Laparoscopic surgery for colorectal cancer: clinical practice guidelines of the Italian Society of Colo-Rectal Surgery

Has the open surgical approach in colorectal cancer really become uncommon?

Colorectal cancer is the third most common cancer in the world. Surgery is mandatory to treat patients with colorectal cancer. Can colorectal cancer be treated in laparoscopy? Scientific literature has validated the oncological quality of laparoscopic approach for the treatment of patients with colorectal cancer. Randomized non-inferiority trials with good remote control have answered positively to this long-debated question. Early as 1994, first publications demonstrated technical feasibility and compliance with oncological imperatives and, as far as short-term outcomes are concerned, there is no difference in terms of mortality and post-operative morbidity between open and minimally invasive surgical approaches, but only longer operating times at the beginning of the experience. Subsequently, from 2007 onwards, long-term results were published that demonstrated the absence of a significant difference regarding overall survival, disease-free survival, quality of life, local and distant recurrence rates between open and minimally invasive surgery. In this editorial, we aim to summarize the clinical and technical aspects which, even today, make the use of open surgery relevant and necessary in the treatment of patients with colorectal cancer.

Recommendations for Optimal Endoscopic Localization of Colorectal Neoplasms: A Delphi Consensus of National Experts

BACKGROUND

Colonoscopy is the standard of care for diagnosis and evaluation of colorectal cancers before surgery. However, varied practices and heterogenous documentation affects communication between endoscopists and operating surgeons, hampering surgical planning.

OBJECTIVE

This study aimed to develop recommendations for the use of standardized localization and reporting practices for colorectal lesions identified during lower GI endoscopy.

DESIGN

A systematic review of existing endoscopy guidelines and thorough narrative review of the overall endoscopy literature were performed to identify existing practices recommended globally.

SETTING

An online Delphi process was used to establish consensus recommendations based on a literature review.

PATIENTS

Colorectal surgeons and gastroenterologists from across Canada who had previously demonstrated leadership in endoscopy, managed large endoscopy programs, produced high-impact publications in the field of endoscopy, or participated in the development of endoscopy guidelines were selected to participate.

PRIMARY OUTCOME MEASURES

The primary outcomes measured were colorectal lesion localization and documentation practice recommendations important to planning surgical or advanced endoscopic excisions.

RESULTS

A total of 129 of 197 statements achieved consensus after 3 rounds of voting by 23 experts from across Canada. There was more than 90% participation in each round. Recommendations varied according to lesion location in the cecum, colon, or rectum and whether the referral was planned for surgical or advanced endoscopic resection. Recommendations were provided for appropriate documentation, indications, location, and method of tattoo placement, in addition to photograph and real-time 3-dimensional scope configuration device use.

LIMITATIONS

Because of a paucity of evidence, recommendations are based primarily on expert opinion. There may be bias, as all representatives were based in Canada.

CONCLUSIONS

Best practices to optimize endoscopic lesion localization and communication are not addressed in previous guidelines. This consensus involving national experts in colorectal surgery and gastroenterology provides a framework for efficient and effective colorectal lesion localization. See Video Abstract at http://links.lww.com/DCR/C71 .

RECOMENDACIONES PARA LA LOCALIZACIN ENDOSCPICA PTIMA DE LAS NEOPLASIAS COLORRECTALES UN CONSENSO DELPHI DE EXPERTOS NACIONALES

ANTECEDENTES:La colonoscopia es el estándar de atención para el diagnóstico y la evaluación de los cánceres colorrectales antes de la cirugía. Sin embargo, las prácticas variadas y la documentación heterogénea afectan la comunicación entre los endoscopistas y los cirujanos operadores, lo que dificulta la planificación quirúrgica.OBJETIVO:Este estudio tuvo como objetivo desarrollar recomendaciones para el uso de prácticas estandarizadas de localización y notificación de lesiones colorrectales identificadas en la endoscopia gastrointestinal inferior.DISEÑO:Se realizó una revisión sistemática de las pautas de endoscopia existentes y una revisión narrativa exhaustiva de la literatura general sobre endoscopia para identificar las prácticas existentes recomendadas a nivel mundial. Se utilizó un proceso Delphi en línea para establecer recomendaciones de consenso basadas en la revisión de la literatura.PARTICIPANTES:Se seleccionaron para participar cirujanos colorrectales y gastroenterólogos de todo Canadá que previamente habían demostrado liderazgo en endoscopia, manejado grandes programas de endoscopia, producido publicaciones de alto impacto en el campo de la endoscopia o que habían participado en el desarrollo de pautas de endoscopia.RESULTADOS:Localización de lesiones colorrectales y recomendaciones prácticas de documentación importantes para planificar escisiones quirúrgicas o endoscópicas avanzadas.RESULTADOS:129 de 197 declaraciones lograron consenso después de tres rondas de votación de 23 expertos de todo Canadá. Hubo >90% de participación en cada ronda. Las recomendaciones variaron según la ubicación de la lesión en el ciego, colon o recto, y si se planificó la derivación para resección quirúrgica o endoscópica avanzada. Se proporcionaron recomendaciones para la documentación adecuada, las indicaciones, la ubicación y el método de colocación del tatuaje, además de la fotografía y el uso del dispositivo de configuración del alcance 3D en tiempo real.LIMITACIONES:Debido a la escasez de evidencia, las recomendaciones se basan principalmente en la opinión de expertos. Puede haber sesgo, ya que los representantes tenían su sede en Canadá.CONCLUSIONES:Las mejores prácticas para optimizar la localización y comunicación de lesiones endoscópicas no se abordan en las guías anteriores. Este consenso que involucra a expertos nacionales en cirugía colorrectal y gastroenterología proporciona un marco para la localización eficiente y efectiva de lesiones colorrectales. Consulte Video Resumen en http://links.lww.com/DCR/C71 . (Traducción-Dr. Mauricio Santamaria ).

Laparoscopic right hemicolectomy with intracorporeal anastomosis

The author presents a technique for performing laparoscopic right hemicolectomy, accompanied by an online video. This method is suitable for a single surgeon working with a single assistant, who is also the cameraman. It starts with a hybrid medial-to-lateral or lateral-to-medial dissection of the right colon and mesentery, adapting to the actual anatomical findings and adhesions encountered in each individual patient. A step-by-step approach is described. Achieving the anatomical goals of each step facilitates the performance of the next step. An intracorporeal technique for anastomosis is demonstrated.

Laparoscopic colon resection by a single general surgeon in a community hospital: a review of 200 consecutive cases

BACKGROUND

We assessed a single surgeon's experience on laparoscopic colorectal surgery (LCR) at a single non academic, community hospital. The surgeon was trained in minimally-invasive techniques and robotic surgery with >500 procedures at another non-university hospital, either as operating surgeon or as assistant.

METHODS

Short-term outcome of patients undergoing LCR for benign/neoplastic disease (June 2005-September 2007) was assessed.

RESULTS

A total of 208 patients (104 males, 104 females; median age 69.1 years, Interquartile Range (IQR):59.3-76.6) underwent LCR. Over 70% of the operations were performed for cancer. Left hemicolectomy was performed in 102 patients (49.1%), right hemicolectomy in 50 (24%), anterior resection in 40 (19.2%), other procedures in 16 (7.7%). One-hundred-ninety (91.3%) operations were elective. The median operative time was 180 min (IQR:150-210). Conversion rate was 4.8%: 3.4% for benign and 5.4% for neoplastic disease (p = n.s.). The median lymph node harvest in cancer patients was 16 (IQR:12-20). Mortality and overall morbidity rates were 0.5% and 13%, with no significant difference between benign and malignant disease, colon and rectum, elective and non elective operations.

CONCLUSIONS

The outcomes of LCR surgery performed by a well-trained laparoscopic surgeon working in a community hospital are comparable with results from academic health science centers.

Electrothermal bipolar vessel sealing system vs. harmonic scalpel in colorectal laparoscopic surgery: a prospective, randomized study

PURPOSE

This study was designed to compare the efficacy and safety of laparoscopic colorectal surgery performed with the aid of LigaSure vessel-sealing system or Ultracision.

METHODS

Patients eligible for elective laparoscopic right or left hemicolectomy or anterior resection of rectum were randomly assigned to either the use of Ligasure or Ultracision. The primary end point was intraoperative reduction of blood loss. Secondary end points were intraoperative and postoperative morbidity and operative time.

RESULTS

Between April 2005 and December 2006, 140 consecutive patients were included in the study (70 Ligasure and 70 Ultracision. We performed 31 right hemicolectomies, 69 left hemicolectomies, and 40 anterior resections of rectum. Blood loss was 109.6 ml (Ultracision 107.9 ml vs. Ligasure 111.2 ml, P value = 0.72). Intraoperative complication rate was 2.8 percent (Ultracision 1.4 percent vs. Ligasure 4.2 percent, P value < 0.01). Postoperative mortality was 0.7 percent. The overall conversion rate was 7.8 percent, 6 in the Ligasure group and 5 in the Ultracision group (P value = 0.09). Operative time, considered from pneumoperitoneum to minilaparotomy, was 115.7 minutes (Ultracision 114.8 minutes vs. Ligasure 116.3 minutes, P value = 0.89).

CONCLUSIONS

Results showed that Ligasure and Ultracision are both useful instruments for laparoscopic colorectal surgery with no significant difference in terms of intraoperative/postoperative morbidity and operative time. Choice of which technique to perform should be according to the surgeon's preference.