Laparoscopic resection of rectal cancer: a comparison of surgical and oncologic outcomes between extraperitoneal and intraperitoneal disease locations

Anastomotic Leak Rate and Prolonged Postoperative Paralytic Ileus in Patients Undergoing Laparoscopic Surgery for Colo-Rectal Cancer After Placement of No-Coil Endoanal Tube

BACKGROUND

Colorectal cancer (CRC) is the second most common gastrointestinal tumor in men and the third in women. Left-hemicolectomy (LC) and low anterior resection (LAR) are considered the gold standard curative treatment. In this retrospective study, we evaluated the presence or absence of post-operative complications, in all patients who underwent Video-laparoscopic (VLS) LAR/LC with No Coil trans-anal tube positioning, and compared the data with the current literature on the topic.

METHODS

Thirty-nine patients diagnosed with CRC of the descending colon, splenic flexure, sigma, and rectum were recruited. LC was performed for sigmoid and descending colon cancers, while LAR was applied for tumors of the upper two-thirds of the rectum. The No Coil trans-anal tube (SapiMed Spa, Alessandria, Italy) was placed in all patients of the study at the end of surgical treatment.

RESULTS

Eighteen patients received a LAR-VLS (46%) and 21 patients received a LC-VLS (54%). The average length of hospital stay after surgery was 7 days. PPOI occurred in only one in 39 patients (2.6%) who had undergone LAR-VLS. As for complications, in no patient of the study did AL (0%) occur.

CONCLUSION

In patients undergoing LAR-VLS and LC-VLS, we performed colorectal anastomosis and in the same surgical operation we introduced the No-Coil device. Although this is a preliminary study and subject to further investigation, we believe that the No Coil tube positioning may reduce the time of presence of first flatus and feces and the risk of AL.

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.

Transanal minimally invasive surgery (TAMIS) for local excision of selected rectal neoplasms: efficacy and outcomes in the first 11 patients

Disposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS) with benefits, when compared to local resection and transanal endoscopic microsurgery (TEM).

Objective To show outcomes and details of the technique.

Method A series of patients with indication for local resection of rectal tumors were submitted to surgery using the TAMIS platform.

Results Eleven patients have been submitted to TAMIS. Distance from anal verge was from 1.5 to 8 cm and maximum tumor diameter was 6 cm. Initial diagnosis of adenoma was the most frequent indication for resection. One partial dehiscence was the only complication seen. Minimal setup time, low cost and the possibility of using regular laparoscopic instruments make TAMIS a good option for transanal resection. The results of this technique are encouraging, concerning the feasibility, maneuverability, upfront cost, setup time, resectability and complication rate. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique that still expects a lot of growing and much remains to be learned.

Robotic-assisted resection for beyond TME rectal cancer: a novel classification and analysis from a specialized center

Locally advanced rectal cancer often requires an extended resection beyond the total mesorectal excision plane (bTME) to obtain clear resection margins. We classified three types of bTME rectal cancer following local disease diffusion: radial (adjacent pelvic organs), lateral (pelvic lateral lymph nodes) and longitudinal (below 3.5 cm from the anal verge, submitted to intersphincteric resection). The primary aim of this study was to evaluate the application of robotic surgery to the three types of bTME regarding the short and long-term oncological outcomes. Secondary aim was to identify survival prognostic factors for bTME rectal cancers. A total of 137 patients who underwent robotic-assisted bTME procedures between 2008 and 2018 were extracted from a prospectively collected database. Patient-related, operative and pathological factors were assessed. Morbidity was moderately high with 66% of patients reporting postoperative complications. Median follow up was 47 months (IQR, 31.5-66.5). Local recurrence rate was 15.3% with a statistical difference between the three types of bTME (p = 0.041). Disease progression/distant metastasis rate was 33.6%. Overall survival was significantly different (p = 0.023) with 1- and 3-years rates of: 77.8% and 55.0% (radial; n = 19); 96.6% and 84.8% (lateral; n = 30); 97.7% and 86.9% (longitudinal; n = 88). No statistical difference was observed for disease-free survival (p = 0.897). Local recurrence-free survival was significantly different between the groups (p = 0.031). Multivariate analysis showed that (y)pT (p = 0.028; HR (95% CI) 5.133 (1.192-22.097)), (y)pN (p = 0.014; HR (95% CI) 2.835 (1.240-6.482)) and type of bTME were associated to OS whilst (y)pT (p = 0.072) and type of bTME were not associated to LRFS.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

A New Prediction Model for Local Recurrence After Curative Rectal Cancer Surgery: Development and Validation as an Asian Collaborative Study

BACKGROUND

Local recurrence is one of the remaining problems in rectal and rectosigmoid cancer, and it is sometimes difficult to treat.

OBJECTIVE

This study aimed to explore various factors that are highly related to local recurrence and to develop a new prediction model for local recurrence after curative resection.

DESIGN

This is a retrospective cohort study SETTINGS:: This study was conducted at 2 academic hospitals in Japan and Korea.

PATIENTS

A total of 2237 patients with stage I to III rectal and rectosigmoid cancer who underwent a curative operation with a negative circumferential margin were selected.

INTERVENTIONS

Surgical treatment was the intervention.

MAIN OUTCOME MEASURES

Local recurrence was the primary outcome measure.

RESULTS

A total of 1232 patients were selected, and rectosigmoid cancer with rare local recurrence (2/221) was excluded. A different set of 792 patients with rectal cancer were chosen for validation. Multivariate analysis showed the following factors as significant for local recurrence: poorly differentiated tumor (HR, 11.2; 95% CI, 4.5-28.0), tumor depth (HR, 5.0), lymph node metastasis (HR, 4.1), operative procedure (HR, 3.2), postoperative complications (HR, 2.9), tumor location (HR, 2.6), and CEA level (HR, 2.4); a new prediction score was created by using these factors. A poorly differentiated tumor was assigned 2 points, and all other factors were assigned 1 point each. Patients who scored more than 5 points (n = 21) were judged as "high risk," with a 2-year local recurrence rate of 66.5%. The new predictive model could also separate the patients into different risk groups in the validation set. The high-risk group had higher recurrence rates than medium- and low-risk groups (2-year local recurrence rate: 41%, 15%, and 2.1%).

LIMITATIONS

This study was limited by its retrospective nature and potential for selection bias.

CONCLUSIONS

Seven factors were shown to be significantly correlated with the local recurrence of rectal cancer, and the usefulness of this new prediction model was demonstrated. See Video Abstract at http://links.lww.com/DCR/A429.

Oncologic outcomes in rectal cancer patients with a ≤1-cm distal resection margin

PURPOSE

Recently, common application of sphincter-saving resection in rectal cancer has led to acceptance of a 1-cm distal resection margin (DRM). The aim of this study was to evaluate oncologic outcomes of a DRM ≤1 cm in sphincter-saving resection for rectal cancer. The outcomes of a DRM ≤0.5 cm was also evaluated.

METHODS

We reviewed prospectively collected data from 415 patients who underwent sphincter-saving resection for mid and low rectal cancer between September 2006 and December 2012 at Korea University Anam Hospital. Patients were divided into two groups according to DRM measured in a formalin fixed specimen: ≤1 cm (n = 132) and >1 cm (n = 283). The DRM ≤1 cm group was divided into two subgroups: ≤0.5 cm (n = 45) and >0.5, ≤1 cm (n = 87).

RESULTS

Median follow-up periods were 47.2 months. The 5-year local recurrence rate was 8.8% in the DRM ≤1 cm group and 8.5% in the DRM >1 cm group (p = 0.630). The 5-year disease-free survival rate was 75.1 and 76.3% (p = 0.895), and the 5-year overall survival rate was 82.6 and 85.9% (p = 0.401), respectively. In subanalysis of the DRM ≤1 cm group, there was also no significant difference in the local recurrence and survival.

CONCLUSIONS

There was no significant difference in local recurrence and survival based on DRM length. We found that DRM length less than 1 cm was not a prognostic factor for local recurrence or survival.

An evidence-based medicine approach to the laparoscopic treatment of colorectal cancer

During the 1990s, laparoscopic resection was established as a treatment for gastrointestinal malignant tumors.　A number of randomized controlled trials comparing laparoscopic-assisted colorectal surgery with conventional open colorectal surgery for colon cancer have been conducted.　These trials have shown short-term benefits, and the vast majority demonstrated no significant difference in long-term outcomes.　Laparoscopic-assisted colorectal surgery is widely performed for the treatment of colon cancer, whereas laparoscopic-assisted colorectal surgery for rectal cancer is less commonly performed.　In recent years, there have been an increasing number of reports of laparoscopic-assisted colorectal surgery for rectal cancer, where improving short-term outcomes was shown, but no definitive effect on long-term survival has been shown to date.　Randomized controlled trials focusing on long-term survival are currently ongoing.

The anthropometric definition of the rectum is highly variable

PURPOSE

The precise definition of the rectum is essential for localizing colorectal pathology, yet current definitions are nebulous. The objective of this study is to determine the anthropometric definition of common pelvic landmarks in relation to patient characteristics.

METHODS

Seventy-one patients underwent open proctectomy with intra-operative measurements from the anal verge to various pelvic landmarks, and patient characteristics were evaluated. Analyses were performed using Spearman correlation and Wilcoxon rank sum.

RESULTS

The mean landmark distance was dentate line = 1.7 cm (range 0.8-4.0 cm), puborectalis muscle = 4.2 cm (range 2.0-8.0 cm), anterior peritoneal reflection = 13.2 cm (range 8.5-21.0 cm), sacral promontory = 17.9 cm (range 13.0-26.0 cm), and confluence of the taenia = 25.5 cm (range 16.0-44.0 cm). Men had longer mean distances to the dentate line (p = 0.0003), puborectalis muscle (p = 0.03), and anterior peritoneal reflection (p = 0.02). Patient weight significantly correlated with distance to all landmarks except for the confluence of the taenia, which did not correlate with any patient factor.

CONCLUSIONS

The location of common pelvic landmarks is highly variable. The use of predefined absolute measurements from the anal verge to localize rectal pathology is inaccurate and fails to account for patient variability.

Incidence and mortality of anastomotic dehiscence requiring reoperation after rectal carcinoma resection

Anastomotic dehiscence (AD) requiring reoperation is the most severe complication following anterior rectal resection. We performed a systematic review on studies that describe AD requiring reoperation and its subsequent mortality after anterior resection for rectal carcinoma. A systematic search was performed on published literature. Data on the definition and rate of AD, the number of ADs requiring reoperation, the mortality caused by AD, and the overall postoperative mortality were pooled and analyzed. A total of 39 studies with 24,232 patients were analyzed. The studies varied in incidence and definition of AD. Systematic review of the data showed that the overall rate of AD was 8.6%, and the rate of AD requiring reoperation was 5.4%. The postoperative mortality caused by AD was 0.4%, and the overall postoperative mortality was 1.3%. We found considerable risk and mortality for AD requiring reoperation, which largely contributed to the overall postoperative mortality.

Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years?

AIM

Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early postoperative complications in laparoscopic rectal cancer surgery have improved over the past 20 years.

METHOD

A literature search of the EMBASE and MEDLINE databases between August 1991 and August 2011 was conducted using the keywords laparoscopy, rectal cancer and postoperative complications. Data were analysed using linear regression ANOVA performed in GNUMERICS software.

RESULTS

Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in the rate of any early postoperative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (P = 0.01).

CONCLUSION

There was no evidence of a statistically significant change in early postoperative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, the limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of ongoing randomized clinical trials might show improved outcomes.

Robotic versus laparoscopic intersphincteric resection for low rectal cancer: comparison of the operative, oncological, and functional outcomes

BACKGROUND

Robotic surgery was developed to overcome the limitations of laparoscopic surgery and is increasingly used to treat low rectal cancer. In this study, we compared the operative, oncological, and functional outcomes of low rectal cancer patients who underwent robotic or laparoscopic intersphincteric resection (ISR).

METHODS

Prospectively collected data from low rectal cancer patients who underwent laparoscopic or robotic ISR between September 2006 and August 2011 were retrospectively compared. The functional outcomes of patients followed up for ≥ 12 months after ileostomy closure were evaluated via questionnaire.

RESULTS

Forty-four and 26 patients underwent robotic and laparoscopic ISR, respectively. The robotic group patients had a higher body mass index (BMI; 21.42 ± 3.13 vs. 24.13 ± 3.33 kg/m(2); p = 0.001), more advanced clinical N stage (p = 0.029), lower cancer location (3.71 ± 0.89 vs. 3.24 ± 0.78 cm; p = 0.023), more frequent chemoradiotherapy (26.9 vs. 54.5 %; p = 0.025), and longer operation time (286.77 ± 51.46 vs. 316.43 ± 65.11 min; p = 0.038). However, no intergroup differences were observed in the pathological details (except the number of retrieved lymph nodes), postoperative morbidity, 3-year overall survival, recurrence-free survival (RFS), local RFS, and functional outcomes.

CONCLUSIONS

Robotic and laparoscopic ISR yielded similar operative, oncological, and functional outcomes in patients with low rectal cancer, despite differences in unfavorable outcome-affecting factors, including BMI, clinical N stage, cancer location, and chemoradiotherapy frequency. A randomized trial will provide more solid methodology for investigating the potential benefits of robotic ISR.

Mitigating the Consequences of Anastomotic Leakage After Laparoscopic Rectal Cancer Resection

Background. With regard to laparoscopic low anterior resection, anastomotic leakage still remains a challenge and continues to account for approximately 30% of postoperative deaths. This study was designed to evaluate whether the intracolonic and perineal drainage is associated with a decreased risk for anastomotic leakage after laparoscopic rectal cancer surgery without stool diversion. Patients and Methods. Prospective data were collected from 337 patients with rectal cancer who underwent laparoscopic resection without defunctioning stoma. Results. A total of 157 patients underwent laparoscopic rectal resection, followed by the placement of intracolonic and perineal drainage, while 180 underwent laparoscopic surgery routinely. No difference in clinically significant leakage was observed between the intracolonic and perineal drainage and the control groups (3.8% vs 8.3%, P = .0874). However, reoperation was underwent at a significantly lower rate after the placement of intracolonic and perineal drainage (intracolonic and perineal drainage: 1 of 6 [16.7%] vs control: 14 of 15 [93.3%]; P < .01). In multivariate analysis, extraperitoneal tumor location and operation duration ≥180 minutes were independently associated with anastomotic leakage. Conclusions. Significant risk factors of anastomotic leakage include extraperitoneal tumor location and operation duration ≥180 minutes. The placement of intracolonic and perineal drainage was not found to be significantly associated with anastomotic leakage, but this method could mitigate the clinical consequences of leakage and decrease the rate of reoperation and transverse colostomy after laparoscopic anterior resection for rectal cancer.

Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer

BACKGROUND

A generally acceptable definition and a severity grading system for anastomotic leakages (ALs) following rectal resection were not available until 2010, when the International Study Group of Rectal Cancer (ISGRC) proposed a definition and a grading system for AL.

METHODS

A search for published data was performed using the MEDLINE database (2000 to December 5, 2012) to perform a systematic review of the studies that described AL, grade AL according to the grading system, pool data, and determine the average rate of AL for each grade after anterior resection (AR) for rectal cancer.

RESULTS

A total of 930 abstracts were retrieved; 40 articles on AR, 25 articles on low AR (LAR), and 5 articles on ultralow AR (ULAR) were included in the review and analysis. The pooled overall AL rate of AR was 8.58% (2,085/24,288); the rate of the asymptomatic leakage (Grade A) was 2.57%, that of AL that required active intervention without relaparotomy (Grade B) was 2.37%, and that of AL that required relaparotomy (Grade C) was 5.40%. The pooled rate of AL that required relaparotomy was higher in AR (5.40%) than in LAR (4.70%) and in ULAR (1.81%), which could be attributed to the higher rate of protective defunctioning stoma in LAR (40.72%) and ULAR (63.44%) compared with that in AR (30.11%).

CONCLUSIONS

The new grading system is simple that the ALs of each grade can be easily extracted from past publications, therefore likely to be accepted and applied in future studies.

Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group

OBJECTIVE

To assess the risk factors for clinical anastomotic leakage (AL) in patients undergoing laparoscopic surgery for rectal cancer.

BACKGROUND

Little data are available about risk factors for AL after laparoscopic rectal cancer resection.

METHODS

This was a retrospective analysis of 1609 patients with rectal cancer who had undergone laparoscopic surgery for rectal cancer with sphincter preservation. Clinical data related to AL were collected from 11 institutions. Univariate and multivariate analyses were performed to determine the risk factors for AL.

RESULTS

AL was noted in 101 (6.3%) of the patients. The leakage rate ranged from 2.0% to 10.3% for each hospital (P = 0.04). In patients without protective stomas (n = 1187), male sex [hazard ratio (HR), 3.468], advanced tumor stage (HR, 2.520), lower tumor level (HR, 2.418), preoperative chemoradiation (HR, 6.284), perioperative transfusion (HR, 10.705), and multiple firings of the linear stapler (HR, 6.181) were significantly associated with AL. Our theoretical model suggested that the HR for patients with 2 risk factors was significantly higher than that the HR for patients with no or only 1 risk factor.

CONCLUSIONS

Male sex, low anastomosis, preoperative chemoradiation, advanced tumor stage, perioperative bleeding, and multiple firings of the linear stapler increased the risk of AL after laparoscopic surgery for rectal cancer. A diverting stoma might be mandatory in patients with 2 or more of the risk factors identified in this analysis.

Pelvic anatomy as a factor in laparoscopic rectal surgery: a prospective study

PURPOSE

The aim of this study was to evaluate factors affecting the difficulty of laparoscopic total mesorectal excision (L-TME), focusing on the pelvic anatomy.

METHODS

Seventy-four patients who underwent L-TME were prospectively enrolled. Tumor and patient factors, including magnetic resonance imaging-based pelvic measurements (obstetric conjugate, sacral length, sacral depth, interspinous distance, and intertuberous distance), were analyzed with respect to pelvic dissection time. Variable significantly correlated with pelvic dissection time in linear regression were considered risk factors which we defined as lower or upper quartile of each significant variable. Patients were categorized into 3 groups: easy group, no risk factors; moderate group, 1 to 2 risk factors; and difficult group, ≥ 3 risk factors.

RESULTS

Multivariate analysis showed that long sacral length, shallow sacral angle, narrow intertuberous diameter, and large tumor size were significantly associated with longer pelvic dissection time (P=0.018, P<0.001, P=0.034, P=0.032, respectively). The cutoff values of the upper quartile were 11.5 cm and 4.5 cm for sacral length and tumor size, and cutoff values of the lower quartile were 3.0 cm and 8.9 cm for sacral depth and intertuberous diameter. Logistic regression analysis showed that difficult group significantly contributed to intraoperative complication (95% confidence interval: 1.364-122.313, P=0.026) but not postoperative complication.

CONCLUSIONS

Having a narrow, deep pelvis and a large tumor were not found to adversely affect postoperative outcomes. However, in terms of operation time and intraoperative difficulty, anatomical factors should be taken into consideration when planning L-TME.

Superiority of laparoscopic rectal surgery: Towards a new era

While laparoscopic colon surgery has been established to some degree over this decade, laparoscopic rectal surgery is not standard yet because of the difficulty of making a clear surgical field, the lack of precise anatomy of the pelvis, immature procedures of rectal transaction and so on. On the other hand, maintaining a clear surgical field via the magnified laparoscopy may allow easier mobilization of the rectum as far as the levetor muscle level and may result less blood loss and less invasiveness. However, some unique techniques to keep a clear surgical field and knowledge about anatomy of the pelvis are required to achieve the above superior operative outcomes. This review article discusses how to keep a clear operative field, removing normally existing abdominal structures, and how to transact the rectum and restore the discontinuity based on anatomical investigations. According to this review, laparoscopic rectal surgery will become a powerful modality to accomplish a more precise procedure which has been technically impossible so far, actually entering a new era.

A Single Centre Retrospective Evaluation of Laparoscopic Rectal Resection with TME for Rectal Cancer: 5-Year Cancer-Specific Survival

Laparoscopic colon resection has established its role as a minimally invasive approach to colorectal diseases. Better long-term survival rate is suggested to be achievable with this approach in colon cancer patients, whereas some doubts were raised about its safety in rectal cancer. Here we report on our single centre experience of rectal laparoscopic resections for cancer focusing on short- and long-term oncological outcomes. In the last 13 years, 248 patients underwent minimally invasive approach for rectal cancer at our centre. We focused on 99 stage I, II, and III patients with a minimum follow-up period of 5 years. Of them 43 had a middle and 56 lower rectal tumor. Laparoscopic anterior rectal resection was performed in 71 patients whereas laparoscopic abdomino-perineal resection in 28. The overall mortality rate was 1%; the overall morbidity rate was 29%. The 5-year disease-free survival rate was 69.7%, The 5-year overall survival rate was 78.8%.

Laparoscopic surgery for rectal cancer

Laparoscopic surgery for rectal cancer is much more challenging than that for colon cancer because of the confined space within the pelvis. Further, because of the tumor's location in the pelvis, maintenance of resection margins is of greater concern. Nonrandomized studies by groups experienced in laparoscopic surgery have shown both that it produces short-term outcomes equivalent to those for open surgery and that it can be performed safely from an oncologic perspective. Nonsurgical complications appear to be fewer, but conversion to open surgery may become a real issue. This review summarizes these findings by addressing technical considerations, early outcomes, late outcomes, costs, and complications.

Robot-assisted intersphincteric resection for low rectal cancer: technique and short-term outcome for 29 consecutive patients

BACKGROUND

Intersphincteric resection (ISR) for low rectal cancer has been described as the ultimate sphincter-saving procedure. Laparoscopic ISR has been proved safe with early postoperative benefits. Recently, some colorectal surgeons have begun to perform robot-assisted ISR to harness the advantages of the da Vinci robotic system. The authors present their short-term results for a robotic technique of ISR.

METHODS

Data from 29 consecutive patients at a single institution with very low rectal cancer (<4 cm) from the anal verge who underwent robot-assisted ISR were prospectively collected between December 2007 and March 2010.

RESULTS

The study enrolled 23 men and 6 women with a median age of 61.5 years (range, 36-82 years). Their median body mass index (BMI) was 23.3 kg/m(2) (range, 17.9-32.5 kg/m(2)). The median distance of the tumor from the anal verge was 3 cm (range, 1-4 cm). The median operative time was 325 min (range, 235-435 min), with a console time of 130 min (range, 110-210 min). There were no conversions to open surgery. A protecting ileostomy was performed for all the patients. The median blood loss was less than 50 ml (range, < 50-1,000 ml). The median size of the tumor was 3 cm (range, 0-6.9 cm), and the median number of lymph nodes harvested was 16 (range, 1-44). The median distal margin was 0.8 cm (range, 0-4 cm), and one margin was positive. The circumferential margin was negative (>2 mm) for 27 patients. Therefore, complete resection (R0) was achieved for 26 (90%) of the 29 patients. The median hospital stay was 9 days (range, 5-15 days). Nine patients experienced complications, including three anastomotic leaks (10%). All the leaks were managed conservatively. No surgical mortalities occurred.

CONCLUSION

Robot-assisted intersphincteric resection for very low rectal cancer is feasible, and its short-term outcome is acceptable.

Predicting the risk of anastomotic leakage in left-sided colorectal surgery using a colon leakage score

BACKGROUND

Anastomotic leakage following colorectal surgery still occurs all too frequently, and this complication is difficult to predict. A nonfunctional stoma may reduce the risk of clinically relevant leaks but is overtreatment for most patients. More accurate assessments of the risk of anastomotic leakage would be very helpful in tailoring treatment in colorectal surgery. Therefore, a Colon Leakage Score (CLS) was developed and tested.

MATERIAL AND METHODS

The CLS was developed based on information from the literature and expert opinions. It was tested in a retrospective cohort of consecutive patients undergoing left-sided colorectal surgery with primary anastomosis in a teaching hospital in The Netherlands.

RESULTS

In the test cohort, 10 of 121 patients who were not treated with a nonfunctional stoma experienced anastomotic leakage. The mean CLS in the leakage group was 16 versus eight in the group that did not have a leak (P < 0.01). Using receiver-operating characteristics, the area under the curve (AUC) showed that the CLS was a good predictor (AUC = 0.95, CI 0.89-1.00) of anastomotic leakage. Furthermore, logistic regression analysis with CLS as a predictor for anastomotic leakage showed an odds ratio of 1.74 (95% CI 1.32-2.28, P < 0.01).

CONCLUSIONS

The CLS can predict the risk of anastomotic leakage following left-sided colorectal surgery. After further validation, this score may help the surgeon make a more individualized, safer decision regarding whether to perform an anastomosis or make a (nonfunctional) stoma.

Laparoscopic rectal surgery: does immediate outcome differ in respect to sex?

PURPOSE

This study analyzed the immediate postoperative outcome of the laparoscopic approach to the rectum in relation to the sex of the patient.

METHODS

Two hundred thirty-nine patients were included in our study. The inclusion criterion was rectal cancer <15 cm from the anal margin. Exclusion criteria were the presence of anesthetic contraindications for pneumoperitoneum, T4, pancolonic polyposis, and ulcerative colitis. The parameters analyzed included demographics, comorbidities, previous abdominal surgery, preoperative chemoradiotherapy, body mass index, operative time, type of operation, difficulty score, conversion, hospital stay, postoperative morbidity according to the Dindo classification, and histopathologic analysis. Analysis was performed on an intention-to-treat basis. Results are given as number of cases and percentages for categorical data, and as median and 95% confidence interval for quantitative variables. Data were analyzed by use of bivariate analysis, contingency tables, and chi or Fisher exact tests for categorical variables, and ANOVA or t test for quantitative variables. The statistical significance level was set at 5% (alpha = 0.05), and two-tailed tests were used throughout.

RESULTS

We did not find any statistical differences related to sex in the global series, pure laparoscopy, or converted patients in relation to mortality, conversion, anastomotic leakage, morbidity, reintervention, and morbidity classification according to Dindo (P > .05). We only observed a trend in relation to a longer duration of surgery in men. This was statistically significant in the low anterior resection subgroup (P = .02) and in the overall series (P = .002). Statistical analysis also showed that postoperative stay was longer in men after an anterior resection (P = .015).

CONCLUSION

We believe that no important differences exist in perioperative outcomes between men and women after a laparoscopic approach to rectum cancer.

Single-stage totally robotic dissection for rectal cancer surgery: technique and short-term outcome in 50 consecutive patients

PURPOSE

To overcome the pitfalls of laparoscopy, a robotic system has been introduced in rectal cancer surgery. However, there is no standard procedure to maximize the advantages of the da Vinci S Surgical System. Therefore, we describe our technique of applying the robotic system during all of the steps of dissection in rectal cancer surgery and the short-term outcome.

METHODS

Prospectively collected data were reviewed from 50 consecutive patients who underwent single-stage, totally robotic dissection for rectal cancer resection between July 2007 and June 2008. Robotic dissection was performed following these steps: 1) ligation of the inferior mesenteric vessels and medial to lateral dissection, 2) mobilization of the sigmoid/descending/splenic flexure colon, and 3) rectal dissection. The remaining steps including rectal transection and anastomosis were performed by a conventional laparoscopic method.

RESULTS

There were 32 (64%) men and 18 (36%) women. The mean distance from the anal verge to the tumor margin was 7.3 (range, 2-13) cm. The conversion rate was 0%. The mean operative time was 304.8 (range, 190-485) minutes, and 20.6 (range, 6-48) lymph nodes were harvested. The circumferential margin was positive in one patient. The length of hospital stay after surgery was 9.2 (range, 5-24) days. Anastomotic leak rate was 8.3%, and all of the patients with leakage were managed conservatively.

CONCLUSIONS

Single-stage robotic dissection for rectal cancer surgery is feasible, and its short-term outcome is acceptable. Our technique can be a suitable procedure to maximize the advantages of the da Vinci system.

Laparoscopic resection for rectal cancer: a review

Despite increasing evidence on the success of laparoscopic resection in colorectal diseases, clinicians remain skeptical about the application of laparoscopic resection in rectal cancer, although it may benefit patients by resulting in early return of bowel function, reduced postoperative pain, and shorter hospital stay. Rectal cancer surgery has been regarded as a technically demanding procedure. Deviation from the oncologic principle of mesrectal dissection will lead to a higher local recurrence rate. Therefore, rectal cancer was not included in earlier studies on laparoscopic versus open resection for colorectal cancer. However, many colorectal surgeons who practice laparoscopic surgery soon appreciated that the improved optics of laparoscopy can provide a much better view of the pelvis, and the Heald principle of meticulous sharp dissection for total mesorectal excision could be performed without compromise. In recent years, there has been increasing number of reports on laparoscopic resection of rectal cancers. Apart from the issues on postoperative outcomes and long-term results, laparoscopic resection has generated interest in its impact on the preservation of sexual and bladder function. We summarize the current evidence on laparoscopic resection for rectal cancer.

Anastomotic leakage after laparoscopic resection of rectal cancer: the impact of fibrin glue

BACKGROUND

The aim of this study was to evaluate whether the use of fibrin glue as a sealant over an anastomosis is a risk factor for anastomotic leakage after laparoscopic rectal cancer surgery.

METHODS

Prospective data were collected from 223 patients with rectal cancer who underwent laparoscopic resection without defunctioning stoma.

RESULTS

A total of 104 patients underwent laparoscopic rectal resection, followed by the application of fibrin glue over the stapled anastomosis, while 119 underwent surgery alone. No difference in clinically significant leakage was observed between the fibrin and the nonfibrin groups (5.8% vs 10.9%, P = .169). In multivariate analysis, extraperitoneal tumor location and operation duration >220 minutes were independently associated with anastomotic leakage.

CONCLUSIONS

Significant predictors of anastomotic leakage include extraperitoneal tumor location and operation length >220 minutes. Fibrin glue application over the stapled anastomosis was not found to be significantly associated with anastomotic leakage.