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Development and validation of neoadjuvant rectal score-based signature nomograms to predict overall survival and disease-free survival in locally advanced rectal cancer: a retrospective, double center, cohort study. Int J Clin Oncol 2023; 28:268-279. [PMID: 36534264 DOI: 10.1007/s10147-022-02281-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
AIM To evaluate the prognostic significance of the NAR score and develop nomograms for locally advanced rectal cancer (LARC) treated after neoadjuvant chemo-radiotherapy (nCRT) combined with total meso-rectal excision (TME) surgery to predict prognostic. METHODS Retrospective collection among LARC patients treated at Fujian Medical University Union Hospital (training cohort) and Fujian Medical University Affiliated Zhangzhou Hospital (external validation cohort) between Jan 10, 2011 and Dec 28, 2021. The NAR score was calculated by formula: [5pN-3(cT-pT) + 12]^2/9.61. NAR score low (< 8), intermediate (8-16), and high (> 16). RESULTS 1665 patients in the training cohort and 256 patients in the external validation cohorts were enrolled. Lower NAR score was significantly associated with better cumulative incidence of OS, DFS, local recurrence (LR), and distant metastasis (DM) (all P < 0.001). Multivariate Cox regression analysis indicates that NAR score, distance to the anal verge, no.253 LN metastasis, post-CRT carbohydrate antigen 19-9, tumor regression grade, and surgery method are independent predictors of OS and DFS (all P < 0.001). Among these independent factors, the NAR score had the highest area under the curve (AUC) and the nomograms to predict OS and DFS were generated. The AUCs for the accuracy of the prediction OS were 1 year = 0.742, 3 years = 0.749, 5 years = 0.713; prediction DFS were 1 year = 0.727, 3 years = 0.739, 5 years = 0.718, the models have good accuracy. CONCLUSIONS The NAR score can effectively classify patients with LARC into groups with varying outcomes of OS, DFS, LR, and DM. Moreover, the novel nomograms comprising the NAR score were developed and validated to help predict OS and DFS.
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Benedek Z, Surján C, Belicza É. Potential considerations in decision making on laparoscopic colorectal resections in Hungary based on administrative data. PLoS One 2021; 16:e0257811. [PMID: 34570819 PMCID: PMC8475994 DOI: 10.1371/journal.pone.0257811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 09/11/2021] [Indexed: 11/20/2022] Open
Abstract
Background Laparoscopic colorectal surgeries offer numerous advantages over their open counterparts. To compare these measurable short-time outcomes of open and laparoscopic resections in Hungary, data of colorectal surgeries were collected and analysed. The study focused on identifying patients’ characteristics that can influence the decision on laparoscopic colorectal resections and on comparing efficiency of Hungarian colorectal operations with international data. Methods Using patients’ data of laparoscopic and open colorectal surgery performed in 2015 and 2016 from the National Health Insurance Fund of Hungary, a countrywide retrospective comparative analysis was done. Logistic regression was used to explore main influencing factors for laparoscopic colorectal surgery. Results A total of 17,876 colorectal surgical cases, including 14,876 open and 3,000 laparoscopic resections were selected and analysed. Laparoscopy was used only in 16.78% of all cases. Comparison of age groups showed that odds ratio (OR) of laparoscopic colorectal resections was significantly lower in over 40 years than in younger patients (18–39 years). In university institutes patients had higher odds (OR: 2.23 p<0.0001) for laparoscopic colorectal resections. Presence of comorbidity codes and preoperative treatment in internal medicine department decreased odds for laparoscopic colorectal operations. Conclusions Patients’ age, comorbidities and hospital type influenced the likelihood of decision on laparoscopic colorectal resection. Selection of patients contributed to improved laparoscopic outcomes.
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Affiliation(s)
- Zsófia Benedek
- Mental Health Sciences Doctoral School, Semmelweis University, Budapest, Hungary
| | - Cecília Surján
- Mental Health Sciences Doctoral School, Semmelweis University, Budapest, Hungary.,Health Services Management Training Centre, Semmelweis University, Budapest, Hungary
| | - Éva Belicza
- Mental Health Sciences Doctoral School, Semmelweis University, Budapest, Hungary.,Health Services Management Training Centre, Semmelweis University, Budapest, Hungary
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Laparoscopic Colorectal Surgery Outcomes Improved After National Training Program (LAPCO) for Specialists in England. Ann Surg 2020; 275:1149-1155. [PMID: 33086313 DOI: 10.1097/sla.0000000000004584] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training. SUMMARY OF BACKGROUND DATA Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England. METHODS We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively. RESULTS One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% [95% confidence interval (CI), 18.5-23.3, P < 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively. CONCLUSIONS Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.
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Miyamoto K, Wakabayashi M, Mizusawa J, Nakamura K, Katayama H, Higashi T, Inomata M, Kitano S, Fujita S, Kanemitsu Y, Fukuda H. Evaluation of the representativeness and generalizability of Japanese clinical trials for localized rectal/colon cancer: Comparing participants in the Japan Clinical Oncology Group study with patients in Japanese registries. Eur J Surg Oncol 2020; 46:1642-1648. [PMID: 32340817 DOI: 10.1016/j.ejso.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/09/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION It is unclear if clinical trial results including patients who meet trial eligibility criteria, are applicable to actual patients in daily practice (generalizability). Moreover, the extent to which are trial participants different from patients seen in daily practice (representativeness) is also unclear. The aim of this study was to evaluate the representativeness of the patients registered in randomized clinical trials to patients in daily practice and examine the generalizability of trial results to daily practice. METHODS We compared the results of surgical trials conducted by the Japan Clinical Oncology Group with data from two Japanese cancer registries, representing patients seen in daily practice. We compared overall survival (OS) between trial participants and registry patients to evaluate representativeness of trial participants. We then compared the OS of registry patients who received open surgery (OP) and laparoscopic surgery (LAP) to evaluate the generalizability of trial results. RESULTS We analyzed 3051 patients (701 in JCOG0212, 2350 registry patients) with rectal cancer and 3116 patients (1057 in JCOG0404, 2059 registry patients) with colon cancer. Trial participants tended to possess lower clinical stages. Multivariable analyses revealed registry patients with significantly worse survival compared with trial participants. The hazard ratio of LAP to OP among registry patients was 0.305 (95% CI; 0.048-2.188), which did not meet the prespecified generalizability criteria of 0.9. CONCLUSIONS Our results failed to ensure either the representativeness or generalizability of clinical trial results, compared to daily practice. Careful considerations are required when applying trial results to patients in daily practice.
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Affiliation(s)
- Kenichi Miyamoto
- Department of Hematology, National Cancer Center Hospital East, Chiba, Japan; JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan.
| | - Masashi Wakabayashi
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Junki Mizusawa
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Kenichi Nakamura
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Katayama
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Takahiro Higashi
- Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | | | - Shin Fujita
- Department of Surgery, Tochigi Cancer Center, Tochigi, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Haruhiko Fukuda
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
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Clinical and oncological outcomes of single-incision vs. conventional laparoscopic surgery for rectal cancer. Surg Endosc 2019; 34:5294-5303. [PMID: 31858246 DOI: 10.1007/s00464-019-07317-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND To evaluate the clinical and oncological outcomes of single-incision laparoscopic surgery (SILS) vs. conventional laparoscopic surgery (CLS) for patients with rectal cancer (RC) who underwent total mesorectal excision (TME) surgery. METHODS This was a retrospective case-control study of patients with RC operated between 12/2013 and 12/2017 in Ruijin Hospital North, Shanghai Jiaotong University School of Medicine. In total, 177 patients who underwent CLS and 51 who underwent SILS met the inclusion and exclusion criteria and were matched 1:1 using propensity score matching method (PSM). RESULTS Compared with the CLS group, the SILS group showed shorter operation time [105 (40) vs. 125 (55) min, P = 0.045], shorter total incision length [4 (1) vs. 6.5 (1.5) cm, P < 0.001], lower VAS score on POD2 [1 (1) vs. 2 (1), P < 0.001], shorter time to soft diet [7 (1) vs. 8 (2) days, P = 0.048], and shorter length of hospital stay [9 (2) vs. 11 (3) days, P < 0.001]. The postoperative complications were similar between two groups [1(2%) vs. 5 (9.8%), P = 0.205]. No readmissions or mortality in either group occurred within 30 days of surgery. All 102 specimens met the requirements of TME. No significant differences were observed in the pathologic outcomes between the two groups. The median follow-up period was 32.6 months in the SILS group and 36.8 months in the CLS group (P = 0.053). The 3-year disease-free survival rates and overall survival rates of the SILS and CLS groups were 89.8% vs. 96.0% (P = 0.224) and 90.9% vs. 96.9% (P = 0.146), respectively. CONCLUSIONS Compared with CLS, TME surgery for rectal cancer can be performed safely and effectively using the SILS technique with better cosmetic results, less postoperative pain, faster postoperative recovery, and acceptable clinical and oncological outcomes.
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Currie AC, Merriman H, Nadia shah Gilani S, Mackenzie P, McFall MR, Baig MK. Validation of the size morphology site access score in endoscopic mucosal resection of large polyps in a district general hospital. Ann R Coll Surg Engl 2019; 101:558-562. [PMID: 31233327 PMCID: PMC6818069 DOI: 10.1308/rcsann.2019.0068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Polyp assessment is multimodal and is vital prior to endoscopic mucosal resection. The size, morphology, site and access (SMSA) score has been validated in specialist endoscopic institutions. this study investigated the ability of this score to predict incomplete endoscopic resection of large colorectal polyps in a district general hospital. METHODS Consecutive patients undergoing endoscopic mucosal resection of large (≥ 20 mm) colorectal polyps at Worthing Hospital. Clinical, endoscopic and histological data were taken from prospective databases. The primary outcome of the study was to investigate the correlation of the SMSA score with incomplete endoscopic resection. RESULTS Between February 2015 and August 2018, 114 patients underwent colorectal endoscopic mucosal resection. Of these, 67 (59%) were male. The median (interquartile range) age of the study population was 72 years (65-78 years). Some 17 lesions (15%) were pedunculated, 76 (67%) were sessile and 21 were (18%) flat; 84 polyps (77%) were located in the left colon/rectum, with the remainder in the right colon; 51 lesions (45%) were 20-30 mm, 27 (24%) were 30-40 mm and 36 (31%) were greater than 40 mm in diameter. When reclassified into the SMSA score, 9 of the polyps (8%) were level 2, 64 (56%) were level 3 and 41 (36%) were level 4. Incomplete resection was clinically diagnosed in 9/114 (8%). The SMSA score was positively correlated with incomplete endoscopic resection, but not with additional procedure usage, complications or advanced histology. CONCLUSIONS Many patients with large polyps can be managed outside of specialist units. This study has validated that the SMSA score was associated with incomplete endoscopic mucosal resection for large polyps in a district general hospital setting.
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Affiliation(s)
- AC Currie
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - H Merriman
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - S Nadia shah Gilani
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - P Mackenzie
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - MR McFall
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - MK Baig
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
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Currie AC, Blazeby JM, Suzuki N, Thomas-Gibson S, Reeves B, Morton D, Kennedy RH. Evaluation of an early-stage innovation for full-thickness excision of benign colonic polyps using the IDEAL framework. Colorectal Dis 2019; 21:1004-1016. [PMID: 30993857 DOI: 10.1111/codi.14650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 04/02/2019] [Indexed: 01/27/2023]
Abstract
AIMS Colectomy is the current approach for patients with endoscopically unresectable benign polyps but risks considerable morbidity. Full-thickness laparoendoscopic excision (FLEX) is a novel procedure, specifically developed to treat endoscopically unresectable benign colonic polyps, which could reduce the treatment burden of the current approach and improve outcomes. However, traditional evaluations of surgical innovations lack methodological rigour. This study reports the development and feasibility of the FLEX procedure in selected patients. METHOD A prospective development study using the Idea, Development, Evaluation, Assessment, Long-term study (IDEAL) framework was undertaken, by one surgeon, of the FLEX procedure in selected patients with endoscopically unresectable benign colonic polyps. Three-dimensional (3D)-CT colonography reconstructions were used preoperatively to rehearse patient-specific, critical manoeuvres. Targetted, full-thickness excision was performed: after marking the margin of the caecal polyp using circumferential endoscopic argon plasma coagulation, transmural endoscopic sutures were used to evert the bowel and resection was undertaken by laparoscopic linear stapling. Feasibility outcomes (establishing 'local success') included evidence of complete polyp resection without adverse events (especially safe closure of the excision site). RESULTS Ten patients [median (interquartile range) age: 74 (59-78) years] with polyp median diameters of 35 (30-41) mm, were referred for and consented to receive the FLEX procedure. During the same time frame, no patient underwent colectomy for benign polyps. One further patient received FLEX for local excision of a presumed malignant polyp because severe comorbidity prohibited standard procedures. The FLEX procedure was successfully performed locally, with complete resection of the polyp and safe closure of the excision site, in eight patients. Three noncompleted procedures were converted to laparoscopic segmental colectomy under the same anaesthetic because of endoscopic inaccessibility (two patients) and transcolonic suture failure (one patient). CONCLUSIONS The FLEX procedure is still under development. Early data demonstrate that it is safe for excision of selected benign polyps. Modifications to transcolonic suture delivery are now required and there is a need for wider adoption before more definitive evaluation can be performed.
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Affiliation(s)
- A C Currie
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK
| | - J M Blazeby
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK.,Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - N Suzuki
- Wolfson Department of Endoscopy, St Mark's Hospital, Harrow, Middlesex, UK
| | - S Thomas-Gibson
- Wolfson Department of Endoscopy, St Mark's Hospital, Harrow, Middlesex, UK
| | - B Reeves
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
| | - D Morton
- Department of Surgery, University of Birmingham, Birmingham, West Midlands, UK
| | - R H Kennedy
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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Multicenter Observational Study of Adhesion Formation After Open-and Laparoscopic Surgery for Colorectal Cancer. Ann Surg 2019; 267:743-748. [PMID: 28207436 DOI: 10.1097/sla.0000000000002175] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The aim of this study was to compare adhesion formation after laparoscopic and open colorectal cancer resection. SUMMARY OF BACKGROUND DATA After colorectal surgery, most patients develop adhesions, with a high burden of complications. Laparoscopy seems to reduce adhesion formation, but evidence is poor. Trials comparing open- and laparoscopic colorectal surgery have never assessed adhesion formation. METHODS Data on adhesions were gathered during resection of colorectal liver metastases. Incidence of adhesions adjacent to the original incision was compared between patients with previous laparoscopic- and open colorectal resection. Secondary outcomes were incidence of any adhesions, extent and severity of adhesions, and morbidity related to adhesions or adhesiolysis. RESULTS Between March 2013 and December 2015, 151 patients were included. Ninety patients (59.6%) underwent open colorectal resection and 61 patients (40.4%) received laparoscopic colorectal resection. Adhesions to the incision were present in 78.9% after open and 37.7% after laparoscopic resection (P < 0.001). The incidence of abdominal wall adhesions and of any adhesion was significantly higher after open resection; the incidence of visceral adhesions did not significantly differ. The extent of abdominal wall and visceral adhesions and the median highest Zühlke score at the incision were significantly higher after open resection. There were no differences in incidence of small bowel obstruction during the interval between the colorectal and liver operations, the incidence of serious adverse events, and length of stay after liver surgery. CONCLUSION Laparoscopic colorectal cancer resection is associated with a lower incidence, extent, and severity of adhesions to parietal surfaces. Laparoscopy does not reduce the incidence of visceral adhesions.
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Yang X, Zhang G, Jiang L, Zhang H, Liu Z, Liu J, Deng Y, Pan K, Man Fan JK. Laparoscopic sphincter-saving surgery for low rectal cancer through marker meeting approach. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:324. [PMID: 30363998 DOI: 10.21037/atm.2018.08.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Laparoscopic low anterior resection (LAR) with sphincter preservation for ultra-low rectal cancer is always a challenging operation in colorectal surgery. To achieve negative margins, reducing the difficulty and risks of the procedure are major goals for us. The marker meeting approach we reported can help to accomplish this goal. The key technique for the marker meeting approach is to ensure a clear distal margin in a low resection of the rectum by transanal dissection. This procedure allows access to the space around the distal rectum and mesorectum and to pack the gauzes in the distal part of the space as a landmark. Routine laparoscopic LAR was performed to dissect the space until reaching the gauzes packed above and achieve complete mobilization of the rectum and mesorectum. This surgical procedure is simpler and reduces the difficulty of the operation. Therefore, it is expected to reduce the risk of surgery-related complications and positive margins and is suitable to be widely applied and extended in clinical practice. The short-term and long-term clinical outcomes of the marker meeting approach need more research in large samples.
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Affiliation(s)
- Xuefei Yang
- Division of Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Guixi Zhang
- Division of Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Li Jiang
- Division of Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Hao Zhang
- Division of Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Zhihai Liu
- Division of Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Jingsi Liu
- Division of Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Yang Deng
- Division of Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Kai Pan
- Department of Gastrointestinal Surgery, Shenzhen People's Hospital & Second Clinical Medical College of Jinan University, Shenzhen 518020, China
| | - Joe King Man Fan
- Division of Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China.,Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Achieving high quality standards in laparoscopic colon resection for cancer: A Delphi consensus-based position paper. Eur J Surg Oncol 2018; 44:469-483. [PMID: 29422252 DOI: 10.1016/j.ejso.2018.01.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/08/2018] [Accepted: 01/16/2018] [Indexed: 12/21/2022] Open
Abstract
AIM To investigate the rate of laparoscopic colectomies for colon cancer using registries and population-based studies. To provide a position paper on mini-invasive (MIS) colon cancer surgery based on the opinion of experts leader in this field. METHODS A systematic review of the literature was conducted using PRISMA guidelines for the rate of laparoscopy in colon cancer. Moreover, Delphi methodology was used to reach consensus among 35 international experts in four study rounds. Consensus was defined as an agreement ≥75.0%. Domains of interest included nosology, essential technical/oncological requirements, outcomes and MIS training. RESULTS Forty-four studies from 42 articles were reviewed. Although it is still sub-optimal, the rate of MIS for colon cancer increased over the years and it is currently >50% in Korea, Netherlands, UK and Australia. The remaining European countries are un-investigated and presented lower rates with highest variations, ranging 7-35%. Using Delphi methodology, a laparoscopic colectomy was defined as a "colon resection performed using key-hole surgery independently from the type of anastomosis". The panel defined also the oncological requirements recognized essential for the procedure and agreed that when performed by experienced surgeons, it should be marked as best practice in guidelines, given the principles of oncologic surgery be respected (R0 procedure, vessel ligation and mesocolon integrity). CONCLUSION The rate of MIS colectomies for cancer in Europe should be further investigated. A panel of leaders in this field defined laparoscopic colectomy as a best practice procedure when performed by an experienced surgeon respecting the standards of surgical oncology.
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Is the laparoscopic approach for rectal cancer superior to open surgery? A systematic review and meta-analysis on short-term surgical outcomes. Wideochir Inne Tech Maloinwazyjne 2018; 13:129-140. [PMID: 30002744 PMCID: PMC6041579 DOI: 10.5114/wiitm.2018.75845] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 02/13/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction Over the past years the incidence of colorectal cancers has increased worldwide. Currently it is the most common gastrointestinal malignancy worldwide. The laparoscopic approach has become the gold standard for surgical treatment. However, a recently published meta-analysis showed no difference in short- and long-term oncological outcomes of laparoscopy for treating rectal cancer. Aim To assess current literature on short-term outcomes of rectal cancer treatment using laparoscopic surgery in comparison to the open approach. Material and methods We performed a systematic review and meta-analysis according to the PRISMA guidelines. The primary outcomes of interest were morbidity and short-term complications. Results We identified 4,328 potential references. In the end we included 13 randomized controlled trials (RCTs). We did not find any significant differences in terms of morbidity, haemorrhage, ureter injury, anastomotic leakage, mortality, intra-abdominal abscess or postoperative ileus. We found significant differences in the rate of surgical site infections, operative time, blood loss, length of hospital stay and time to first bowel movement. Conclusions This systematic review based on available RCTs confirms that laparoscopic rectal cancer surgery is associated with short-term outcomes comparable to the open approach. Moreover, in some aspects it provides better results (e.g. functional postoperative recovery, lower rate of surgical site infections (SSIs)). The quality of evidence is high; therefore in our opinion it is very unlikely that future trials will alter these results, and for this reason the laparoscopic approach can be considered the gold standard for the treatment of the majority of patients.
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Pędziwiatr M, Małczak P, Mizera M, Witowski J, Torbicz G, Major P, Pisarska M, Wysocki M, Budzyński A. There is no difference in outcome between laparoscopic and open surgery for rectal cancer: a systematic review and meta-analysis on short- and long-term oncologic outcomes. Tech Coloproctol 2017; 21:595-604. [PMID: 28795243 PMCID: PMC5602007 DOI: 10.1007/s10151-017-1662-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/04/2017] [Indexed: 12/20/2022]
Abstract
Background
Until recently there has been little data available about long-term outcomes of laparoscopic rectal cancer surgery. But new randomized controlled trials regarding laparoscopic colorectal surgery have been published. The aim of this study was to compare the short- and long-term oncologic outcomes of laparoscopy and open surgery for rectal cancer through a systematic review of the literature and a meta-analysis of relevant RCTs. Methods A systematic review of Medline, Embase and the Cochrane library from January 1966 to October 2016 with a subsequent meta-analysis was performed. Only randomized controlled trials with data on circumferential resection margins were included. The primary outcome was the status of circumferential resection margins. Secondary outcomes included lymph node yield, distal resection margins, disease-free and overall survival rates for 3 and 5 years and local recurrence rates. Results Eleven studies were evaluated, involving a total of 2018 patients in the laparoscopic group and 1526 patients in the open group. The presence of involved circumferential margins was reported in all studies. There were no statistically significant differences in the number of positive circumferential margins between the laparoscopic group and open group, RR 1.16, 95% CI 0.89–1.50 and no significant differences in involvement of distal margins (RR 1.13 95% CI 0.35–3.66), completeness of mesorectal excision (RR 1.22, 95% CI 0.82–1.82) or number of harvested lymph nodes (mean difference = −0.01, 95% CI −0.89 to 0.87). Disease-free survival rates at 3 and 5 years were not different (p = 0.26 and p = 0.71 respectively), and neither were overall survival rates (p = 0.19 and p = 0.64 respectively), nor local recurrence rates (RR 0.88, 95% CI 0.63–1.23). Conclusions Laparoscopic surgery for rectal cancer is associated with similar short-term and long-term oncologic outcomes compared to open surgery. The oncologic quality of extracted specimens seems comparable regardless of the approach used. Electronic supplementary material The online version of this article (doi:10.1007/s10151-017-1662-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland.
| | - P Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - M Mizera
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
| | - J Witowski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - G Torbicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland
| | - P Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - M Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - M Wysocki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - A Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
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13
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Ye X, Kang WM, Yu JC, Ma ZQ, Xue ZG. Comparison of short- and long-term outcomes of laparoscopic vs open resection for gastric gastrointestinal stromal tumors. World J Gastroenterol 2017; 23:4595-4603. [PMID: 28740348 PMCID: PMC5504375 DOI: 10.3748/wjg.v23.i25.4595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/10/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the short- and long-term outcomes of laparoscopic (LR) vs open resection (OR) for gastric gastrointestinal stromal tumors (gGISTs).
METHODS In total, 301 consecutive patients undergoing LR or OR for pathologically confirmed gGISTs from 2005 to 2014 were enrolled in this retrospective study. After exclusion of 77 patients, 224 eligible patients were enrolled (122 undergoing LR and 102 undergoing OR). The demographic, clinicopathologic, and survival data of all patients were collected. The intraoperative, postoperative, and long-term oncologic outcomes were compared between the LR and OR groups following the propensity score matching to balance the measured covariates between the two groups.
RESULTS After 1:1 propensity score matching for the set of covariates including age, sex, body mass index, American Society of Anesthesiology score, tumor location, tumor size, surgical procedures, mitotic count, and risk stratification, 80 patients in each group were included in the final analysis. The baseline parameters of the two groups were comparable after matching. The LR group was significantly superior to the OR group with respect to the operative time, intraoperative blood loss, postoperative first flatus, time to oral intake, and postoperative hospital stay (P < 0.05). No differences in perioperative blood transfusion or the incidence of postoperative complications were observed between the two groups (P > 0.05). No significant difference was found in postoperative adjuvant therapy (P = 0.587). The mean follow-up time was 35.30 ± 26.02 (range, 4-102) mo in the LR group and 40.99 ± 25.07 (range, 4-122) mo in the OR group with no significant difference (P = 0.161). Survival analysis showed no significant difference in the disease-free survival time or overall survival time between the two groups (P > 0.05).
CONCLUSION Laparoscopic surgery for gGISTs is superior to open surgery with respect to intraoperative parameters and postoperative outcomes without compromising long-term oncological outcomes.
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Currie AC, Askari A, Rao C, Saunders BP, Athanasiou T, Faiz OD, Kennedy RH. The potential impact of local excision for T1 colonic cancer in elderly and comorbid populations: a decision analysis. Gastrointest Endosc 2016; 84:986-994. [PMID: 27189656 DOI: 10.1016/j.gie.2016.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 05/09/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Population-based bowel cancer screening has resulted in increasing numbers of patients with T1 colonic cancer. The need for colectomy in this group is questioned due to the low risk of lymphatic spread and increased treatment morbidity, particularly for elderly, comorbid patients. This study examined the quality-of-life benefits and risks of endoscopic resection compared with results after colectomy, for low-risk and high-risk T1 colonic cancer. METHODS Decision analysis using a Markov simulation model was performed; patients were managed with either endoscopic resection (advanced therapeutic endoscopy) or colectomy. Lesions were considered high risk according to accepted national guidelines. Probabilities and utilities (perception of quality of life) were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients with low-risk or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs). RESULTS In low-risk T1 colonic neoplasia, endoscopic resection increases QALE by 0.09 QALYS for fit 65-year-olds and by 0.67 for unfit 80-year-olds. For high-risk T1 cancers, the QALE benefit for surgical resection is 0.24 QALYs for fit 65-year-olds and the endoscopic QALE benefit is 0.47 for unfit 80-year-olds. The model findings only favored surgery with high local recurrence rates and when quality of life under surveillance was perceived poorly. CONCLUSIONS Under broad assumptions, endoscopic resection is a reasonable treatment option for both low-risk and high-risk T1 colonic cancer, particularly in elderly, comorbid patients. Exploration of methods to facilitate endoscopic resection of T1 colonic neoplasia appears warranted.
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Affiliation(s)
- Andrew C Currie
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK
| | - Alan Askari
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK
| | - Christopher Rao
- Department of Surgery, Queen Elizabeth Hospital, Woolwich, London, UK
| | - Brian P Saunders
- Wolfson Department of Endoscopy, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Omar D Faiz
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK
| | - Robin H Kennedy
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK
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15
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Currie AC, Malietzis G, Jenkins JT, Yamada T, Ashrafian H, Athanasiou T, Okabayashi K, Kennedy RH. Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer. Br J Surg 2016; 103:1783-1794. [PMID: 27762436 DOI: 10.1002/bjs.10306] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/28/2016] [Accepted: 07/25/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality. METHODS MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data. RESULTS Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy. CONCLUSION Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).
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Affiliation(s)
- A C Currie
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - G Malietzis
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - J T Jenkins
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
| | - T Yamada
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - H Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - T Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - K Okabayashi
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - R H Kennedy
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, UK
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16
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Penna M, Buchs NC, Bloemendaal AL, Hompes R. Transanal total mesorectal excision for rectal cancer: the journey towards a new technique and its current status. Expert Rev Anticancer Ther 2016; 16:1145-1153. [PMID: 27690685 DOI: 10.1080/14737140.2016.1240040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The surgical approach to total mesorectal excision (TME) for rectal cancer has undergone a substantial evolution with the adoption of more minimally invasive procedures. Transanal TME (taTME) is the latest advanced technique pioneered to tackle difficult pelvic dissections. Areas covered: The evolution of TME surgery from open to laparoscopic, robotic and transanal techniques was explored in this review. The outcomes to date on the latest approach, taTME, are reviewed and the future direction of rectal cancer surgery proposed. A literature search was performed using Embase, Medline, Web of Science and Cochrane databases for articles published between January 2005 to May 2016 using the keywords 'transanal', 'TME', 'laparoscopy', 'robotics', 'minimally invasive', 'outcomes' and 'training'. Expert commentary: Surgical experience in taTME is growing and randomised controlled trials have been planned and initiated worldwide. However, the learning curve for this procedure remains to be established and a structured training programme is necessary to ensure safe introduction and dissemination of the technique in the clinical setting. Further innovation including stereotactic navigation and more specialised transanal equipment are currently being explored and are likely to enhance the technique further.
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Affiliation(s)
- Marta Penna
- a Department of Colorectal Surgery, Churchill Hospital , University Hospitals of Oxford , Oxford , UK
| | - Nicolas C Buchs
- a Department of Colorectal Surgery, Churchill Hospital , University Hospitals of Oxford , Oxford , UK
| | - Alexander L Bloemendaal
- a Department of Colorectal Surgery, Churchill Hospital , University Hospitals of Oxford , Oxford , UK
| | - Roel Hompes
- a Department of Colorectal Surgery, Churchill Hospital , University Hospitals of Oxford , Oxford , UK
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