Long-term oncologic outcomes of laparoscopic versus open resection following stent insertion for obstructing colon cancer: a multi-center retrospective study

Short-term and three-year long-term outcomes of laparoscopic surgery versus open surgery for obstructive colorectal cancer following self-expandable metallic stent placement: a meta-analysis

BACKGROUND

A bridge to surgery (BTS) after self-expandable metallic stent (SEMS) placement is a widely recognized treatment strategy for obstructive colorectal cancer. However, there is still a lack of evidence for the efficacy and safety of laparoscopic surgery following SEMS placement. The aim of this systematic review and meta-analysis was to compare the short-term and long-term outcomes of laparoscopic surgery with those of open surgery following SEMS placement in patients with obstructive colorectal cancer.

METHODS

An electronic literature search through to December 2022 was performed to identify studies comparing short-term and long-term outcomes between laparoscopic and open surgery following SEMS placement for obstructive colorectal cancer. The main outcome measures were postoperative complication rates and mortality. Secondary outcome measures were the 3-year recurrence-free survival (RFS) and 3-year overall survival (OS) rates. The meta-analysis was performed using fixed-effect or random-effects methods to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

The meta-analysis included 15 studies and 883 patients, of whom 467 (52.9%) underwent laparoscopic surgery and 416 (47.1%) underwent open surgery following SEMS placement. The postoperative complication rate was significantly lower in the laparoscopic surgery group than in the open surgery group (OR 0.47, 95% CI 0.32-0.67, P < 0.001). There was no significant difference in the 3-year RFS rate or 3-year OS rate between the laparoscopic and open surgery groups (3-year RFS, OR 0.78, 95% CI 0.50-1.24, P = 0.30; 3-year OS, OR 0.68, 95% CI 0.41-1.12, P = 0.13).

CONCLUSION

This meta-analysis found that the short-term outcome was better in patients who underwent laparoscopic surgery following SEMS placement than in those who underwent open surgery. Furthermore, there was no significant difference in long-term outcomes between the two groups. Laparoscopic surgery following SEMS placement may be a safe and effective treatment option for obstructive colorectal cancer.

Laparoscopic versus open surgery in obstructive colorectal cancer patients following stents placement: a comprehensive meta-analysis of cohort studies

BACKGROUND

Over the past decade, the use of stent placement as a bridge to surgery (BTS) has emerged as an alternative to emergency surgery for patients with (OCRC). However, the optimal surgical approach remains indeterminate. This study seeks to evaluate the safety and feasibility of a combined treatment modality involving stent placement and laparoscopic surgery for OCRC presenting with malignant obstruction.

METHODS

A comprehensive search of PubMed, Cochrane Library, EMBASE, Web of Science, and ClinicalTrials.gov was conducted until June 2023 to identify studies that compared laparoscopic to open surgery in patients with OCBC following stent insertion.

RESULTS

The meta-analysis incorporated 12 cohort studies, encompassing 933 patients. There was no statistically significant difference in the 30-day mortality rates between the two groups (relative risk [RR], 1.09; 95% confidence interval [CI] 0.26 to 4.48; P = 0.95). Compared to the laparoscopic approach group, the open approach group had a higher rate of overall postoperative complications (POCs) (RR 0.52; 95% CI 0.37 to 0.72, P < 0.0001). There was no significant variance in lymph node (LN) dissection number between the groups (mean differences [MD], 1.64; 95% CI - 1.51 to 4.78; P = 0.31). Notably, laparoscopic surgery resulted in less intraoperative blood loss (MD, - 25.84 ml; 95% CI - 52.16 to 0.49; P = 0.05) and a longer operation time (MD, 20.99 mins; 95% CI 2.31 to 39.44; P = 0.03). The laparoscopic approach was associated with a shorter length of hospital stay (LOS) (MD - 3.29 days; 95% CI - 5.27 to 1.31; P = 0.001). Conversely, the open approach group had a higher rate of postoperative surgical site infection (SSI) (RR 0.47; 95% CI 0.23 to 0.96, P = 0.04). Although the number of included studies was insufficient to conduct a meta-analysis, several of them imply that laparoscopic surgery may yield more favorable outcomes in terms of the 3-year overall survival rate (OS), 3-year disease-free survival rate (DFS), 5-year OS, and 5-year DFS when compared to open surgery. It is worth noting that these differences lack statistical significance.

CONCLUSION

In patients with OCRC subjected to stent insertion, laparoscopic surgery arguably presents a modest superiority over open surgery by diminishing the overall postoperative risk and potentially reducing the LOS.

Comparison between liquid skin adhesive and wound closure strip for skin closure after subcuticular suturing in single-port laparoscopic appendectomy: a single-center retrospective study in Korea

Purpose

This study was performed to evaluate the safety and feasibility of skin adhesives and to compare postoperative and cosmetic outcomes after wound closure in single-port laparoscopic appendectomy (SPLA) between skin adhesives and steri-strips.

Methods

This was a single-center retrospective study. We included 22 and 47 patients in whom skin adhesive and steri-strips were used respectively, for skin closure after subcuticular suturing in SPLA between August 2014 and 2020. The patient scar assessment questionnaire (PSAQ) was completed postoperatively to assess postoperative cosmetic outcomes.

Results

On the postoperative day, patients in whom skin adhesive was used had significantly lower numeric rating scores than in whom steri-strips were used (2.8 ± 0.8 vs. 3.9 ± 0.8, p < 0.001). The frequency of analgesic administration within 24 hours and between 24 and 48 hours after surgery was significantly lower in the skin adhesive group compared to the wound closure strip group (1.4 ± 0.8 vs. 2.7 ± 1.2, p = 0.013 and 0.2 ± 0.4 vs. 0.7 ± 0.9, p = 0.002, respectively). In the PSAQ, "satisfaction with appearance" and "satisfaction with symptoms" subitem scores were significantly lower in patients in whom skin adhesive was used (11.3 ± 3.0 vs. 15.1 ± 4.5, p = 0.006 and 6.5 ± 1.8 vs. 9.5 ± 3.3, p = 0.003), whereas, "appearance" and "consciousness" subitems revealed no statistically significant differences between the groups.

Conclusion

Liquid skin adhesive closures seem to be safe and feasible and cause less postoperative pain, resulting in greater patient satisfaction with postoperative scars than wound closure strip closure after subcuticular suturing in SPLA.

A prospective randomized controlled study comparing patient-reported scar evaluation of single-port versus multiport laparoscopic appendectomy for acute appendicitis

Purpose

This study aimed to compare the postoperative outcomes and patient-surveyed scar assessments of single-port laparoscopic appendectomy (SPLA) with the outcomes of multiport laparoscopic appendectomy (MPLA).

Methods

Between August 2014 and November 2017, the prospective randomized study comprised 98 patients diagnosed with acute appendicitis and indicated for surgery. Fifty-one patients had MPLA and 47 patients received SPLA. The primary endpoint was the total score of Patient Scar Assessment Questionnaire (PSAQ) administered to patients 6 weeks after surgery.

Results

SPLA involved a shorter median operative time than MPLA (47.5 minutes vs. 60.0 minutes, p = 0.02). There were no apparent differences in the time before diet tolerance, length of hospital stay, and postoperative complication. SPLA patients had shorter total incision length (2.0 cm vs. 2.5 cm, p < 0.01) and required fewer analgesics on the day of surgery than MPLA patients (p = 0.011). The PSAQ favored the SPLA approach, revealing significant differences in total score (48 vs. 55, p = 0.026), appearance (15 vs. 18, p = 0.002), and consciousness (8 vs. 10, p = 0.005), while satisfaction with appearance and symptoms scale did not (p = 0.162 and p = 0.690, respectively).

Conclusion

The postoperative scar evaluated by the patient was better with SPLA than with MPLA, and patient satisfaction with the scar was comparable between the two techniques.

Fluoroscopic Stent Placement as a Bridge to Surgery for Malignant Colorectal Obstruction: Short- and Long-Term Outcomes

Purpose

To assess the outcomes of single-stage surgery following fluoroscopic stent placement for malignant colorectal obstruction.

Materials and Methods

This retrospective study included 46 patients (28 male and 18 female; mean age, 67.2 years) who had undergone fluoroscopic stent placement followed by laparoscopic resection (n = 31) or open surgery (n = 15) for malignant colorectal obstruction. The surgical outcomes were analyzed and compared. After a mean follow-up of 38.9 months, the recurrence-free and overall survival were estimated, and prognostic factors were evaluated.

Results

The mean interval between stent placement and surgery was 10.2 days. Primary anastomosis was possible in all patients. The mean postoperative length of hospitalization was 11.0 days. Bowel perforation was detected in six patients (13.0%). During the follow-up, ten patients (21.7%) developed recurrence; these included five of the six patients with bowel perforation. Bowel perforation had a significant effect on recurrence-free survival (p = 0.010).

Conclusion

Single-stage surgery following fluoroscopic stent placement may be effective for treating malignant colorectal obstruction. Stent-related bowel perforation is a significant predictive factor for tumor recurrence.

Stenting as a bridge to surgery in obstructing colon cancer: Long-term recurrence pattern and competing risk of mortality

BACKGROUND

Stenting as a bridge to curative surgery (SBTS) for obstructing colon cancer (OCC) has been associated with possibly worse oncological outcomes.

AIM

To evaluate the recurrence patterns, survival outcomes, and colorectal cancer (CRC)-specific death in patients undergoing SBTS for OCC.

METHODS

Data from 62 patients undergoing SBTS at a single tertiary centre over ten years between 2007 and 2016 were retrospectively examined. Primary outcomes were recurrence patterns, overall survival (OS), cancer-specific survival (CSS), and CRC-specific death. OS and CSS were estimated using the Kaplan-Meier curves. Competing risk analysis with cumulative incidence function (CIF) was used to estimate CRC-specific mortality with other cause-specific death as a competing event. Fine-Gray regressions were performed to determine prognostic factors of CRC-specific death. Univariate and multivariate subdistribution hazard ratios and their corresponding Wald test P values were calculated.

RESULTS

28 patients (45.2%) developed metastases after a median period of 16 mo. Among the 18 patients with single-site metastases: Four had lung-only metastases (14.3%), four had liver-only metastases (14.3%), and 10 had peritoneum-only metastases (35.7%), while 10 patients had two or more sites of metastatic disease (35.7%). The peritoneum was the most prevalent (60.7%) site of metastatic involvement (17/28). The median follow-up duration was 46 mo. 26 (41.9%) of the 62 patients died, of which 16 (61.5%) were CRC-specific deaths and 10 (38.5%) were deaths owing to other causes. The 1-, 3-, and 5-year OS probabilities were 88%, 74%, and 59%; 1-, 3-, and 5-year CSS probabilities were 97%, 83%, and 67%. The highest CIF for CRC-specific death at 60 mo was liver-only recurrence (0.69). Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictive of CRC-specific death.

CONCLUSION

The peritoneum was the most common metastatic site among patients undergoing SBTS. Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictors of CRC-specific death.

Safety of early surgery after self-expandable metallic stenting for obstructive left-sided colorectal cancer

BACKGROUND

Self-expanding metallic stenting (SEMS) is usual for the temporary resolution of obstructive left-sided colorectal cancer (CRC) as a bridge to elective surgery. However, there is no consensus regarding adequate time intervals from stenting to radical surgery. The aim of this study was to identify the optimal time interval that results in favorable short- and long-term outcomes.

METHODS

Data on patients with obstructive left-sided CRC who underwent elective radical surgery after clinically successful SEMS deployment in five tertiary referral hospitals from 2004 to 2016 were analyzed, retrospectively. An inverse probability treatment-weighted propensity score analysis was used to minimize bias. Postoperative short- and long-term outcomes were compared between two groups: an early surgery (within 8 days) group and delayed surgery (after 8 days) group.

RESULTS

Of 311 patients, 148 (47.6%) underwent early and 163 (52.4%) underwent delayed surgery. The median surgery interval was 9.0 days. After adjustment, the groups had similar patient and tumor characteristics. In terms of short-term outcomes, there was no difference in hospitalization length or postoperative complications. No deaths were observed. With a median follow-up of 71.0 months, no significant difference was observed between the groups in 5-year overall survival (early vs. delayed surgery: 79.6% vs. 71.3%, P = 0.370) and 5-year disease-free survival (early vs. delayed surgery: 59.1% vs. 60.4%, P = 0.970).

CONCLUSIONS

In obstructive left-sided CRC, the time interval between SEMS and radical surgery did not significantly influence short- and long-term outcomes. Therefore, early surgery after SEMS could be suggested if there is no reason to postpone surgery for preoperative medical optimization.

Self-expanding metal stent placement and pathological alterations among obstructive colorectal cancer cases

BACKGROUND

Experimental studies suggest that self-expanding metal stents (SEMSs) enhance the aggressive behavior of obstructive colorectal cancer. The influence of SEMS placement on pathological alterations remains to be elucidated.

AIM

To determine whether SEMS placement is associated with molecular or pathological features of colorectal carcinoma tissues.

METHODS

Using a nonbiased molecular pathological epidemiology database of patients with obstructive colorectal cancers, we examined the association of SEMS placement with molecular or pathological features, including tumor size, histological type, American Joint Committee on Cancer (AJCC)-pTNM stage, and mutation statuses in colorectal cancer tissues compared with the use of transanal tubes. A multivariable logistic regression model was used to adjust for potential confounders.

RESULTS

SEMS placement was significantly associated with venous invasion (P < 0.01), but not with the other features examined, including tumor size, disease stage, mutation status, and lymphatic invasion. In both the univariable and multivariable models with adjustment for potential factors including tumor location, histological type, and AJCC-pT stage, SEMS placement was significantly associated with severe venous invasion (P < 0.01). For the outcome category of severe venous invasion, the multivariable odds ratio for SEMS placement relative to transanal tube placement was 19.4 (95% confidence interval: 5.24–96.2). No significant differences of disease-free survival and overall survival were observed between SEMS and transanal tube groups.

CONCLUSION

SEMS placement might be associated with severe venous invasion in colorectal cancer tissue, providing an impetus for further investigations on the pathological alterations by SEMSs in colorectal cancer development.

Long-term and short-term outcomes of laparoscopic versus open resection following tube decompression for obstructive colorectal cancer: a single-center retrospective study

PURPOSE

The benefits of laparoscopic surgery over open surgery are well documented; however, the suitability of laparoscopic surgery for obstructive colorectal cancer is still controversial. The aim of this retrospective study was to compare the clinical benefits of laparoscopic surgery vs. open surgery for obstructive colorectal cancer after tube decompression.

METHODS

We analyzed the outcomes of patients who underwent laparoscopic surgery vs. open surgery for curative resection after tube decompression for obstructive colorectal cancer at our hospital between January, 2007 and March, 2018.

RESULTS

This study comprised 67 patients: 29 patients who underwent open surgery and 38 patients who underwent laparoscopic surgery. The morbidity within 30 days after surgery was comparable between the groups. The 3-year overall survival rates of the open and laparoscopic groups were 83.3 and 79.4%, respectively (p = 0.6244), and the 3-year disease-free survival rates were 59.3 and 71.2%, respectively (p = 0.3200). Multivariate analysis showed that nodal stage (p = 0.021) was an independent prognostic factor for OS and sex (p = 0.010) and side-ness (p = 0.048) were independent prognostic factors for DFS.

CONCLUSION

If adequate decompression is achieved, laparoscopic resection following tube decompression for obstructive colorectal cancer can be a safe alternative to open surgery.

Oncologic safety of laparoscopic surgery after metallic stent insertion for obstructive left-sided colorectal cancer: a multicenter comparative study

BACKGROUND

Self-expanding metallic stents (SEMSs) are used as a bridge to surgery in patients with obstructive colorectal cancer. However, the role of laparoscopic resection after successful stent deployment is not well established. We aimed to compare the oncologic outcomes of laparoscopic vs open surgery after successful colonic stent deployment in patients with obstructive left-sided colorectal cancer.

METHODS

In this multicenter study, 179 (97 laparoscopy, 82 open surgery) patients with obstructive left-sided colorectal cancer who underwent radical resection with curative intent after successful stent deployment were retrospectively reviewed. To minimize bias, we used inverse probability treatment-weighted propensity score analysis. The short- and long-term outcomes between the groups were compared.

RESULTS

Both groups had similar demographic and tumor characteristics. The operation time was longer, but the degree of blood loss was lower in the laparoscopy than in the open surgery group. There were nine (9.3%) open conversions. After adjustment, the groups showed similar patient and tumor characteristics. The 5-year disease-free survival (DFS) (laparoscopic vs open: 68.7% vs 48.5%, p = 0.230) and overall survival (OS) (laparoscopic vs open: 79.1% vs 69.0%, p = 0.200) estimates did not differ significantly across a median follow-up duration of 50.5 months. Advanced stage disease (DFS: hazard ratio [HR] 1.825, 95% confidence interval [CI]: 1.072-3.107; OS: HR 2.441, 95% CI 1.216-4.903) and post-operative chemotherapy omission (DFS: HR 2.529, 95% CI 1.481-4.319; OS: HR 2.666, 95% CI 1.370-5.191) were associated with relatively worse long-term outcomes.

CONCLUSION

Stent insertion followed by laparoscopy with curative intent is safe and feasible; the addition of post-operative chemotherapy should be considered after successful treatment.

Robot-assisted laparoscopic surgery after placing a self-expanding metallic stent for malignant rectal obstruction: a case report

BACKGROUND

Approximately 20% of colorectal cancer patients show complete or incomplete bowel obstruction as an early symptom. Preoperative nonsurgical decompression such as placing a self-expanding metallic stent for malignant colorectal obstruction has been shown to be effective for reducing perioperative morbidity and mortality. However, there is a lack of published studies reporting robot-assisted laparoscopic surgery (RALS) after self-expanding metallic stent (SEMS) placement for malignant rectal obstruction (MRO). To our knowledge, this is the first report to do so.

CASE PRESENTATION

An 80-year-old man with incomplete paralysis of the lower limbs as well as bladder-rectal disorder due to a spine fracture sustained in a fall accident 26 years ago presented with lower abdominal pain and vomiting. Abdominal multi-detector computed tomography revealed an obstructive rectal tumor with distended bowel on the oral side. Emergency colonoscopy was performed, and an SEMS placed. The patency of SEMS and decompression of the distended bowel was confirmed, and elective RALS was performed 29 days after SEMS placement. To our knowledge, this is the first report of RALS after decompression with SEMS placement for MRO.

CONCLUSIONS

RALS after SEMS placement is a safe and feasible therapeutic strategy for MRO.