Laparoscopic translevator approach to abdominoperineal resection for rectal adenocarcinoma: feasibility and short-term oncologic outcomes

Needlescopic surgery for very low rectal cancer with no abdominal skin incision

INTRODUCTION

Needlescopic surgery (NS) is a minimally invasive operation beyond traditional laparoscopic surgery. This study aimed to describe NS for intersphincteric resection (ISR) and abdominoperineal resection (APR) for low rectal cancer without a small abdominal skin incision for extracting the specimen and to evaluate the safety and feasibility of the operation.

METHODS

From January 2011 to April 2016, 36 patients underwent NS for either ISR or APR. By definition, NS for ISR or APR at our institution uses three 3-mm ports and two 5-mm ports at the umbilicus and in the right lower quadrant. The specimen was extracted through the anus or the perineal wound. The feasibility of this operation was determined based on short-term outcomes and pathological findings.

RESULTS

No patients required conversion to open surgery. The mean operation time was 299 minutes, and the mean estimated blood loss was 30 mL. Postoperative complications higher than Clavien-Dindo grade III occurred in 2.8% of patients (n = 1). The median number of harvested lymph nodes was 16 (range, 0-30), and in no case was there a positive circumferential resection margin.

CONCLUSIONS

Needlescopic surgery for ISR or APR is technically safe and feasible for low rectal cancer based on the short-term outcomes and the oncological quality, particularly when compared to conventional laparoscopic surgery as described in previous reports.

Disease-free Survival and Local Recurrence for Laparoscopic Resection Compared With Open Resection of Stage II to III Rectal Cancer: Follow-up Results of the ACOSOG Z6051 Randomized Controlled Trial

OBJECTIVE

To determine the disease-free survival (DFS) and recurrence after the treatment of patients with rectal cancer with open (OPEN) or laparoscopic (LAP) resection.

BACKGROUND

This randomized clinical trial (ACOSOG [Alliance] Z6051), performed between 2008 and 2013, compared LAP and OPEN resection of stage II/III rectal cancer, within 12 cm of the anal verge (T1-3, N0-2, M0) in patients who received neoadjuvant chemoradiotherapy. The rectum and mesorectum were resected using open instruments for rectal dissection (included hybrid hand-assisted laparoscopic) or with laparoscopic instruments under pneumoperitoneum. The 2-year DFS and recurrence were secondary endpoints of Z6051.

METHODS

The DFS and recurrence were not powered, and are being assessed for superiority. Recurrence was determined at 3, 6, 9, 12, and every 6 months thereafter, using carcinoembryonic antigen, physical examination, computed tomography, and colonoscopy. In all, 486 patients were randomized to LAP (243) or OPEN (243), with 462 eligible for analysis (LAP = 240 and OPEN = 222). Median follow-up is 47.9 months.

RESULTS

The 2-year DFS was LAP 79.5% (95% confidence interval [CI] 74.4-84.9) and OPEN 83.2% (95% CI 78.3-88.3). Local and regional recurrence was 4.6% LAP and 4.5% OPEN. Distant recurrence was 14.6% LAP and 16.7% OPEN.Disease-free survival was impacted by unsuccessful resection (hazard ratio [HR] 1.87, 95% CI 1.21-2.91): composite of incomplete specimen (HR 1.65, 95% CI 0.85-3.18); positive circumferential resection margins (HR 2.31, 95% CI 1.40-3.79); positive distal margin (HR 2.53, 95% CI 1.30-3.77).

CONCLUSION

Laparoscopic assisted resection of rectal cancer was not found to be significantly different to OPEN resection of rectal cancer based on the outcomes of DFS and recurrence.

A systematic review of transabdominal levator division during abdominoperineal excision of the rectum (APER)

BACKGROUND

The aim of the present study was to evaluate the surgical technique, short-term oncological and perioperative outcomes for the transabdominal division of the levator ani muscles during abdominoperineal excision of the rectum (APER).

METHODS

A systematic review was performed to identify studies reporting on transabdominal division of the levator ani during APER. A comprehensive literature search was performed using a combination of free-text terms and controlled vocabulary when applicable on the following databases: MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library. The search period was from January 1945 to December 2015. The following search headings were used: "transabdominal", "transpelvic", "abdominal" or "pelvic" combined with either "levator" or "extralevator" and with "abdominoperineal".

RESULTS

Nine publications were identified reporting on 99 participants. The male/female distribution was 1.44:1, respectively, and the mean age was 56.6 (30-77) years. All tumours were less than 5 cm from the anal verge. The preoperative radiological staging was T2 in 18% of cases, T3 in 53.5% and T4 in 28.5%. Transabdominal division of the levators was performed laparoscopically in 55 cases, robotically in 34 and open in 10. The mean operating time was 255 (177-640) min. Mean intraoperative blood loss was 140 (92-500) ml. There were no conversions to open. Circumferential resection margins were positive in two cases, and there was one intraoperative perforation. Mean post-operative length of stay was 9.3 (3-67) days. Follow-up (from 0 to 31 months) revealed 19 perineal wound infections, 15 cases of sexual dysfunction and 7 cases of urinary retention. There was no mortality and 1 readmission.

CONCLUSIONS

Transabdominal division of the levators during APER is feasible and reproducible, with acceptable perioperative and good early oncological outcomes. Further comparative studies are needed.