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Rogier-Mouzelas F, Piquard A, Karam E, Dussart D, Michot N, Saint-Marc O, Thebault B, Artus A, Bucur P, Pabst-Giger U, Salame E, Ouaissi M. Comparison of a robotic surgery program for rectal cancer: short- and long-term results from a comparative, retrospective study between two laparoscopic and robotic reference centers. Surg Endosc 2024; 38:3738-3757. [PMID: 38789622 DOI: 10.1007/s00464-024-10867-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/14/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND It is assumed that robotic-assisted surgery (RAS) may facilitate complex pelvic dissection for rectal cancer compared to the laparoscopic-assisted resection (LAR). The aim of this study was to compare perioperative morbidity, short- and long-term oncologic, and functional outcomes between the RAS and LAR approaches. METHODS Between 2015 and 2021, all rectal cancers operated on by (LAR) or (RAS) were retrospectively reviewed in two colorectal surgery centers. RESULTS A total of 197 patients were included in the study, with 70% in the LAR group and 30% in the RAS group. The tumor location and stage were identical in both groups (not significant = NS). The overall postoperative mortality rate was not significantly different between the two groups. (0% LAR; 0.5% RAS; NS). The postoperative morbidity was similar between the two groups (60% LAR vs 57% RAS; NS). The number of early surgical re-interventions within the first 30 days was similar (10% for the LAR group and 3% for the RAS group; NS). The rate of complete TME was similar (88% for the LAR group and 94% for the RAS group; NS). However, the rate of circumferential R1 was significantly higher in the LAR group (13%) compared to the RAS group (2%) (p = 0.009). The 3-year recurrence rate did not differ between the two groups (77% for both groups; NS). After a mean follow-up of three years, the incidence of anterior resection syndrome was significantly lower in the LAR group compared to the RAS group (54 vs 76%; p = 0.030). CONCLUSIONS The use of a RAS was found to be reliable for oncologic outcomes and morbidity. However, the expected benefits for functional outcomes were not observed. Therefore, the added value of RAS for rectal cancer needs to be reassessed in light of new laparoscopic technologies and patient management options.
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Affiliation(s)
- Fabien Rogier-Mouzelas
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Colorectal Surgery Unit, Trousseau Hospital, University Hospital of Tours, Avenue de La République, 37044, Tours, France
| | - Arnaud Piquard
- Department of Digestive Surgery, University Hospital of Orleans, 14 avenue de l'hôpital, 45100, Orleans, France
| | - Elias Karam
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Colorectal Surgery Unit, Trousseau Hospital, University Hospital of Tours, Avenue de La République, 37044, Tours, France
| | - David Dussart
- Department of Digestive Surgery, University Hospital of Orleans, 14 avenue de l'hôpital, 45100, Orleans, France
| | - Nicolas Michot
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Colorectal Surgery Unit, Trousseau Hospital, University Hospital of Tours, Avenue de La République, 37044, Tours, France
| | - Olivier Saint-Marc
- Department of Digestive Surgery, University Hospital of Orleans, 14 avenue de l'hôpital, 45100, Orleans, France
| | - Baudouin Thebault
- Department of Digestive Surgery, University Hospital of Orleans, 14 avenue de l'hôpital, 45100, Orleans, France
| | - Alice Artus
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Colorectal Surgery Unit, Trousseau Hospital, University Hospital of Tours, Avenue de La République, 37044, Tours, France
| | - Petru Bucur
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Colorectal Surgery Unit, Trousseau Hospital, University Hospital of Tours, Avenue de La République, 37044, Tours, France
| | - Urs Pabst-Giger
- Fliedner Fachhochschule, University of Applied Sciences, Düsseldorf, Germany
| | - Ephrem Salame
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Colorectal Surgery Unit, Trousseau Hospital, University Hospital of Tours, Avenue de La République, 37044, Tours, France
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Colorectal Surgery Unit, Trousseau Hospital, University Hospital of Tours, Avenue de La République, 37044, Tours, France.
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2
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Li X, Liu ZH, Wang N, Ding J, Fan F, Cen XY, Wu M, Mi R, Liu H, Zhang YL. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of long-term survival and urogenital functional outcomes. Minerva Gastroenterol (Torino) 2023; 69:403-411. [PMID: 33860661 DOI: 10.23736/s2724-5985.21.02850-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Robotic surgical technology has been widely introduced and applied in various fields of surgery. The aim of this study was to analyze long-term oncological and urogenital functional outcomes following laparoscopic/robotic total mesorectal excision (TME) in rectal cancer surgery. EVIDENCE ACQUISITION We identified studies that compared oncological and functional outcomes following laparoscopic TME (LTME) and robotic TME (RTME) for treatment of rectal cancer over the past 16 years. Data related to overall survival (OS), disease-free survival (DFS), International Prostate Symptom Score (IPSS), and International Index of Erectile Function (IIEF) were subjected to meta-analysis. EVIDENCE SYNTHESIS There was no difference in long-term OS and DFS in the pooled data. Compared with LTME, there were significant differences in the score of IPSS at 3, 6 and 12 months for RTME, in the pooled data for male patients. There were significant differences in IIEF score for male patients at 3 and 6 months. CONCLUSIONS Compared with LTME, RTME has better preservation of urinary and sexual functions and comparable long-term oncological outcome in rectal cancer.
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Affiliation(s)
- Xian Li
- Department of Gastrointestinal Surgery, Guizhou Provincial People's Hospital, Guiyang, China
| | - Zhen-Hua Liu
- Department of Pharmacy, Guizhou Orthopedic Hospital, Guiyang, China
| | - Ning Wang
- Department of Hepatobiliary Surgery, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jie Ding
- Department of Gastrointestinal Surgery, Guizhou Provincial People's Hospital, Guiyang, China - dingjiesydoc@ 126.com
| | - Fei Fan
- Department of Gastrointestinal Surgery, Guizhou Provincial People's Hospital, Guiyang, China
| | - Xiang-Ying Cen
- Graduate School of Zunyi Medical University, ZunYi, China
| | - Ming Wu
- Department of Emergency Medicine, Guizhou Provincial People's Hospital, Guiyang, China
| | - Rui Mi
- Department of Gastrointestinal Surgery, Zhijin County People's Hospital, Bijie, China
| | - Hang Liu
- Department of Integrated Surgery, Chongqing General Hospital, Chongqing, China
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3
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Giesen LJX, Dekker JWT, Verseveld M, Crolla RMPH, van der Schelling GP, Verhoef C, Olthof PB. Implementation of robotic rectal cancer surgery: a cross-sectional nationwide study. Surg Endosc 2023; 37:912-920. [PMID: 36042043 PMCID: PMC9945537 DOI: 10.1007/s00464-022-09568-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022]
Abstract
AIM An increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches. METHODS Patients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach. RESULTS Between 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13-16%) in 2018 to 22% (95% CI 20-24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3-5%) versus 7% (95% CI 6-8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38-46%) versus 29% (95% CI 26-31%)]. CONCLUSION Rectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.
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Affiliation(s)
- L J X Giesen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.
| | - J W T Dekker
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - M Verseveld
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - C Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - P B Olthof
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Mueller AN, Vossler JD, Yim NH, Harbison GJ, Murayama KM. Predictors and Consequences of Unplanned Conversion to Open During Robotic Colectomy: An ACS-NSQIP Database Analysis. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2021; 80:3-9. [PMID: 34820629 PMCID: PMC8609196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Robotic-assisted surgery has become a desired modality for performing colectomy; however, unplanned conversion to an open procedure may be associated with worse outcomes. The purpose of this study is to examine predictors and consequences of unplanned conversion to open in a large, high fidelity data set. A retrospective analysis of 11 061 robotic colectomies was conducted using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) 2012-2017 database. Predictors of conversion and the effect of conversion on outcomes were analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of conversion and morbidity/mortality. Overall, 10 372 (93.8%) patients underwent successful robotic colectomy, and 689 (6.2%) had an unplanned conversion. Predictors of conversion included age ≥ 65 years, male gender, obesity, functional status not independent, American Society of Anesthesia (ASA) classification IV-V, non-oncologic indication, emergency case, smoking, recent weight loss, bleeding disorder, and preoperative organ space infection. Conversion is an independent risk factor for mortality, overall morbidity, cardiac morbidity, pulmonary morbidity, renal morbidity, venous thromboembolism morbidity, wound morbidity, sepsis, bleeding, readmission, return to the operating room, and extended length of stay (LOS). Unplanned conversion to open during robotic colectomy is an independent predictor of morbidity and mortality.
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Affiliation(s)
- Andrew N. Mueller
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (ANM, JDV, KMM)
| | - John D. Vossler
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (ANM, JDV, KMM)
| | - Nicholas H. Yim
- John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (NHY, GJH)
| | - Gregory J. Harbison
- John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (NHY, GJH)
| | - Kenric M. Murayama
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (ANM, JDV, KMM)
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5
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Cuk P, Kjær MD, Mogensen CB, Nielsen MF, Pedersen AK, Ellebæk MB. Short-term outcomes in robot-assisted compared to laparoscopic colon cancer resections: a systematic review and meta-analysis. Surg Endosc 2021; 36:32-46. [PMID: 34724576 PMCID: PMC8741661 DOI: 10.1007/s00464-021-08782-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/17/2021] [Indexed: 12/12/2022]
Abstract
Background Robot-assisted surgery is increasingly adopted in colorectal surgery. However, evidence for the implementation of robot-assisted surgery for colon cancer is sparse. This study aims to evaluate the short-term outcomes of robot-assisted colon surgery (RCS) for cancer compared to laparoscopic colon surgery (LCS). Methods Embase, MEDLINE, and Cochrane Library were searched between January 1, 2005 and October 2, 2020. Randomized clinical trials and observational studies were included. Non-original literature was excluded. Primary endpoints were anastomotic leakage rate, conversion to open surgery, operative time, and length of hospital stay. Secondary endpoints were surgical efficacy and postoperative morbidity. We evaluated risk of bias using RoB2 and ROBINS-I quality assessment tools. We performed a pooled analysis of primary and secondary endpoints. Heterogeneity was assessed by I2, and possible causes were explored by sensitivity- and meta-regression analyses. Publication bias was evaluated by Funnel plots and Eggers linear regression test. The level of evidence was assessed by GRADE. Results Twenty studies enrolling 13,799 patients (RCS 1740 (12.6%) and LCS 12,059 (87.4%) were included in the meta-analysis that demonstrated RCS was superior regarding: anastomotic leakage (odds ratio (OR) = 0.54, 95% CI [0.32, 0.94]), conversion (OR = 0.31, 95% CI [0.23, 0.41]), overall complication rate (OR = 0.85, 95% CI [0.73, 1.00]) and time to regular diet (MD = − 0.29, 95% CI [− 0.56, 0.02]). LCS proved to have a shortened operative time compared to RCS (MD = 42.99, 95% CI [28.37, 57.60]). Level of evidence was very low according to GRADE. Conclusion RCS showed advantages in colonic cancer surgery regarding surgical efficacy and morbidity compared to LCS despite a predominant inclusion of non-RCT with serious risk of bias assessment and a very low level of evidence. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08782-7.
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Affiliation(s)
- Pedja Cuk
- Surgical Department, University Hospital of Southern Jutland, Kresten Philipsens Vej 15, 6200, Aabenraa, Denmark. .,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Mie Dilling Kjær
- Research Unit for Surgery, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | | | - Michael Festersen Nielsen
- Surgical Department, University Hospital of Southern Jutland, Kresten Philipsens Vej 15, 6200, Aabenraa, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Odense University Hospital and University of Southern Denmark, Odense, Denmark
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6
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Cuk P, Pedersen AK, Lambertsen KL, Mogensen CB, Nielsen MF, Helligsø P, Gögenur I, Ellebæk MB. Systemic inflammatory response in robot-assisted and laparoscopic surgery for colon cancer (SIRIRALS): study protocol of a randomized controlled trial. BMC Surg 2021; 21:363. [PMID: 34635066 PMCID: PMC8507379 DOI: 10.1186/s12893-021-01355-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/23/2021] [Indexed: 01/10/2023] Open
Abstract
Background Robot-assisted surgery is being increasingly adopted in treating colorectal cancer, and the transition from laparoscopic surgery to robot-assisted surgery is a trend. The evidence of the benefits of robot-assisted surgery is sparse. However, findings are associated with improved patient-related outcomes and overall morbidity rates compared to laparoscopic surgery. This induction is unclear, considering both surgical modalities are characterized as minimally invasive. This study aims to evaluate the systemic and peritoneal inflammatory stress response induced by robot-assisted surgery compared with laparoscopic surgery for elective colon cancer resections in a prospective, randomized controlled clinical trial. Methods This study is a single-centre randomized controlled superiority trial with 50 colon cancer participants. The primary endpoint is the level of systemic inflammatory response expressed as serum C-reactive protein (CRP) and interleukin 6 (IL-6) levels between postoperative days one and three. Secondary endpoints include (i) levels of systemic inflammation in serum expressed by a panel of inflammatory and pro-inflammatory cytokines measured during the first three postoperative days, (ii) postoperative surgical and medical complications (30 days) according to Clavien-Dindo classification and Comprehensive Complication Index, (iii) intraoperative blood loss, (iv) conversion rate to open surgery, (v) length of surgery, (vi) operative time, (vii) the number of harvested lymph nodes, and (viii) length of hospital stay. The exploratory endpoints are (i) levels of peritoneal inflammatory response in peritoneal fluid expressed by inflammatory and pro-inflammatory cytokines between postoperative day one and three, (ii) patient-reported health-related quality of recovery-15 (QoR-15), (iii) 30 days mortality rate, (iv) heart rate variability and (v) gene transcript (mRNA) analysis. Discussion To our knowledge, this is the first clinical randomized controlled trial to clarify the inflammatory stress response induced by robot-assisted or laparoscopic surgery for colon cancer resections. Trial registration This trial is registered at Clinicaltrials.gov (Identifier: NCT04687384) on December, 29, 2020, Regional committee on health research ethics, Region of Southern Denmark (N75709) and Data Protection Agency, Hospital Sønderjylland, University Hospital of Southern Denmark (N20/46179). Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01355-4.
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Affiliation(s)
- Pedja Cuk
- Surgical Department, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens vej 15, 6200, Aabenraa, Denmark. .,OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark. .,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | | | - Kate Lykke Lambertsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,Department of Neurology, Odense University Hospital, Odense, Denmark.,BRIDGE, Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Michael Festersen Nielsen
- Surgical Department, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens vej 15, 6200, Aabenraa, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Per Helligsø
- Surgical Department, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens vej 15, 6200, Aabenraa, Denmark
| | - Ismail Gögenur
- Surgical Department, Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
| | - Mark Bremholm Ellebæk
- Surgical Research Unit, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
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7
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Update on Robotic Total Mesorectal Excision for Rectal Cancer. J Pers Med 2021; 11:jpm11090900. [PMID: 34575677 PMCID: PMC8472541 DOI: 10.3390/jpm11090900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 12/16/2022] Open
Abstract
The minimally invasive treatment of rectal cancer with Total Mesorectal Excision is a complex and challenging procedure due to technical and anatomical issues which could impair postoperative, oncological and functional outcomes, especially in a defined subgroup of patients. The results from recent randomized controlled trials comparing laparoscopic versus open surgery are still conflicting and trans-anal bottom-up approaches have recently been developed. Robotic surgery represents the latest consistent innovation in the field of minimally invasive surgery that may potentially overcome the technical limitations of conventional laparoscopy thanks to an enhanced dexterity, especially in deep narrow operative fields such as the pelvis. Results from population-based multicenter studies have shown the potential advantages of robotic surgery when compared to its laparoscopic counterpart in terms of reduced conversions, complication rates and length of stay. Costs, often advocated as one of the main drawbacks of robotic surgery, should be thoroughly evaluated including both the direct and indirect costs, with the latter having the potential of counterbalancing the excess of expenditure directly related to the purchase and maintenance of robotic equipment. Further prospectively maintained or randomized data are still required to better delineate the advantages of the robotic platform, especially in the subset of most complex and technically challenging patients from both an anatomical and oncological standpoint.
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8
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Cuk P, Simonsen RM, Komljen M, Nielsen MF, Helligsø P, Pedersen AK, Mogensen CB, Ellebæk MB. Improved perioperative outcomes and reduced inflammatory stress response in malignant robot-assisted colorectal resections: a retrospective cohort study of 298 patients. World J Surg Oncol 2021; 19:155. [PMID: 34022914 PMCID: PMC8141231 DOI: 10.1186/s12957-021-02263-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023] Open
Abstract
Background Robot-assisted surgery is increasingly implemented for the resection of colorectal cancer, although the scientific evidence for adopting this technique is still limited. This study’s main objective was to compare short-term complication rates, oncological outcomes, and the inflammatory stress response after colorectal resection for cancer performed laparoscopic or robot-assisted. Methods We conducted a retrospective cohort study comparing the robot-assisted approach to laparoscopic surgery for elective malignant colorectal neoplasm. Certified colorectal and da Vinci ® robotic surgeons performed resections at a Danish tertiary colorectal high volume center from May 2017 to March 2019. We analyzed the two surgical groups using uni- and multivariate regression analyses to detect differences in intra- and postoperative clinical outcomes and the inflammatory stress response. Results Two hundred and ninety-eight patients were enrolled in the study. Significant differences favoring robot-assisted surgery was demonstrated for; length of hospital stay (4 days, interquartile range (4, 5) versus 5 days, interquartile range (4–7), p < 0.001), and intraoperative blood loss (50 mL, interquartile range (20–100) versus 100 mL, interquartile range (50–150), p < 0.001) compared to laparoscopic surgery. The inflammatory stress response was significantly higher after laparoscopic compared to robot-assisted surgery reflected by an increase in C-reactive protein concentration (exponentiated coefficient = 1.23, 95% confidence interval (1.06–1.46), p = 0.008). No differences between the two groups were found concerning mortality, microradical resection rate, conversion to open surgery, and surgical or medical short-term complication rates. Conclusion Robot-assisted surgery is feasible and can be safely implemented for colorectal resections. The robot-assisted approach, when compared to laparoscopic surgery, was associated with improved intra- and postoperative outcomes. Extensive prospective studies are needed to determine the short- and long-term outcomes of robotic surgery for colorectal cancer.
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Affiliation(s)
- Pedja Cuk
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark. .,Department of Regional Health Research, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark. .,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark.
| | | | - Mirjana Komljen
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Michael Festersen Nielsen
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark.,Department of Regional Health Research, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark
| | - Per Helligsø
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Andreas Kristian Pedersen
- Department of Regional Health Research, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark.,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Christian Backer Mogensen
- Department of Regional Health Research, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Surgical Department, Odense University Hospital, Odense, Denmark
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9
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Denadai MVA, Melani AGF, Neto MC, Romagnolo LGC, Diniz FD, Véo CAR. Robotic rectal surgery: Outcomes of the first 102 totally robotic cases handled using the single-docking technique in a reference institution. J Surg Oncol 2020; 123:997-1004. [PMID: 33368284 DOI: 10.1002/jso.26351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Rectal cancer is often surgically treated, but it is still associated with morbidity rates. Minimally invasive techniques are increasingly being used to reduce complications, and the use of such techniques can be found in the literature. This study aims to report our experience in a reference oncology center. METHODS A retrospective cohort study was performed on a prospective database of patients who underwent robotic surgery for rectal cancer using the single-docking technique from September 2014 to April 2018. Clinical and surgical variables, as well as morbidity and mortality rates, were analyzed. RESULTS One hundred and two patients underwent robotic surgery. Intraoperative complications occurred in six patients (4.9%), and postoperative complications in 24 patients (23.5%), of which anastomotic fistula represented 3.9%. The conversion rate was 1.96%. Two cases (1.9%) faced death within 30 days. The median length of hospitalization was 3 days. The median number of lymph nodes dissected was 15. Clinical and surgical data were correlated with postoperative complications, and no statistically significant differences were found. CONCLUSION Robotic surgery is a safe and feasible approach to manage rectal cancer. The method presents satisfactory results with regard to the rate of operative complications, conversion rate, oncologic outcomes, and length of hospitalization.
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Affiliation(s)
- Marcos V A Denadai
- Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Armando G F Melani
- Americas Medical City, Rio de Janeiro, State of Rio de Janeiro, Brazil.,Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil
| | - Maximiliano C Neto
- Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Luis G C Romagnolo
- Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.,Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil
| | - Felipe D Diniz
- Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Carlos A R Véo
- Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
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10
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Achilli P, Radtke TS, Lovely JK, Behm KT, Mathis KL, Kelley SR, Merchea A, Colibaseanu DT, Larson DW. Preoperative predictive risk to cancer quality in robotic rectal cancer surgery. Eur J Surg Oncol 2020; 47:317-322. [PMID: 32928609 DOI: 10.1016/j.ejso.2020.08.019] [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: 03/13/2020] [Revised: 06/30/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery. METHODS This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated. RESULTS A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35-36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33-17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72-33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present. CONCLUSION Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes.
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Affiliation(s)
- Pietro Achilli
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
| | | | - Jenna K Lovely
- Reporting and Analytics, Mayo Clinic, Rochester, MN, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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11
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Darwich I, Stephan D, Klöckner-Lang M, Scheidt M, Friedberg R, Willeke F. A roadmap for robotic-assisted sigmoid resection in diverticular disease using a Senhance™ Surgical Robotic System: results and technical aspects. J Robot Surg 2020; 14:297-304. [PMID: 31161448 PMCID: PMC7125057 DOI: 10.1007/s11701-019-00980-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/25/2019] [Indexed: 12/17/2022]
Abstract
Since the turn of the century, robotic-assisted colorectal surgery has been synonymous with the da Vinci® robotic surgical system. We report in this study our first results in robotic-assisted sigmoid resection for diverticular disease using the Senhance™ Surgical Robotic System, while introducing a standardized roadmap for engaging the robotic arms. 12 patients underwent a sigmoid resection using the Senhance™ Surgical Robotic System. All four arms of the robotic system were engaged during all procedures according to a previously devised roadmap. A 4-trocar technique was used in all patients. Perioperative data, including those regarding technical difficulties, were collected and analyzed. Two procedures were converted into standard laparoscopy. There were no conversions to open surgery. The mean age of the patients was 62.5 years (47-79). One third of the patients were males. The mean BMI was 27 kg/m2 (19-38). The mean operative time, the mean console time and the mean docking time were 219 min (204-305), 149 min (124-205) and 10 min (6-15), respectively. The mean length of stay was 9 days (6-15). There was one major complication (8.3%, Clavien-Dindo IIIb). There were no mortalities. No other complications were observed. No patients were readmitted after discharge. The Senhance™ Surgical Robotic System can be used safely in sigmoid resection for diverticular disease after adequate training and systematic planning of the different steps of the procedure. Further experience is needed to judge the benefit for patient and surgeon, as well as the cost and time effectiveness.
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Affiliation(s)
- Ibrahim Darwich
- Department of Surgery, St. Marien Hospital Siegen, Kampenstr. 51, 57074, Siegen, Germany.
| | - D Stephan
- Department of Surgery, St. Marien Hospital Siegen, Kampenstr. 51, 57074, Siegen, Germany
| | - M Klöckner-Lang
- Department of Surgery, St. Marien Hospital Siegen, Kampenstr. 51, 57074, Siegen, Germany
| | - M Scheidt
- Department of Surgery, St. Marien Hospital Siegen, Kampenstr. 51, 57074, Siegen, Germany
| | - R Friedberg
- Department of Surgery, St. Marien Hospital Siegen, Kampenstr. 51, 57074, Siegen, Germany
| | - F Willeke
- Department of Surgery, St. Marien Hospital Siegen, Kampenstr. 51, 57074, Siegen, Germany
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12
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Robotic Surgery for Rectal Cancer Provides Advantageous Outcomes Over Laparoscopic Approach: Results From a Large Retrospective Cohort. Ann Surg 2020; 274:e1218-e1222. [PMID: 32068552 DOI: 10.1097/sla.0000000000003805] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare short term outcomes of patients undergoing laparoscopic or robotic rectal cancer surgery. BACKGROUND Significant benefits of robotic rectal cancer surgery over laparoscopy have yet to be demonstrated. Operative time and direct institutional cost seem in favor of the laparoscopic approach. METHODS We performed a retrospective review of consecutive patients operated on for rectal cancer with a mini-invasive approach at Mayo Clinic from 2005 to 2018. The primary aim of this study was to investigate the difference in postoperative morbidity between the laparoscopic and robotic approach. Multivariable models for odds to complications and prolonged (≥6 days) length of stay were built. RESULTS A total of 600 patients were included in the analysis. The number of patients undergoing robotic surgery was 317 (52.8%). The 2 groups were similar in respect to age, sex, and body mass index. Laparoscopic surgery was correlated to shorter operative time (214 vs 324 minutes; P < 0.001). Patients undergoing robotic surgery had a lower overall complications rate (37.2% vs 51.2%; P < 0.001). Robotic surgery was found to be the most protective factor [odds ratio (OR) 0.485; P = 0.006] for odds to complications. The event of a complication (OR 9.33; P < 0.001) and conversion to open surgery (OR 3.095; P = 0.002) were identified as risk factors for prolonged length of stay whereas robotic surgery (OR 0.62; P = 0.027) was the only independent protective factor. CONCLUSIONS Robotic rectal cancer surgery is strongly associated with better short-term outcomes over laparoscopic surgery.
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13
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Functional outcomes after laparoscopic versus robotic-assisted rectal resection: a systematic review and meta-analysis. Surg Endosc 2020. [PMID: 32025924 DOI: 10.1007/s00464‐019‐07361‐1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Surgical resection is crucial for curative treatment of rectal cancer. Through multidisciplinary treatment, including radiochemotherapy and total mesorectal excision, survival has improved substantially. Consequently, more patients have to deal with side effects of treatment. The most recently introduced surgical technique is robotic-assisted surgery (RAS) which seems equally effective in terms of oncological control compared to laparoscopy. However, RAS enables further advantages which maximize the precision of surgery, thus providing better functional outcomes such as sexual function or contience without compromising oncological results. This review was done according to the PRISMA and AMSTAR-II guidelines and registered with PROSPERO (CRD42018104519). The search was planned with PICO criteria and conducted on Medline, Web of Science and CENTRAL. All screening steps were performed by two independent reviewers. Inclusion criteria were original, comparative studies for laparoscopy vs. RAS for rectal cancer and reporting of functional outcomes. Quality was assessed with the Newcastle-Ottawa scale. The search retrieved 9703 hits, of which 51 studies with 24,319 patients were included. There was a lower rate of urinary retention (non-RCTs: Odds ratio (OR) [95% Confidence Interval (CI)] 0.65 [0.46, 0.92]; RCTs: OR[CI] 1.29[0.08, 21.47]), ileus (non-RCTs: OR[CI] 0.86[0.75, 0.98]; RCTs: OR[CI] 0.80[0.33, 1.93]), less urinary symptoms (non-RCTs mean difference (MD) [CI] - 0.60 [- 1.17, - 0.03]; RCTs: - 1.37 [- 4.18, 1.44]), and higher quality of life for RAS (only non-RCTs: MD[CI]: 2.99 [2.02, 3.95]). No significant differences were found for sexual function (non-RCTs: standardized MD[CI]: 0.46[- 0.13, 1.04]; RCTs: SMD[CI]: 0.09[- 0.14, 0.31]). The current meta-analysis suggests potential benefits for RAS over laparoscopy in terms of functional outcomes after rectal cancer resection. The current evidence is limited due to non-randomized controlled trials and reporting of functional outcomes as secondary endpoints.
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14
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Kowalewski KF, Seifert L, Ali S, Schmidt MW, Seide S, Haney C, Tapking C, Shamiyeh A, Kulu Y, Hackert T, Müller-Stich BP, Nickel F. Functional outcomes after laparoscopic versus robotic-assisted rectal resection: a systematic review and meta-analysis. Surg Endosc 2020; 35:81-95. [PMID: 32025924 PMCID: PMC7746565 DOI: 10.1007/s00464-019-07361-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/24/2019] [Indexed: 12/15/2022]
Abstract
Surgical resection is crucial for curative treatment of rectal cancer. Through multidisciplinary treatment, including radiochemotherapy and total mesorectal excision, survival has improved substantially. Consequently, more patients have to deal with side effects of treatment. The most recently introduced surgical technique is robotic-assisted surgery (RAS) which seems equally effective in terms of oncological control compared to laparoscopy. However, RAS enables further advantages which maximize the precision of surgery, thus providing better functional outcomes such as sexual function or contience without compromising oncological results. This review was done according to the PRISMA and AMSTAR-II guidelines and registered with PROSPERO (CRD42018104519). The search was planned with PICO criteria and conducted on Medline, Web of Science and CENTRAL. All screening steps were performed by two independent reviewers. Inclusion criteria were original, comparative studies for laparoscopy vs. RAS for rectal cancer and reporting of functional outcomes. Quality was assessed with the Newcastle–Ottawa scale. The search retrieved 9703 hits, of which 51 studies with 24,319 patients were included. There was a lower rate of urinary retention (non-RCTs: Odds ratio (OR) [95% Confidence Interval (CI)] 0.65 [0.46, 0.92]; RCTs: OR[CI] 1.29[0.08, 21.47]), ileus (non-RCTs: OR[CI] 0.86[0.75, 0.98]; RCTs: OR[CI] 0.80[0.33, 1.93]), less urinary symptoms (non-RCTs mean difference (MD) [CI] − 0.60 [− 1.17, − 0.03]; RCTs: − 1.37 [− 4.18, 1.44]), and higher quality of life for RAS (only non-RCTs: MD[CI]: 2.99 [2.02, 3.95]). No significant differences were found for sexual function (non-RCTs: standardized MD[CI]: 0.46[− 0.13, 1.04]; RCTs: SMD[CI]: 0.09[− 0.14, 0.31]). The current meta-analysis suggests potential benefits for RAS over laparoscopy in terms of functional outcomes after rectal cancer resection. The current evidence is limited due to non-randomized controlled trials and reporting of functional outcomes as secondary endpoints.
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Affiliation(s)
- K F Kowalewski
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Department of Urology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - L Seifert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - S Ali
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M W Schmidt
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - S Seide
- Institute for Medical Biometry and Informatics, Heidelberg University, Im Neuenheimer, Feld 130.3, 69120, Heidelberg, Germany
| | - C Haney
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - C Tapking
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - A Shamiyeh
- Klinik für Allgemein-Und Viszeralchirurgie, Kepler Universitätsklinikum GmbH, Med Campus III., Krankenhausstraße 9, 4021, Linz, Austria
| | - Y Kulu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - B P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - F Nickel
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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15
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Crippa J, Grass F, Achilli P, Mathis KL, Kelley SR, Merchea A, Colibaseanu DT, Larson DW. Risk factors for conversion in laparoscopic and robotic rectal cancer surgery. Br J Surg 2020; 107:560-566. [PMID: 31976558 DOI: 10.1002/bjs.11435] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 10/24/2019] [Accepted: 10/27/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of this study was to review risk factors for conversion in a cohort of patients with rectal cancer undergoing minimally invasive abdominal surgery. METHODS A retrospective analysis was performed of consecutive patients operated on from February 2005 to April 2018. Adult patients undergoing low anterior resection or abdominoperineal resection for primary rectal adenocarcinoma by a minimally invasive approach were included. Exclusion criteria were lack of research authorization, stage IV or recurrent rectal cancer, and emergency surgery. Risk factors for conversion were investigated using logistic regression. A subgroup analysis of obese patients (BMI 30 kg/m2 or more) was performed. RESULTS A total of 600 patients were included in the analysis. The overall conversion rate was 9·2 per cent. Multivariable analysis showed a 72 per cent lower risk of conversion when patients had robotic surgery (odds ratio (OR) 0·28, 95 per cent c.i. 0·15 to 0·52). Obese patients experienced a threefold higher risk of conversion compared with non-obese patients (47 versus 24·4 per cent respectively; P < 0·001). Robotic surgery was associated with a reduced risk of conversion in obese patients (OR 0·22, 0·07 to 0·71). CONCLUSION Robotic surgery was associated with a lower risk of conversion in patients undergoing minimally invasive rectal cancer surgery, in both obese and non-obese patients.
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Affiliation(s)
- J Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - F Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - P Achilli
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - S R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - A Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - D T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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16
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Makris MC, Athanasopoulos PG, Kornaropoulos M, Chrysocheris P, Antonakopoulos F, Mathioulaki A, Tsilimigras DI, Ioannidis A, Konstantinidis MK, Moris D, Konstantinidis KM. Robotic resection of a giant retroperitoneal leiomyosarcoma: A case report. Mol Clin Oncol 2019; 11:599-601. [PMID: 31693012 DOI: 10.3892/mco.2019.1928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 04/11/2019] [Indexed: 11/06/2022] Open
Abstract
The management of abdominal leiomyosarcoma is challenging. Surgical excision is considered the only effective treatment; however, this is associated with considerable morbidity. Robotic surgery has emerged during the past decades and has enhanced the general surgery armamentarium, allowing surgeons to carry out demanding operations in a safe manner. The surgical resection of retroperitoneal leiomyosarcoma (RPLM) can be associated with significant morbidity, which is primarily due to the origin or the close proximity of the tumor with important vascular structures, including the inferior vena cava and tributaries, the duodenum and the ureter. The present case describes the first case of robotic resection of RPLM in a high-volume robotic center. In the present case, a large RPLM was safely removed with respect to oncological principles with the use of the Da Vinci platform.
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Affiliation(s)
- Marinos C Makris
- First Surgical Department, General Hospital of Athens 'G. Gennimatas', Athens 11527, Greece.,Alpha Institute of Biomedical Sciences (AIBS), Athens 15123, Greece
| | - Panos G Athanasopoulos
- Department of General, Laparoscopic, Robotic and Bariatric Surgery, Athens Medical Center, Athens 15125, Greece
| | - Michael Kornaropoulos
- First Surgical Department, General Hospital of Athens 'G. Gennimatas', Athens 11527, Greece
| | - Periclis Chrysocheris
- Department of General, Laparoscopic, Robotic and Bariatric Surgery, Athens Medical Center, Athens 15125, Greece
| | - Fotios Antonakopoulos
- Department of General, Laparoscopic, Robotic and Bariatric Surgery, Athens Medical Center, Athens 15125, Greece
| | - Antonia Mathioulaki
- Department of General, Laparoscopic, Robotic and Bariatric Surgery, Athens Medical Center, Athens 15125, Greece
| | | | - Argyrios Ioannidis
- Second Surgical Department, Sismanoglion General Hospital, Athens 15126, Greece
| | | | - Demetrios Moris
- School of Medicine, National and Kapodistrian University of Athens, Athens 11527, Greece
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17
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Kamarajah SK, Sutandi N, Robinson SR, French JJ, White SA. Robotic versus conventional laparoscopic distal pancreatic resection: a systematic review and meta-analysis. HPB (Oxford) 2019; 21:1107-1118. [PMID: 30962137 DOI: 10.1016/j.hpb.2019.02.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/08/2019] [Accepted: 02/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Robotic surgery offers theoretical advantages to conventional laparoscopic surgery including improved instrument dexterity, 3D visualization and better ergonomics. This review aimed to determine if these theoretical advantages translate into improved patient outcomes in patients undergoing distal pancreatectomy through laparoscopic (LDP) or robotic (RDP) approaches. METHOD A systematic literature search was conducted for studies reporting minimally invasive surgery for distal pancreatectomy. Meta-analysis of intraoperative (blood loss, operating times, conversion and R0 resections) and postoperative outcomes (overall complications, pancreatic fistula, length of hospital stay) was performed using random effects models. RESULT Twenty non-randomised studies including 3112 patients (793 robotic and 2319 laparoscopic) were considered appropriate for inclusion. LDP had significantly shorter operating time than RDP (mean: 28, p < 0.001) but no significant difference in blood loss (mean: 52 mL, p = 0.07). RDP was associated with significantly lower conversion rates than LDP (OR 0.48, p < 0.001), but no difference in spleen preservation rate and R0 resection. There were no significant differences in overall and major complications, overall and high-grade pancreatic fistula. However, RDP was associated with a shorter length of hospital stay (mean: 1, p < 0.001). CONCLUSION Robotic distal pancreatectomy appears to offer some advantages compared to conventional laparoscopic surgery, although both techniques appear equivalent. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomised trial comparing both techniques are needed.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Academic Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.
| | - Nathania Sutandi
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Academic Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Stuart R Robinson
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Academic Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Jeremy J French
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Academic Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Steven A White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Academic Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
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18
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Holmer C, Benz S, Fichtner-Feigl S, Jehle EC, Kienle P, Post S, Schiedeck T, Weitz J, Kreis ME. [Transanal total mesorectal excision-a critical appraisal]. Chirurg 2019; 90:478-486. [PMID: 30911795 DOI: 10.1007/s00104-019-0945-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence. METHOD The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken. RESULTS A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME. CONCLUSION Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.
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Affiliation(s)
- C Holmer
- Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Hindenburgdamm 30, 12200, Berlin, Deutschland
| | - S Benz
- Klinikum Sindelfingen-Böblingen, Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Klinikverbund Südwest, Böblingen, Deutschland
| | - S Fichtner-Feigl
- Klinik für Allgemein- und Viszeralchirurgie, Department Chirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - E C Jehle
- Klinik für Allgemein- und Viszeralchirurgie, St. Elisabethen-Klinikum, Ravensburg, Deutschland
| | - P Kienle
- Klinik für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland
| | - S Post
- Chirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - T Schiedeck
- Klinik für Allgemein- und Viszeralchirurgie, Klinikum Ludwigsburg, Ludwigsburg, Deutschland
| | - J Weitz
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Deutschland
| | - M E Kreis
- Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Hindenburgdamm 30, 12200, Berlin, Deutschland.
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19
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Kamarajah SK, Bundred J, Marc OS, Jiao LR, Manas D, Abu Hilal M, White SA. Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis. Eur J Surg Oncol 2019; 46:6-14. [PMID: 31409513 DOI: 10.1016/j.ejso.2019.08.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/03/2019] [Accepted: 08/06/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) offers theoretical advantages to conventional laparoscopic surgery including improved instrument dexterity, 3D visualization and better ergonomics. This review aimed to determine if these theoretical advantages translate into improved patient outcomes comparing patients having either robotic pancreaticoduodenectomy or laparoscopic (LPD) equivalent. METHOD A systematic literature search was conducted for studies reporting minimally invasive surgery for pancreaticoduodenectomy either robotic assisted or totally laparoscopic. Meta-analysis of intra-operative (blood loss, operating times, conversion and R0 resections) and postoperative outcomes (overall complications, pancreatic fistula, length of hospital stay) was performed using a random effects model. RESULT This review identified 44 studies, of which six were non-randomised comparative studies including 3462 patients (1025 robotic and 2437 laparoscopic). Intraoperatively, RPD was associated with significantly lower conversion rates (OR 0.45, p < 0.001) and transfusion rates (OR: 0.60, p = 0.002) compared to LPD. However, no significant difference in blood loss (mean: 220 vs 287 mL, p = 0.1), operating time (mean: 405 vs 418 min, p = 0.3) was noted. Postoperatively RPD was associated with a shorter hospital stay (mean: 12 vs 11 days, p < 0.001) but no significant difference was noted in postoperative complications, incidence of pancreatic fistulae and R0 resection rates. CONCLUSION RPD appears to offer some advantages compared to conventional laparoscopic surgery, although both approaches appear to offer equivalent clinical outcomes. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomised trial comparing both techniques is needed.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK.
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, UK
| | - Olivier Saint Marc
- Department of Surgery, Centre Hospitalier Régional Orleans, Orleans, France
| | - Long R Jiao
- Department of Surgery and Cancer, HPB Surgical Unit, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Derek Manas
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Steven A White
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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20
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Kim JC, Lee JL, Bong JW, Seo JH, Kim CW, Park SH, Kim J. Oncological and anorectal functional outcomes of robot-assisted intersphincteric resection in lower rectal cancer, particularly the extent of sphincter resection and sphincter saving. Surg Endosc 2019; 34:2082-2094. [DOI: 10.1007/s00464-019-06989-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/15/2019] [Indexed: 01/06/2023]
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Size and lipid modification determine liposomal Indocyanine green performance for tumor imaging in a model of rectal cancer. Sci Rep 2019; 9:8566. [PMID: 31189986 PMCID: PMC6561977 DOI: 10.1038/s41598-019-45038-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 05/29/2019] [Indexed: 01/16/2023] Open
Abstract
Localization of rectal tumors is a challenge in minimally invasive surgery due to the lack of tactile sensation. We had developed liposomal indocyanine green (Lip-ICG) for localization of rectal tumor. In this study we evaluated the effects of liposome size and lipid PEGylation on imaging. We used an endoscopically-guided orthotopic experimental rectal cancer model in which tumor fluorescence was determined at different time points after intravenous (i.v.) administration of Lip-ICG and PEGylated liposomes (PEG-Lip-ICG). Signal intensity was measured by tumor-to-background ratio (TBR), or normalized TBR (compared to TBR of free ICG). Fluorescence microscopy of tumor tissue was performed to determine fluorescence localization within the tissue and blood vessels. Liposomes of 60 nm showed an increased TBR compared with free ICG at 12 hours after i.v. injection: normalized TBR (nTBR) = 3.11 vs. 1, respectively (p = 0.006). Larger liposomes (100 nm and 140 nm) had comparable signal to free ICG (nTBR = 0.98 ± 0.02 and 0.78 ± 0.08, respectively), even when additional time points were examined (0.5, 3 and 24 hours). PEG-Lip- ICG were more efficient than Lip-ICG (TBR = 4.2 ± 0.18 vs. 2.5 ± 0.12, p < 0.01) presumably because of reduced uptake by the reticulo-endothelial system. ICG was found outside the capillaries in tumor margins. We conclude that size and lipid modification impact imaging intensity.
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Vignali A, Elmore U, Milone M, Rosati R. Transanal total mesorectal excision (TaTME): current status and future perspectives. Updates Surg 2019; 71:29-37. [PMID: 30734896 DOI: 10.1007/s13304-019-00630-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/02/2019] [Indexed: 12/14/2022]
Abstract
Total mesorectal excision (TME) is the gold standard surgical treatment for mid- and low rectal cancer; however, it is associated with specific technical hurdles. Transanal TME (TaTME) is a new procedure developed to overcome these difficulties, through an enhanced visualization of the dissection plane. This potentially could result in a more accurate distal dissection with a lower rate of positive circumferential resection margins, increasing the rate of sphincter-saving procedures. The indications for TaTME are currently expanding, despite not being yet standardized, and structured training programs are ongoing to help overcome the steep learning curve related to the technique. The procedure is feasible and safe with similar intraoperative complications and readmission rates when compared with conventional open or laparoscopic TME. Favorable short-term oncologic results have been reported: in particular, TaTME is associated with mesorectal specimen of a better quality and a longer distal resection margin that is established at the beginning of the procedure under direct view. Robotics, when available, will probably overcome the steep learning curve related to the complexity of TaTME. Long-term follow-up and ongoing RCT trials data are awaited regarding functional results, local recurrence and survival, and to facilitate the comparison with standard laparoscopic or robotic rectal resections. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, its indications, short- and long-term results and future direction in the application of TaTME.
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Affiliation(s)
- Andrea Vignali
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy.
| | - Ugo Elmore
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
| | - Marco Milone
- Department of Surgical Specialties, Nephrology University "Federico II" of Naples, Naples, Italy
| | - Riccardo Rosati
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
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