of 60 ± 27 months and an mean follow-up of global disease recurrence of 27 ± 11 months. Hepatic metastases occurred in 7.5% of the population, most from stage III, and the mean recurrence period was 25 ± 16 months.

Conclusions Laparoscopic resection for potentially curable CRC in this cohort did not change the long-term incidence of hepatic metastases, considering that our results are comparable to large randomized clinical trial results. Laparoscopic resection was effective and safe for analyzed patients, regarding long-term oncologic results.

Relationship between anastomotic leakage and CT value of the mesorectum in laparoscopic anterior resection for rectal cancer

OBJECTIVE

This study aims to indicate whether the CT value of the mesorectum could be correlated with the incidence of anastomotic leakage (AL) in laparoscopic surgery for rectal cancer.

METHODS

The study subjects included 173 patients who underwent laparoscopic anterior resection (LAR) for rectal cancer from September 2005 to 2016 in our institution as well as reliable contrast-enhanced CT preoperatively. Univariate and multivariate analyses were performed to determine the correlation between surgical outcomes, including AL and CT value of the mesorectum.

RESULTS

AL was observed in 30 (17.3%) patients. Amongst short-term surgical outcomes, overall complication showed significant correlation with the CT value of the mesorectum (P = 0.003). In addition, AL was the only factor, which significantly correlated with the CT value of the mesorectum (P = 0.017). By plotting receiver operating characteristic curve, -75 HU was the threshold of the CT value of the mesorectum for predicting AL with an area under the curve of 0.772. Categorized into two groups as per the threshold, low group showed significantly higher incidence of AL (OR, 2.738; 95% CI, 1.105-6.788; P = 0.030) as well as whole complications (OR, 4.431; 95%CI, 1.912-10.266; P = 0.001).

CONCLUSION

The CT value of the mesorectum may be a helpful preoperative radiological biomarker to predict AL after LAR for rectal cancer.

Paradigm shift in the management of rectal cancer

Surgery for rectal cancer in the pre-Total Mesorectal Excision (TME) era was associated with high local recurrence rates. The widespread adoption of the TME technique together with the addition of neoadjuvant oncological therapies have reduced local failure rates and improved survival for patients with rectal cancer. Advances in our knowledge, better understanding of tumour biology and refinement in minimal access techniques and equipment have significantly changed the management of rectal cancer. This paper reviews these changes and proposes a paradigm shift in how rectal cancer management is conceptualised and treated, such that the treatment of rectal cancer is separated into early tumours (potentially suitable for local excison), TME tumours (optimally managed by TME) and beyond TME tumours (optimally managed by multivisceral resection outside the TME plane).

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.

[Outcomes following rectal and recto-sigmoid cancer resections: comparison of the laparoscopic and open techniques]

BACKGROUND/AIMS

Surgical technique and experience are considered as significant determinants of the successful treatment of recto-sigmoid malignancies.

METHODS

Two hundred patients operated on between 2005 and 2009 were prospectively followed with an average of 39.8 months. Patients with rectosigmoid or rectal cancer were included, either with primary resection or resection after neoadjuvant therapy. The primary aim was to assess the average survival in the two groups; secondary outcomes were stage specific survival and the incidence of loco-regional recurrence and distant metastases. Intra- and postoperative complications, operating time, onco-pathological specimen quality and length of stay were also analysed.

RESULTS

During the follow-up comparable rates for 3-year survival and recurrence rates were found without statistical difference. Hospital stay in the laparoscopic group was significantly shorter and the mid-term survival rates were also better in the more advanced stages. Incisional hernia rate was significantly lower in the laparoscopic group.

CONCLUSIONS

The results of laparoscopic rectal and recto-sigmoid resections were not inferior, and - in some aspects - they were even better compared to open procedures. Adding the properties of the minimally invasive technique (shorter recovery, reduced surgical stress reaction) this should be the preferred method of operative approach.

Reduced-port laparoscopic surgery for rectal cancer: feasibility based on our early experience

We report our experience of a reduced-port laparoscopic surgery as an advanced laparoscopic surgery for rectal cancer. Twelve selected patients with clinical T1-2 and N0 rectal cancer (clinical stage I) underwent low anterior resection of the rectum. The procedures were performed with one port plus a multiple-instrument access port with three channels. The multiple-instrument access port was placed at the umbilicus or the site of diverting stoma, and another port was placed in the right abdomen or in the opposite abdomen of ostomy. The median operative time and intraoperative bleeding were 280 min and 15 mL, respectively. The median number of harvested lymph nodes was 20. No major perioperative morbidities occurred in this series. The median postoperative hospital stay was 10 days. Low anterior resection performed by reduced-port laparoscopic surgery is feasible as multiport laparoscopic surgery, and it is a reliable surgical option in selected patients with rectal cancer.

The effect of the introduction of the ERAS protocol in laparoscopic total mesorectal excision for rectal cancer

OBJECTIVE

The aim of the study was to determine whether the introduction of the Enhanced Recovery after Surgery (ERAS) protocol in laparoscopic total mesorectal excision (TME) for rectal cancer offers additional advantages concerning postoperative hospital stay compared to laparoscopy and conventional care.

METHODS

A consecutive series of patients that underwent a laparoscopic TME for rectal cancer in a single institution between January 2004 and July 2009 were retrospectively included in this study. The ERAS protocol was introduced in this cohort in January 2007. The study cohort was divided in a conventional care group and an ERAS group. Both groups were compared for primary and secondary outcome measures. The primary outcome measure was postoperative length of hospital stay.

RESULTS

Seventy-six patients were included: 43 in the ERAS group and 33 in the conventional care (control) group. Median hospital stay was 7 days (range 2-83 days) in the ERAS group and 10 days (range 4-74 days) in the control group (p = 0.04). Return of bowel function occurred on days 2 and 3 respectively (p < 0.001). There were no significant differences between both groups concerning postoperative complications, readmission rate and reoperations. Thirty-day mortality was absent in both groups.

CONCLUSION

These results suggest that the introduction of the ERAS protocol in laparoscopic TME leads to a further reduction in length of hospital stay.

Laparoscopic surgery for rectal cancer

Laparoscopic surgery for rectal cancer is much more challenging than that for colon cancer because of the confined space within the pelvis. Further, because of the tumor's location in the pelvis, maintenance of resection margins is of greater concern. Nonrandomized studies by groups experienced in laparoscopic surgery have shown both that it produces short-term outcomes equivalent to those for open surgery and that it can be performed safely from an oncologic perspective. Nonsurgical complications appear to be fewer, but conversion to open surgery may become a real issue. This review summarizes these findings by addressing technical considerations, early outcomes, late outcomes, costs, and complications.

Evaluations of laparoscopic proctocolectomy versus traditional technique in patients with rectal cancer

BACKGROUND

This was a retrospective study that evaluated the surgical outcomes of laparoscopic surgery (LS) for rectal cancer, in comparison with a case control series of open surgery (OS), during an 8-year period.

METHODOLOGY

Between October 1998 and December 2006, 203 patients with rectal malignancies underwent colectomy; 146 of them had colectomy with the traditional technique (OS), while 57 underwent resection of rectal cancer laparoscopically (LS). The LS group was compared with 60 patients from the OS group (selected from the 146 OS group patients), matched by size, sex, age, anatomical location of the tumor, type, extent of resection, and pathological stage. Data were obtained from patients' medical records. Statistical analysis was performed with the t test and chi-square test. All data are expressed as mean +/- standard error of the mean (SEM).

RESULTS

Mean age of the LS group was 63.7+/-12 years versus 69+/-12 years in the OS group. There were more men than women in both the laparoscopic (33 males, 24 females) and OS groups (35 men, 25 women). The mean follow-up period was 38 months and 78 months for LS and OS groups, respectively. The procedure included low anterior resection (43 in LS and 45 in OS), and 13 patients in both groups underwent abdominoperineal resection and 3 transanal resections (2 in OS and 1 in LS). Mean tumor size was 4.2+/-2.12cm in the LS versus 5.2+/-2.02cm in the OS group. Conversion to an open procedure occurred in 4 patients (6.7%), all in the first 20 cases. Postoperative complications developed in 28 patients (11.7%), 13 in the LS group and 15 in the OS group. Median operative time was longer, but median blood loss was significantly lower in the LS group. The length of hospital stay was significantly shorter for the LS group.

CONCLUSION

Laparoscopic surgery is feasible and safe for patients with rectal cancer and provides benefits during the postoperative period without increased morbidity or mortality.

Modifiable surgical and anesthesiologic risk factors for the development of cardiac and pulmonary complications after laparoscopic colorectal surgery

BACKGROUND

In contrast to patient-related risk factors, which are difficult to influence, factors relating to surgery and anesthesia that can be influenced have hardly been investigated. This study aimed to identify such risk factors.

METHODS

Pre- and intraoperative surgical and anesthesiologic factors of 388 colonic and 112 rectal procedures performed by a single surgeon within 50 months were recorded and analyzed for correlations with postoperative complications requiring treatment.

RESULTS

Higher American Society of Anesthesiology (ASA) emergency interventions and intraoperative factors (bleeding, long operating time) had an elevated risk for general complications. Furthermore, patients benefited from the clinical experience of the anesthesiologist, especially in terms of emergency procedures, hemorrhagic complications, and a longer operating time.

CONCLUSIONS

Standardization of the surgical technique, "bloodless" surgery, standardization of intraoperative monitoring, and the use of board-certified anesthesiologists for high-risk cases, emergency procedures, and patients with high ASA stages are able to reduce postoperative morbidity.

Laparoscopic and minimally invasive resection of malignant colorectal disease

Minimally invasive surgery for colorectal cancer is a burgeoning field of general surgery. Randomized controlled trials have assessed short-term patient-oriented and long-term oncologic outcomes for laparoscopic resection. These trials have demonstrated that the laparoscopic approach is equivalent to open surgery with a shorter hospital stay. Laparoscopic resection also may result in improved short-term patient-oriented outcomes and equivalent oncologic resections versus the open approach. Transanal excision of select rectal cancer using endoscopic microsurgery is promising and robotic-assisted laparoscopic surgery is an emerging modality. The efficacy of minimally invasive treatment for rectal cancer compared with conventional approaches will be clarified further in randomized controlled trials.