Long-term oncologic outcome after laparoscopic surgery for rectal cancer. Surg Endosc. 2014;28:1119-1125. [PMID: 24202710 DOI: 10.1007/s00464-013-3286-8]

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.

Long-Term Oncologic Outcomes of Minimally Invasive Proctectomy for Rectal Adenocarcinoma

BACKGROUND

Long-term oncologic outcomes after minimally invasive surgery (MIS) for rectal adenocarcinoma compared to open surgery continue to be debated. We aimed to review our high-volume single-institution outcomes in MIS rectal cancer surgery.

METHODS

A retrospective review of a prospectively collected database was completed of all consecutive adult patients with rectal adenocarcinoma treated from January 2005 through December 2011. Stage IV or recurrent disease was excluded. Demographics and operative and pathologic details were reviewed and reported. Primary endpoints include survival and recurrence.

RESULTS

A total of 324 patients were included and median follow-up was 54 months (IQR = 37.0, 78.8). The mean age was 58.2 ± 14.1 years. Tumors were in the upper rectum in 111 patients, mid-rectum in 113 patients, and lower rectum in 100 patients. Stage III disease was most common (49.4%). Overall conversion to open procedure rate was 13.9%. The circumferential radial margin was positive in only 1 patient (0.3%) and the mean lymph node yield was 24.7 ± 17.2. Cancer recurred in 42 patients (13%), 10 (2.5%) patients developed local recurrence, 32 (9.8%) developed distant metastasis, and 2 (0.6%) patients had both. The 5-year overall survival for stage 0, 1, 2, and 3 disease is 96, 91, 80, and 77%, respectively (p = 0.015).

CONCLUSION

In carefully selected rectal cancer patients treated with MIS, long-term outcomes of survival and recurrence appear to compare favorably to previously published series.

Long-term outcomes and propensity score matching analysis: rectal cancer resection for patients with elevated preoperative risk

BACKGROUND

It is still controversial about the treatment strategy for rectal cancer patients with elevated operative risk and elder rectal cancer patients.

METHODS

This study presented a retrospective single center experience in rectal cancer proctectomy for high operative risk patients. High operative risk patient was defined as Cr-POSSUM > 5% combined with associated risk factors. 220 in 1477 consecutive patients met the inclusion criteria.

RESULTS

132 patients were selected (66:66) after propensity score matching. The total complication rate between conventional open rectal resection (71 %) and laparoscopic surgery (41%) was significantly different (p = 0.0005). There is a significantly positive correlation between open surgery and advanced Dindo Classification (p = 0.02). Cr-POSSUM is positively correlated with Dindo Classification (p = 0.01). There was no significant difference in survival rate among stage I∼II, different age groups or different Cr-POSSUM score sub-groups. However, stage III-IV tumor patients in laparoscopic group experienced improved overall survival rate. (p < 0.0001). For patients with preoperative pulmonary or renal disease, patients in laparoscopic group also had better long term prognosis (p = 0.03, p = 0.049).

CONCLUSIONS

The results demonstrate the potential advantages of laparoscopic rectal cancer resection for high operative risk patients, especially for the patients with preoperative respiratory or renal disease and stage III cancer.

Evaluation of the robotic approach concerning pitfalls in rectal surgery

INTRODUCTION

The feasibility and advantages of robotic rectal surgery (RRS) in comparison to conventional open or laparoscopic rectal resections have been postulated in several reports. But well-known challenges and pitfalls of minimal invasive rectal surgery have not been evaluated by a prospective, multicenter setting so far. Aim of this study was to analyze the perioperative outcome of patients following RRS especially in regard to the pitfalls such as obesity, male patients and low tumors by a European multicenter setting.

METHODS

This prospective study included 348 patients undergoing robotic surgery due to rectal cancer in six major European centers. Clinicopathological parameters, morbidity, perioperative recovery and short-term outcome were analyzed.

RESULTS

A total of 283 restorative surgeries and 65 abdominoperineal resections were carried out. The conversion rate was 4.3%, mean blood loss was 191 ml, and mean operative time was 315 min. Postoperative complications with a Clavien-Dindo score >2 were observed in 13.5%. Obesity and low rectal tumors showed no significant higher rates of major complications or impaired oncological parameters. Male patients had significant higher rates of major complications and anastomotic leakage (p = 0.048 and p = 0.007, respectively).

DISCUSSION

RRS is a promising tool for improvement of rectal resections. The well-known pitfalls of minimal-invasive rectal surgery like obesity and low tumors were sufficiently managed by RRS. However, RRS showed significantly higher rates of major complications and anastomotic leakage in male patients, which has to be evaluated by future randomized trials.

Critical appraisal of laparoscopic vs open rectal cancer surgery

AIM: To evaluate the long-term clinical and oncological outcomes of laparoscopic rectal resection (LRR) and the impact of conversion in patients with rectal cancer.

METHODS: An analysis was performed on a prospective database of 633 consecutive patients with rectal cancer who underwent surgical resection. Patients were compared in three groups: Open surgery (OP), laparoscopic surgery, and converted laparoscopic surgery. Short-term outcomes, long-term outcomes, and survival analysis were compared.

RESULTS: Among 633 patients studied, 200 patients had successful laparoscopic resections with a conversion rate of 11.1% (25 out of 225). Factors predictive of survival on univariate analysis include the laparoscopic approach (P = 0.016), together with factors such as age, ASA status, stage of disease, tumor grade, presence of perineural invasion and vascular emboli, circumferential resection margin < 2 mm, and postoperative adjuvant chemotherapy. The survival benefit of laparoscopic surgery was no longer significant on multivariate analysis (P = 0.148). Neither 5-year overall survival (70.5% vs 61.8%, P = 0.217) nor 5-year cancer free survival (64.3% vs 66.6%, P = 0.854) were significantly different between the laparoscopic group and the converted group.

CONCLUSION: LRR has equivalent long-term oncologic outcomes when compared to OP. Laparoscopic conversion does not confer a worse prognosis.

[Management of more frequent complications of laparoscopic surgery. Minimally invasive or always open surgery?]

BACKGROUND

Two decades after the far-reaching establishment of elective laparoscopic surgery, the questions arise whether and when the benefits of this technology can be sufficiently and safely implemented even in cases of complications.

MATERIAL AND METHODS

The currently available literature was analyzed in the context of recommendations for the management of complications in laparoscopic surgery.

RESULTS

Intraoperative and postoperative complications of minimally invasive surgery necessitating treatment are extremely rare and can be expected in only 0.1–5 % of interventions, depending on the complexity of the intervention. In addition to adhesion-related and anatomical limitations, they are responsible for the necessity to convert to open surgery in approximately 40–60 % of the cases.

DISCUSSION

Due to the relative rarity and great variety of potential complications, there is no scientific evidence at the study level that can give reliable recommendations for a management strategy in every situation. It still has to be decided on an individual basis and depending on the particular clinical situation if a successful laparoscopic management can be sufficiently and safely carried out. It has been found that a number of complications can be well controlled by minimally invasive procedures; however, in addition to a high level of personal experience in laparoscopy, optimal technical, institutional and instrumental conditions must be available. If these factors are not present in total, a conventional open approach should still be given preference.

Robotic general surgery: current practice, evidence, and perspective

BACKGROUND

Robotic technology commenced to be adopted for the field of general surgery in the 1990s. Since then, the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) has remained by far the most commonly used system in this domain. The da Vinci surgical system is a master-slave machine that offers three-dimensional vision, articulated instruments with seven degrees of freedom, and additional software features such as motion scaling and tremor filtration. The specific design allows hand-eye alignment with intuitive control of the minimally invasive instruments. As such, robotic surgery appears technologically superior when compared with laparoscopy by overcoming some of the technical limitations that are imposed on the surgeon by the conventional approach.

PURPOSE

This article reviews the current literature and the perspective of robotic general surgery.

CONCLUSIONS

While robotics has been applied to a wide range of general surgery procedures, its precise role in this field remains a subject of further research. Until now, only limited clinical evidence that could establish the use of robotics as the gold standard for procedures of general surgery has been created. While surgical robotics is still in its infancy with multiple novel systems currently under development and clinical trials in progress, the opportunities for this technology appear endless, and robotics should have a lasting impact to the field of general surgery.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Robotic Rectal Cancer Resection: A Retrospective Multicenter Analysis

BACKGROUND

Conventional laparoscopy has been applied to colorectal resections for more than 2 decades. However, laparoscopic rectal resection is technically demanding, especially when performing a tumor-specific mesorectal excision in a difficult pelvis. Robotic surgery is uniquely designed to overcome most of these technical limitations. The aim of this study was to confirm the feasibility of robotic rectal cancer surgery in a large multicenter study.

METHODS

Retrospective data of 425 patients who underwent robotic tumor-specific mesorectal excision for rectal lesions at seven institutions were collected. Outcome data were analyzed for the overall cohort and were stratified according to obese versus non-obese and low versus ultra-low resection patients.

RESULTS

Mean age was 60.9 years, and 57.9 % of patients were male. Overall, 51.3 % of patients underwent neoadjuvant therapy, while operative time was 240 min, mean blood loss 119 ml, and intraoperative complication rate 4.5 %. Mean number of lymph nodes was 17.4, with a positive circumferential margin rate of 0.9 %. Conversion rate to open was 5.9 %, anastomotic leak rate was 8.7 %, with a mean length of stay of 5.7 days. Operative times were significantly longer and re-admission rate higher for the obese population, with all other parameters comparable. Ultra-low resections also had longer operative times.

CONCLUSION

Robotic-assisted minimally invasive surgery for the treatment of rectal cancer is safe and can be performed according to current oncologic principles. BMI seems to play a minor role in influencing outcomes. Thus, robotics might be an excellent treatment option for the challenging patient undergoing resection for rectal cancer.